Endoscopic management of obesity: Impact of endoscopic sleeve gastroplasty on weight loss and co-morbidities at six months and one year.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) is one of the new minimally invasive endoscopic treatments aimed at inducing weight loss. Its effectiveness in terms of weight loss is proven. Gastric volume reduction and delayed gastric emptying are the mechanisms that drive weight loss. However, potential benefits for co-morbidities in relation to weight loss after ESG are still being investigated. This study aims to evaluate the effect of ESG procedures on major obesity-associated co-morbidities, and on some biological parameters. PATIENTS AND METHODS: This is a series of consecutive cases from a prospective observational study carried out in a specialized center that follows a standardized care pathway for the multimodal management of obesity. Patients who have undergone ESG with endoscopic and laboratory follow-up at six and twelve months after this intervention were included in the study. Prospectively recorded data on weight loss, co-morbidities and laboratory parameters at six and twelve months after surgery was analyzed retrospectively. Changes in body mass index (BMI), absolute weight loss (AWL), percent of excess weight loss (%EWL) and percent total weight loss (%TWL) were assessed at six and twelve months. Reduction in various obesity-related co-morbidities (arterial hypertension [AHT], type 2 diabetes mellitus [T2DM], gastroesophageal reflux disease [GERD], obstructive sleep apnea syndrome [OSAS] and dyslipidemia was also evaluated at six and twelve months. Changes in blood glucose, liver function tests and lipid blood tests were also analyzed at six and twelve months. RESULTS: From October 2016 to July 2021, 99 of the 227 patients who underwent ESG in our unit (43.6%) subsequently underwent a complete endoscopic and laboratory follow-up at six and twelve months. The initial BMI was 42.7±7.8kg/m2 and age was 45±12.7 years. Seventy-four patients (74.8%) were female. Total weight loss (%TWL) and excess weight loss (%EWL) were 16.6±7.4% and 43.3±21.2%, respectively, at six months, 16.6±9.6% and 42.9±25.6%, respectively, at one year. At six and twelve month follow-up, a statistically significant reduction was observed for the rates of T2DM (30.8 and 32.7%), hypertension (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). A statistically significant difference was found in the reduction in blood glucose between the pre-operative period and six months post-operatively (P<0.01) and between the pre-operative period and twelve months post-operatively (P<0.01). The reduction in triglycerides and total cholesterol between the pre-operative values and at six months was statistically significant (P<0.01) as was the reduction at twelve months (P<0.01) (P=0.017). For liver function tests, the reduction in AST was statistically significant at six and twelve months after ESG (P=0.048) (P=0.048) as was ALT (P<0.01) (P<0.01) respectively. From October 2016 to July 2021, of the 227 patients who underwent ESG, 99 (43.6%) had follow-up gastro-duodenoscopy at 6 and 12 months. %TWL and %EWL were respectively 16.6±7.4% and 43.3%±21.2 at 6 months, 16.6±9.6% and 42.9±25.6% at one year. Statistically significant reduction rates at 6 and 12 months were observed in T2DM (30.8 and 32.7%), AHT (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). Moreover, glycemic levels were statistically significantly reduced between the pre-operative period and 6 months post-operative (1.11±0.22mg/L vs. 1.01±0.17mg/L, P<0.01), and between the pre-operative period and 12 months post-operative (1.11±0.22mg/L vs. 1.06±0.32mg/L, P<0.01). A statistically significant reduction was also observed in triglycerides and total cholesterol levels at 6 months (1.52±0.74mmol/L vs. 1.14±0.52mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.85±0.36mmol/L, P<0.01) and at 12 months (1.52±0.74mmol/L vs. 1.18±0.67mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.82±0.39mmol/L, P=0.017) and in AST (27.2±11.7 IU/L vs. 23.7 IU/L; P=0.048) (27.2±11.7 IU/L vs. 24.7±14.65 IU/L, P=0.048) and ALAT levels (34±21.32 IU/L vs. 22.3±10.4 IU/L, P<0.01 and 34±21.32 IU/L vs. 27.07±25 IU/L, P<0.01) at 6 and 12 months after ESG, respectively. CONCLUSION: ESG is a well-tolerated and safe surgical procedure that is effective in terms of weight loss and reduction of obesity-related co-morbidities at six months and one year. This procedure could thus be adopted on a broader clinical scale and be more widely promoted as an effective treatment for morbid obesity.

Randomized trial of Roux-en-Y gastric bypass versus sleeve gastrectomy in achieving excess weight loss.

