The impact of intensive laparoscopic training course with structured assessment and immediate feedback on residents' operative performance in animal lab.

INTRODUCTION: The objective of this study was to examine the impact of an intensive laparoscopic training course incorporating structured assessment and immediate feedback on residents' operative performance in animal lab. METHODS: Surgical residents participated in a 2-day intensive laparoscopic training course. They performed the same procedures on two consecutive days on live pigs. Junior residents (PGY1-2) performed laparoscopic cholecystectomy and incisional hernia repair and the senior residents (PGY3-5) performed laparoscopic Nissen fundoplication, splenectomy, and low anterior colon resection. Assessment tools with proven validity evidence (global and procedure-specific rating tools for operative assessment of laparoscopic skills) were used to assess their operative performance. Faculty assessment and self-assessments were completed immediately after each procedure on both days. The Wilcoxon rank test was used to examine the effect of training on resident performance after one repetition. RESULTS: Forty surgical residents (20 junior and 20 senior residents) participated. There was a significant improvement in general laparoscopic skills during incisional hernia repair and Nissen fundoplication using global rating scales (p < 0.05). Moreover, there was an improvement in their performance during cholecystectomy, incisional hernia repair, and low anterior colectomy when procedure-specific skills assessments were used (p < 0.05). There was a positive correlation between residents' self-reported confidences and their operative performance CONCLUSION: Trainees showed significant improvements in performance in general and procedure-specific laparoscopic skills in a wide range of procedures after an intensive training course. This study demonstrates the benefit of a structured training curriculum in improving operative performance in basic and advanced laparoscopic skills in a simulated environment. Future studies are needed to examine the duration of training required to achieve skill retention and competency.

Laparoscopic aneurysm resection and splenectomy for splenic artery aneurysm in the third trimester of pregnancy.

BACKGROUND: Splenic artery aneurysms (SAA) are a rare entity most commonly diagnosed incidentally. Their association with pregnancy increases the risk of rupture resulting in a disproportionately high maternal and fetal mortality. Accordingly, elective surgical treatment is recommended in asymptomatic patients with aneurysms less than 2 cm. In this case, we present a patient during her third trimester of pregnancy with a SAA who was treated by laparoscopic aneurysm resection and splenectomy. METHODS: The patient is a 38-year-old multiparous woman, with an incidental diagnosis of a SAA in 2010. Subsequently, the patient became pregnant and at 27 weeks started to develop abdominal pain. Failed embolization was attempted with worsening of the patient's symptoms. A CT angiogram revealed a 1.6 cm distal third SAA without any evidence of rupture. Due to the localization of the lesion, the patient was offered a laparoscopic aneurysm resection and splenectomy. RESULTS: Operating time was 90 min and estimated blood loss was 5 cc. Postoperative fetal monitoring was normal. No perioperative complications were observed. The patient was discharged on postoperative day 3. Two months after laparoscopic splenectomy, the patient delivered a male infant in perfect health. CONCLUSIONS: Although this is a rare disease, the risk of aneurysmal rupture is increased during pregnancy. As a result of high maternal and fetal mortality, elective surgery should be performed. Laparoscopic surgery is the technique of choice.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BACKGROUND: Preoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial. METHODS: A retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016. RESULTS: Two hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m2. Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett's esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p  =   < 0.0001) and symptoms were a poor indicator for GERD. CONCLUSIONS: Preoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

[Liver resection in Privado Hospital's general surgery department: 13-year-experience liver resections]. / Resecciones hepáticas en el servicio de cirugía general del hospital privado: 13 años de experiencia resecciones hepáticas.

BACKGROUND: Liver resection constitutes the treatment of choice in the liver primary neoplasms and some cases of metastatic tumors, but entail significant morbidity and mortality rates. OBJECTIVE: To present our experience in hepatic surgery. MATERIAL AND METHODS: We included 40 patients who underwent hepatectomies in our Institution from December 1991 through December 2004. The information was collected retrospectively and was analized descriptive and statistically. RESULTS: 40 patients underwent 40 hepatectomies. The diagnosis included primary benign hepatic disease (n= 9, 22.5%), primary hepatic malignancy (n= 7, 17.5%) and metastatic hepatic disease (n= 24, 60%). In the metastatic group, the most frecuent pathology was colonic adenocarcinoma (n= 17, 42%). There were 4 perioperatory deaths (10%) and the average hospitaly stay was 10.8 days. CONCLUSIONS: our data shows that the most frequent indication of hepatic resection in our experience was metastatic colonic adenocarcinoma as compared to the other Institutions with similar experience.

Robotic-Assisted Paraesophageal Hernia Repair: Initial Experience at a Single Institution.

BACKGROUND: Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with a significant learning curve. Data about the safety and utility of the robotically assisted paraesophageal hernia repair (RA-PEHR) are scarce. The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH. MATERIALS AND METHODS: Between June 2010 and December 2015, patients who underwent elective RA-PEHR were included in a prospectively collected database. Demographic data, American Society of Anesthesiologists (ASA) classification, preoperative testing, operative time (OT), length of hospital stay (LOS), conversion rate, morbidity, and mortality were recorded and reviewed retrospectively. RESULTS: Sixty-one patients underwent RA-PEHR with mesh, 72% were female (mean age of 63 and mean body mass index [BMI] of 30). ASA classification was 2.6 (57% of patients had an ASA III). With respect to the type of the hernia, the preoperative diagnosis was: Type II 26%, III 64%, and IV 13%. OT averaged 186 minutes (88-360), including robot setup time. After the 16th case, OT significantly decreased by 4.09 minutes (P = .01). There were no conversions. The average blood loss was 51 mL. Perioperative complications, including intraoperative and 30-day complications, were 6% and 23%, respectively. The mean length of hospitalization was 2.6 (1-18) days. There were no deaths. Forty patients (66%) were available for follow-up, and length of follow-up was 17 ± 15 months. Anatomic recurrence was observed in 42% of patients and only 23% of patients were symptomatic. CONCLUSIONS: This report represents the largest series to date of RA-PEHR. RA-PEHR has proved to be feasible and safe with a learning curve comparable to the standard laparoscopic approach.

