Antireflux surgery.

Gastro-oesophageal reflux disease is extremely common throughout Europe and the United States. This review on antireflux surgery examines the best evidence for surgical treatment of gastro-esophageal reflux disease. Comparison is made with medical antireflux therapy including histamine H2 receptor antagonist and proton pump inhibitor therapy. The randomized trials and systematic reviews available on gastro-esophageal reflux disease are reviewed and where data are scarce, the largest cohort studies available are discussed. Overall, laparoscopic antireflux surgery is safe and has a similar efficacy to open antireflux surgery and best medical therapy with proton pump inhibitors. There is a failure rate, which in some series is greater than 50% at 5 years. Due to the cost of a proportion of patients still taking antireflux medications, it cannot be recommended on cost-effectiveness grounds over best medical therapy. The choice of procedure lies between complete wrap with Nissen's fundoplication and partial fundoplication (most frequently Toupet). Division of the short gastric vessels is not usually necessary and is associated with increased wind-related complications. Total fundoplication tends to produce superior reflux control, but at the cost of increased risk of dysphagia. There is a trend for antireflux surgery to be superior to best medical therapy in cancer prevention in Barrett's oesophagus, but this has not reached statistical significance.

Assessing surgical skill using bench station models.

BACKGROUND: The acquisition of surgical skill is one of the essentials of good surgical practice. The training of plastic surgeons is presently unstructured, with few objective measures of surgical skill. The trainee's time to acquire skills may be inadequate because of the shortened time for training with the Calman system. There is also increasing pressure from the government to introduce testing of surgical competency for all surgeons. The authors introduce a series of tasks that allow assessment of technical skill among plastic surgical trainees. METHODS: A range of surgeons with differing surgical skill were tested. They performed three tasks designed to assess their ability to suture skin, take a medium-thickness skin graft, and repair a tendon. The candidates were videotaped during the procedures and scored by four independent observers using the Objective Structured Assessment of Technical Skill scoring system. Each candidate was then given an overall competence score. RESULTS: Sixty-five candidates were tested with an experience range from consultant to junior senior health officer. Results showed significant differences down the grades, with consultants performing the tasks with greater competency than their juniors (p = 0.004). CONCLUSIONS: The authors have demonstrated a valid and reliable method of objectively measuring the surgical skill of plastic surgical trainees. The authors have shown that consultants perform better than the juniors and that the tasks are easily reproduced. This has implications for future assessment in that these tests may be used as formal assessment programs for testing and teaching trainees throughout their careers.

Measurement of surgical dexterity using motion analysis of simple bench tasks.

The possibility of using quantitative motion analysis for objective assessment of simple surgical dexterity is investigated using the Imperial College Surgical Assessment Device (ICSAD) with qualitative analysis undertaken by inspection. Bench-top knot tying and suturing skills were performed and examined for the ability to discriminate between surgeons of varying experience. These exercises were found to discriminate significantly between junior and senior surgeons in terms of both time taken and the number of movements required. The relation between time and motion was found to be variable depending on what skill was being undertaken: simple suturing, suturing at depth, or knot tying (1.71 vs. 1.86 vs. 2.36; p = 0.002 for 1 vs. 2; p < 0.001 for others). When the number of movements in a minute (standardized movements per minute) were considered, both groups were found to work at a similar rate, depending on the task, implying that the more experienced surgeon is more economical, performing the same exercise with fewer moves rather than with higher speed. Motion analysis exhibits face and construct validity and is a reliable assessment of simple surgical dexterity. Its use for objective assessment of dexterity and competence should be encouraged.

Laboratory-based validation of a novel suture technique for wound closure.

Wound closure in open surgery is a fundamental skill acquired early during the surgeon's career. Individual modifications are adopted frequently by the more experienced surgeon in an effort to increase efficiency. To date, there has been no objective measurement regarding whether these modifications significantly impact economy of movement or procedure time. The advent of the Imperial College Surgical Assessment Device (ICSAD) allows standardized, objective evaluation of a novel suture technique for wound closure (study group) developed by one of the senior authors (DBH) and compares the technique to the current method taught by the Royal College of Surgeons of Great Britain and Ireland (control group). Ten surgical registrars underwent both tasks in a standardized manner for five repetitions. Mean total movements and duration of procedure were decreased significantly for the study group (analysis of variance: = 0.018 and = 0.033 respectively) with an economy index (total movements/total time) of 0.79 movements per second for the control group vs. 0.67 for the study group. This study demonstrates ICSAD's usefulness in defining a novel suture technique as a more efficient method of cutaneous closure than the currently advocated technique.