BACKGROUND: Robust data on quality of life (QoL) after different techniques of bariatric surgery are sparse. This RCT compared excess weight loss (EWL) and QoL after sleeve gastrectomy versus Roux-en-Y gastric bypass (RYGB). METHODS: Obese patients were assigned randomly to RYGB or sleeve gastrectomy. The primary outcome measure was EWL. Secondary outcomes included QoL, co-morbidity, adverse events, vitamin and glycolipid status. QoL was assessed before and annually after surgery, using the Moorehead-Ardelt Quality of Life Questionnaire II (M-A-QoLQII) and Gastrointestinal Quality of Life Index (GIQLI). RESULTS: One hundred patients were enrolled, 45 in the RYGB group and 55 in the sleeve gastrectomy group. Mean postoperative EWL at 1, 2, 3 and 5 years was 80·4, 79·8, 83·0 and 74·8 per cent respectively after RYGB, and 83·0, 77·8, 66·3 and 65·1 per cent after sleeve gastrectomy (P = 0·017). Mean M-A-QoLQII score before surgery and at 1, 2, 3 and 5 years after operation was 0·5, 1·6, 1·7, 2·1 and 1·4 respectively after RYGB, and 0·3, 1·7, 1·5, 1·5 and 1·2 after sleeve gastrectomy. Mean GIQLI score before and at 1, 2, 3, 5 years after RYGB was 96·4, 113·8, 113·3, 113·4, 111·7, compared with 90·7, 113·9, 114·5, 113·1 and 113·0 for sleeve gastrectomy. The improvement was significant compared with preoperative values (P < 0·001 for M-A-QoLQII and GIQLI), with no difference between groups (P = 0·418 and P = 0·323 respectively). RYGB resulted in higher readmission rates (P = 0·002) and length of hospital stay (P = 0·006) than sleeve gastrectomy. CONCLUSION: RYGB and sleeve gastrectomy resulted in equivalent, long-standing QoL improvement. RYGB resulted in more stable weight loss but was associated with higher readmission rates. Registration number: NCT02475590.

Laparoscopic treatment of incisional and primary ventral hernia in morbidly obese patients with a BMI over 35.

INTRODUCTION: Incisional and ventral hernias are common surgical indications. Their management is associated with significant complications and recurrences in open surgery (15-25%). Since laparoscopy has become a standard in bariatric surgery, there has been a natural trend to treat obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and the results of the laparoscopic management of parietal wall defects in patients with a BMI >35. MATERIALS AND METHODS: A series of 79 patients were included. Data were acquired prospectively and analyzed retrospectively. The surgical procedure was standardized: 3 ports, mesh type (Parietex™ Composite mesh, Covidien, France), fixation with non-absorbable transfascial sutures, and tackers. Complications were evaluated. RESULTS: Out of 79 patients (29 men, 50 women), 43 had umbilical and 36 had ventral hernias. Mean age was 52.4 years, and mean BMI was 40.83 kg/m(2). Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by visual analog scale was 2.86. No intraoperative complications or deaths occurred. Seven postoperative complications occurred (8.86%): two parietal wall hematomas treated by radiological embolization, two significant cases of postoperative pain, one postoperative obstruction, one spontaneously resolved respiratory failure, and one early (day 1) parietal wall defect with immediate reoperation. Postoperative seroma rate was 26.58% (21 patients, all of whom were treated conservatively). Postoperative follow-up was 18.10 months (1-84 months), and recurrence rate was 3.8% (3 patients). DISCUSSION: This study confirms the feasibility and safety of the laparoscopic approach for ventral hernias in morbidly obese patients. Recurrence rates (3.8%) appeared lower than the ones observed in the literature (15-25%). Postoperative hemorrhage and port-site hernia are specific complications of this approach. Postoperative hospital stay is low (2 days) as compared to open surgery. Laparoscopic management of parietal wall defects should be considered a standard option in morbidly obese patients.

Innovations in minimally invasive surgery: lessons learned from translational animal models.