Multipurpose internal retractor for Single-incision surgery (SIS): single-institution case series.

Single-incision laparoscopic surgery (SIS) is less invasive than standard laparoscopic surgery; however, it is more difficult due to restriction of motion and the impossibility to use assistants. To overcome these obstacles, we developed a self-sustaining multipurpose internal retractor by attaching a Lone Star retractor hook to a laparoscopic bulldog clamp. Herein, we report our SIS experience using our novel retractor. Between October 2008 and April 2011, 104 patients underwent SIS using the internal retractor: 67 bandings (43% simultaneous hiatal hernia repair), 8 sleeve gastrectomies, 27 cholecystectomies, and 2 Nissen fundoplication. Mean age was 40 (range, 21 to 85) and mean body mass index was 40 kg/m (range, 20 to 64 kg/m). No intraoperative complications were observed from the use of the retractor but 2 cases required additional retraction due to liver size. This retractor has been successfully used for different SIS procedures showing to be safe, adaptable, and easy to use, lessening some challenges of SIS.

Preservation of pancreas graft function after complete venous thrombosis: report of four cases treated conservatively.

BACKGROUND: Pancreas graft thrombosis is the most common cause of technical graft failure, with an incidence of up to 20% is some series. In most instances, vascular thrombosis of the graft will require immediate removal to avoid further abdominal complications. We present a total of four cases of complete venous thrombosis with preservation of function that were managed conservatively, resulting in long-term graft function. METHODS: Retrospective analysis of our case series over 10 years was carried out, obtaining patients with complete graft thrombosis by Doppler ultrasound. We included in the study only those patients who remained asymptomatic with preserved graft function. The clinical status of the patients, radiological findings, and therapeutic approach are evaluated. Patient and graft outcomes are analyzed. RESULTS: Retrospective evaluation of 227 transplants, a total of four patients were found to have complete thrombosis of the graft, remaining asymptomatic and preserving function without complications. Graft thrombosis was found on routine Doppler ultrasound evaluation of the transplanted organs at a median time of 19 days (range, 11-28 days), angiographic confirmation was obtained in all cases. The clinical condition and the presence of collateral flow allowed for conservative treatment. Median hospital stay was 29 days (range, 16-38 days), with a median follow-up of 106 months (range, 24-110 months), all patients are alive with a functioning graft. CONCLUSIONS: In rare instances with complete thrombosis of the pancreas transplant in absence of clinical manifestations, the grafts can be closely monitored and treated with systemic anticoagulation, allowing long-term patient and graft survival.

Reseccionea hepáticas en el servicio de cirugía general del Hospital Privado: 13 años de experiencia resecciones hepátidas / Liver resection in hospital privado's general surgery department: 13- year experience liver resections

Las resecciones hepáticas constituyen el tratamiento de elección en las neoplasias hepáticas primárias y en algunos casos de tumores metastáticos, pero conllevan tasas significativas de morbilidad y mortalidad. Objetivo: Presentar nuestra experiencia en cirurgías hepáticas. Material y método: Se incluyeron 40 paciente sometidos a hepatectomías en nuestra Institución desde diciembre de 1991 a diciembre de 2004. Los datos fueron recolectados en forma retrospectiva y analizados mediante método estadístico descriptivo. Resultados: Los diagnósticos incluyeron enfermedades hepáticas primarias benignas (n=9, 22.5%) y malígnas (n=7, 17.5%) y enfermedades hepáticas metastásicas (n=24, 60%). Dentro de las metástasis, la más frecuente fue el adenocarcinoma de colon (n=7, 17.42%). El índice de complicaciones quirúrgicas inmediatas fue del 55% (n=22). Hubo 4 muertees peri-operatorias (10%) y la tasa promedio de estadía hospitalaria fue de 10,8 días. Conclusiones: Nuestros hallazgos demostraron que la indicación más frecuentes de resección hepática en nuestra experiencia es las metástasis de adenocarcinoma de colon y que los resultados observado en nuestra serie son comparables a los obtenidos por otras Instituciones a nivel mundial con similar flujo de pacientes.

Liver resection constitutes the treatment of choice in the liver primary neoplasms and some cases of metastatic tumors, but entail significant morbidity and mortality rates. OBJECTIVE: To present our experience in hepatic surgery. MATERIAL AND METHODS: We included 40 patients who underwent hepatectomies in our Institution from December 1991 through December 2004. The information was collected retrospectively and was analized descriptive and statistically. RESULTS: 40 patients underwent 40 hepatectomies. The diagnosis included primary benign hepatic disease (n= 9, 22.5%), primary hepatic malignancy (n= 7, 17.5%) and metastatic hepatic disease (n= 24, 60%). In the metastatic group, the most frecuent pathology was colonic adenocarcinoma (n= 17, 42%). There were 4 perioperatory deaths (10%) and the average hospitaly stay was 10.8 days. CONCLUSIONS: our data shows that the most frequent indication of hepatic resection in our experience was metastatic colonic adenocarcinoma as compared to the other Institutions with similar experience.