PURPOSE: Animal models are key elements of surgical research and promotion of new techniques. Inanimate models, anatomical specimens, and living animals are all necessary to solve the various problems encountered by the advent of a new surgical technique. The development of Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedures is a representative model. METHODS: Over 400 experimental procedures were performed in inanimate models, ex vivo tissues and animals to solve all problems faced by the development of NOTES surgery: peritoneal access, gastrotomy closure, exposure, retraction, dissection as well as education to start this new procedure. RESULTS: The successive use of all models allows to identify the ideal solution for each problem and to precisely define the safest and most reliable option to apply the new technique in patients. It allowed to perform the first transvaginal and transgastric cholecystectomy in patients in a safe way. CONCLUSION: Animal experimentation remains necessary as even sophisticated computer-based solutions are unable to model all interactions between molecules, cells, tissues, organisms, and their environment. Animal research is required in many areas to validate new technologies, develop training, let alone its major goal (namely to avoid using patients for experimentation) which is to be the first "model" for the surgeon.

PerFix™ plug versus 4DDOME(®) implants for inguinal hernia repair: prospective multicentric randomised controlled trial.

INTRODUCTION: Anterior mesh placement is the standard of care for hernia repair. The use of partially absorbable meshes may limit post-operative pain without altering the durability of the repair. We designed a prospective randomised study, which aims to compare the PerFix™ plug to the 4DDOME(®), a partially absorbable mesh. MATERIALS AND METHODS: Inguinal hernia patients were prospectively and randomly included in the study. Hernia repair was performed using either the PerFix™ plug (Davol) or the 4DDOME(®) implant (Cousin Biotech). Operative evaluation included type and duration of anaesthesia, characteristics of the incision, post-operative hospital stay and pain evaluated through a visual analogue scale (VAS) at day 1, day 8, month 1, month 6, and year 1. Return to personal or professional activity was evaluated. Quality of life was measured by a SF36 questionnaire at 1, 6, and 12 months' follow-up. RESULTS: Ninety-five patients were prospectively enrolled and randomised to one type of prosthetic repair. The two groups of patients did not differ in terms of clinical characteristics, type of hernia, and intra-operative course. When comparing PerFix™ plug to 4DDOME(®) groups, the post-operative course was similar: pain (VAS 3.42 (SD 1.83) vs. 3.82 (SD 2.0), p = 0.69); in-hospital stay (2.12 (SD 1.36) vs. 2.25 (SD 1.62), p = 0.67); and return to personal (9.39 days (SD 8.15) vs. 9.48 days (SD 11.68), p = 0.96) and professional activity (25.71 days (SD 17.47) vs. 22.82 days (SD 18.10), p = 0.62). Post-operative pain and discomfort assessed by the SF36 questionnaire at day 8, months 1, 6, and 12 were similar, but significantly lower after 4DDOME(®) repair at 3 months for "pain" (p = 0.021) and at 6 months for "health" criteria (p = 0.028). CONCLUSION: This clinical study demonstrated similar short-term results. The 4DDOME(®) was associated with less pain and discomfort after 3 and 6 months. The combination of the dome shape and the double component mesh including an absorbable part meet the conflicting demands of early strength with a long-term low-weight material to minimise shrinkage and fibrosis. This design represents a potential advance in anterior tension-free hernia repair with mesh.

Video. Repeated transvaginal notes: is it possible?

PURPOSE: Transvaginal surgery has been performed by gynecologists for decades with abundant literature supporting its efficacy and safety. Recently, several groups reported on the NOTES transvaginal (TV) approach for extrapelvic disease. Nevertheless, repeated TV access for NOTES has never been reported to date. Two cases of "repeated" TV access for NOTES cholecystectomy after TV hybrid sleeve gastrectomy are described. METHODS: Two women, aged 57 and 32 years, developed symptomatic cholelithiasis respectively 6 and 8 months after TV sleeve gastrectomy for morbid obesity. Sleeve gastrectomy: a 2-cm posterior colpotomy was performed under laparoscopic control between the uterosacral ligaments. A double-channel endoscope and a 60-cm-long laparoscopic grasper were introduced transvaginally. Two abdominal ports were placed to allow the introduction of the stapling device and to assist during the procedure. An intragastric endoscope served to expose the stomach and to calibrate the gastric sleeve, which was performed in the standard fashion. Colpotomy was closed by separate 3/0 Vicryl stitches. At cholecystectomy, an exploratory laparoscopy ascertained the feasibility of a NOTES cholecystectomy. The posterior vaginal vault was carefully examined before regaining peritoneal access with the technique described above. Cholecystectomy was performed by using a double-channel endoscope introduced TV and a 5-mm transabdominal port. Follow-up consisted of 3 and 6 months pelvic examination and interview, which included sexual function assessment by sexual function questionnaire (SFQ31). RESULTS: Both operations were performed successfully with no intraoperative or postoperative complications. At cholecystectomy, minimal pelvic adhesions were found with no vaginal scarring at the colpotomy site. No bleeding, pain, or vaginal infection occurred after both procedures. Patients resumed sexual activity 5.2 weeks postoperatively with a consistently normal SFQ31. CONCLUSIONS: This report suggests that, in experienced hands, repeated TV access for extrapelvic surgery is possible and safe, putting forward the intriguing promises of less adhesions formation.

[Peripheral neuropathies after bariatric surgery]. / Polyneuropathies après chirurgie bariatrique.

INTRODUCTION: Peripheral neuropathies sometimes complicate bariatric surgery. PATIENTS AND METHODS: We report the detailed clinical, electrophysiological, biological and histological characteristics of five patients who developed peripheral neuropathy after bariatric surgery. RESULTS: Three patients presented with small fiber neuropathy, one presented with axonal polyneuropathy, and one with demyelinating polyradiculoneuropathy. All patients had in common prominent neuropathic pain, massive weight loss, and multiple nutritional deficiencies. The pathophysiology of postbariatric surgery polyneuropathies is complex and involves nutritional, infectious and dysimmune mechanisms. CONCLUSION: The spectrum of peripheral neuropathies complicating bariatric surgery is wide, and includes pure small fiber neuropathy, axonal polyneuropathy, and demyelinating polyradiculoneuropathy. Treatment is mainly preventive, but sometimes surgical revision is needed.

The new 4DDome prosthesis: an original light and partially absorbable composite mesh for hernia repair.

INTRODUCTION: The use of non-absorbable meshes for the repair of inguinal hernias has become standard; however, these meshes have been associated with complications including long-term postoperative pain. To this end, a new partially absorbable composite mesh has been developed, and the aim of this study was to investigate its efficacy in animal and human trials. MATERIALS AND METHODS: Sixty male Wistar rats were used to evaluate the behavior of the newly designed composite mesh. Composite meshes were implanted in the extra-peritoneal plane for 2, 4 and 8 weeks and compared to a standard polypropylene mesh. Forty patients with symptomatic inguinal hernias were treated using a new 4DDome designed prosthesis. Follow-up was by clinical and ultrasound examination at 1, 6 and 12 months. RESULTS: The animal study demonstrated that the inflammatory reaction associated with the new composite mesh was significantly lower than a standard polypropylene mesh, characterized by a lower macrophage infiltrate (P < 0.001). The mesh did not shrink over the 8-week period, unlike the polypropylene mesh (P < 0.05). The human study showed that there were three minor postoperative complications, no recurrences and the mesh was well tolerated. Follow-up with serial ultrasound showed that at 10 days and 1 month the dome was clearly visible in position; however, by 6 months it had flattened out, been partially absorbed and become incorporated into the repair. CONCLUSION: These experimental and clinical studies have validated the concept of the new 4DDome composite mesh. It was well tolerated and was associated with good short-term results. The combination of the dome shape and the new composite mesh means that less polypropylene is required and represents a significant advance in anterior hernia repair.

Two-stage totally minimally invasive approach for acute complicated diverticulitis.

OBJECTIVES: Surgical options for acute diverticulitis with peritonitis include Hartmann's procedure or resection and primary anastomosis with or without a stoma. Initial laparoscopic lavage and drainage can control the acute intra-abdominal sepsis to allow for a delayed definitive procedure in nonemergency conditions. Potential advantages include the avoidance of a laparotomy, stoma and local infections at the origin of dehiscence and incisional hernias. We evaluated this approach in a selected group of patients. METHODS: Patients with intra-abdominal pus secondary to diverticular perforation requiring surgery were included in the study. Patients with localized pus amenable to computerized tomography (CT)-guided drainage, faecal peritonitis, severe generalized peritonitis, and those in which the perforation was spontaneously visible were excluded. Standard demographic data, CT findings, intra-operative findings and postoperative outcomes were analysed. RESULTS: Ten patients were suitable for the approach. Mean patient age was 60.2 years. Mean body mass index was 28.2 m2/kg. Mean postoperative stay was 8.5 days and uneventful in all patients. One patient re-presented after 3 weeks with acute peritonitis requiring open sigmoidectomy. Six patients successfully underwent laparoscopic sigmoidectomy with primary anastomosis 2-3 months later. Two patients were not re-operated because of comorbidity and one refused surgery. CONCLUSIONS: A two-stage totally minimally invasive approach may be a safe alternative strategy for selected cases of acute complicated diverticulitis.

A difficult case of mediastinal parathyroid adenoma: theoretical and clinical considerations.

About one quarter of patients with primary hyperparathyroidism have ectopic parathyroid tissue. The majority of parathyroid glands can be reached through a cervical approach, but in about 2% of the cases the ectopic gland is in the mediastinum in a location that requires a thoracic approach. Failure to remove ectopic mediastinal parathyroid tissue results in persistent hyperparathyroidism. Reoperative exploration for persistent hyperparathyroidism is often difficult even in the hands of experienced surgeons. Recent advances in preoperative localization techniques and intraoperative parathyroid hormone measurement have improved the rates of successful resection. We present a difficult case of persistent hyperparathyroidism secondary to an ectopic middle mediastinal parathyroid adenoma, which was eventually successfully managed in a specialised unit.

Sarcoma of the thyroid gland: a case report.

Sarcoma of the thyroid gland is a very uncommon malignant tumor (<1% of thyroid cancers) characterized by severe local course and rapid metastatic dissemination and very poor prognosis. We report the case of an 84-year-old woman hospitalized for expiratory dyspnea, severe malnutrition and swallowing disorders leading to bronchial infection. She had a voluminous (20 cm) extra-thoracic right-neck goiter with a considerable superficial venous pattern that had developed on an old goiter before growing recently. CEA and calcitonin levels were normal. The cervical-thoracic CT demonstrated a partially necrosed heterogeneously hypodense tumor compressing the esophagus and the trachea with displacement of adjacent structures which were not directly invaded. Large areas of necrosis and a probable metastatic image measuring 3 cm in the right median pulmonary lobe were observed. Macrobiopsy disclosed grade 3 sarcoma. Complete resection delivered a 3.170 kg tumor. Histology confirmed the diagnosis of sarcoma without neoplastic extension. Apart from right recurrent palsy, the initial post-operative period was satisfactory and the patient was discharged. Four and a half months later she was rehospitalized with local recurrence with a large metastatis in the right lung. She died two weeks later.

Safety of laparoscopic approach for acute cholecystitis: retrospective study of 609 cases.

Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.

Virtual university applied to telesurgery: from teleeducation to telemanipulation.

UNLABELLED: PROBLEM/BACKGROUND: In order to improve patient care by minimal invasive surgery (MIS), we perfected a Virtual TeleSurgical University that allows for teleeducation, teleconcertation, surgical planning and telemanipulation, through new Virtual Reality and multimedia systems. TOOLS AND METHODS: The organization of this innovative school was federated around three major research programs. First, the TESUS program focused on the teletransmission of medical information, allowing for videoconferencing around the world and telementoring. Next, the WeBS-Surg program is a multimedia continuous surgical education system on internet, that allows for teleeducation and teleconcertation between world experts in MIS. Then, the MASTER program (Minimal Access Surgery by Telecommunications and Robotics) allowed the development of the third millenium Operating room. It included Virtual Reality systems that delineate automatically anatomical and pathological structures of a patients from him CT-scan, and that allow for an interactive surgical planning and force-feed-back simulation. It also included a telesurgical robot named Zeus controlled by surgeons through telemanipulation system. RESULTS: Tests and validation shows that all these systems improved all steps of the surgical procedure: preoperatively due to a better continuous education and a computer assisted surgical planning, and peroperatively due to teleconcertation, telementoring and telemanipulation systems. CONCLUSION: Revolutionary tools for minimal invasive surgery learning, planning and performing are all ready available. These tools represents the first prototype of the computer assisted tele-robotical surgery that will be the future of surgery.

An evaluation of telemedicine in surgery: telediagnosis compared with direct diagnosis.

HYPOTHESIS: Telemedicine for real-time transmission of clinical documents and interactive remote telediagnosis allows accurate clinical application in surgery. DESIGN: Prospective cohort study in which 2 hospitals, 120 miles apart, were connected via integrated services digital network (ISDN) teleconferencing units, and each evaluated clinical cases in real time. SETTING: A tertiary care university hospital and primary care county hospital. PARTICIPANTS: Between May 1, 1998, and June 30, 1998, 112 patients undergoing digestive or endocrine surgery were evaluated by teletransmission (study group) and direct vision (control group). Diagnosis had to be known by the viewer, and either conventional magnetic resonance imaging or computed tomographic scans were available. MAIN OUTCOME MEASURES: Picture quality, organ structure, and pathologic finding viewed on telemedicine documents were evaluated by radiologists and surgeons blind to diagnosis. Accuracy of remote 128-kilobit (kb)/s transmission-rate diagnoses and results were compared with those obtained directly. RESULTS: Picture quality was "good" or "excellent" in 92.9% of transmitted documents and 95.5% of live images (P>.4). The target organ was always recognized, structure and pathologic finding were analyzable in 98.2% of transmitted documents and 99.1% of live documents, and fine structures were assessable in 89.3% of transmitted pictures and 95.5% of live pictures (P>.05). Diagnosis was made in 84.8% of transmitted cases and 93.8% of live cases (P = .02). CONCLUSIONS: Low bandwidth (128 kb/s) telemedicine application in surgery is reliable in evaluating remote cases. Loss of image quality through teletransmission occurred in 2.7% of cases, and diagnosis was not possible in 15.2% of transmitted vs 6.2% of live cases, suggesting factors other than technical quality (choice of radiological studies, additional clinical information required, etc). This underscores the importance of real-time interactive discussion during surgical teleconferences.

Assessment of telemedicine in surgical education and patient care.

OBJECTIVE: To analyze the value of teleconferencing for patient care and surgical education by assessing the activity of an international academic network. SUMMARY BACKGROUND DATA: The uses of telemedicine include teleeducation, training, and consulting, and surgical teams are now involved, sharing diagnostic information and opinions without the need for travel. However, the value of telematics in surgery remains to be assessed. METHODS: During a 2-year period, weekly surgical teleconferences were held among six university hospitals in four European countries. To assess the accuracy of telediagnosis for surgical cases, 60 randomly selected cases were analyzed by a panel of surgeons. Participants' opinions were analyzed by questionnaire. RESULTS: Seventy teleconferences (50 lectures and 271 case presentations) were held. Ninety-five of the 114 participants (83.3%) completed the final questionnaire. Eighty-six percent rated the surgical activity as good or excellent, 75.7% rated the scientific level as good or excellent, 55.8% rated the daily clinical activity as good or excellent, and 28.4% rated the manual surgical technique as good or excellent. The target organ was identified in all the cases; the organ structure and pathology were considered well defined in 93.3%, and the fine structure was considered well defined in 58.3%. Diagnosis was accurate in 17 cases (28.3%), probable in 25 (41.7%), possible but uncertain in 16 (26.7%), and not possible in 2 cases (3.3%). Discussion among the remote sites increased the rate of valuable therapeutic advice from 55% of cases before the discussion to 95% after the discussion. Eighty-six percent of the surgeons expressed satisfaction with telematics for medical education and patient care. CONCLUSIONS: Participant satisfaction was high, transmission of clinical documents was accurate, and the opportunity to discuss case documentation and management significantly improved diagnostic potential, resulting in an accuracy rate of up to 95%. Teleeducation and teleconsultation in surgery appear to be beneficial.

[The Virtual University applied to telesurgery: from tele-education to tele-manipulation]. / L'Université Virtuelle appliquée à la téléchirurgie: de la télé-éducation à la télé-manipulation.

The advent of new computer technologies appears as a revolution of surgical teaching, as well as the planning and realisation of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of miniaturised camera constitutes the greatest alteration that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution was announces further changes: the development of telecommunication devices applied to medicine (tele-education, teletraining, telementoring, teleproctoring and tele-accreditation) constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of telepresence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery of Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realisation of international multi-site video conferences between surgeons. The WEBS project created the first Virtual University concept placing surgical techniques at the surgeon's disposal through Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows to develop the concept of distant telemanipulation. It is now possible to face surgical teaching outside of the restricted University frame and to conceive teaching on a world level, offering to the practitioner unimaginable possibilities of formation, training and planning of surgical procedures.

[The virtual university applied to telesurgery: from tele-education to telemanipulation]. / L'université virtuelle appliquée à la téléchirurgie: de la télé-éducation à la télé-manipulation.

The advent of new computer technologies can appear as a revolution in surgical teaching, as well as in the planing and realization of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of a miniaturized camera, constitutes the greatest change that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution also predicts further changes: the development of telecommunication devices applied to medicine (tele-education, tele-training, tele-mentoring, tele-proctoring and tele-accreditation), constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of tele-presence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery at Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realization of international multi-site video conferences between surgeons. The WEBS project created the first virtual university concept by placing surgical techniques at the surgeon's disposal through the Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows the development of the concept of distant telemanipulation. It is now possible to face surgical teaching outside of the restricted University framework, and to conceive teaching on a world-wide level, offering the practitioner unimaginable possibilities of formation, training and the planning of surgical procedures.