A prospective, multicenter trial of a long-term bioabsorbable mesh with Sepra technology in cohort of challenging laparoscopic ventral or incisional hernia repairs (ATLAS trial).

BACKGROUND: This prospective, multicenter, single-arm, open-label study evaluated P4HB-ST mesh in laparoscopic ventral or incisional hernia repair (LVIHR) in patients with Class I (clean) wounds at high risk for Surgical Site Occurrence (SSO). METHODS: Primary endpoint was SSO requiring intervention <45 days. Secondary endpoints included: surgical procedure time, length of stay, SSO >45 days, hernia recurrence, device-related adverse events, reoperation, and Quality of Life at 1, 3, 6, 12, 18, and 24-months. RESULTS: 120 patients (52.5% male), mean age of 55.0 ± 14.9 years, and BMI of 33.2 ± 4.5 kg/m2 received P4HB-ST mesh. Patient-reported comorbid conditions included: obesity (86.7%), active smoker (45.0%), COPD (5.0%), diabetes (16.7%), immunosuppression (2.5%), coronary artery disease (7.5%), chronic corticosteroid use (2.5%), hypoalbuminemia (0.8%), advanced age (10.0%), and renal insufficiency (0.8%). Hernia types were primary ventral (44.2%), primary incisional (37.5%), recurrent ventral (5.8%), and recurrent incisional (12.5%). Patients underwent LVIHR in laparoscopic (55.8%) or robotic-assisted cases (44.2%), mean defect size 15.7 ± 28.3 cm2, mean procedure time 85.9 ± 43.0 min, and mean length of stay 1.0 ± 1.4 days. There were no SSOs requiring intervention beyond 45 days, n = 38 (31.7%) recurrences, n = 22 (18.3%) reoperations, and n = 2 (1.7%) device-related adverse events (excluding recurrence). CONCLUSION: P4HB-ST mesh demonstrated low rates of SSO and device-related complications, with improved quality of life scores, and reoperation rate comparable to other published studies. Recurrence rate was higher than expected at 31.7%. However, when analyzed by hernia defect size, recurrence was disproportionately high in defects ≥7.1 cm2 (43.3%) compared to defects <7.1 cm2 (18.6%). Thus, in LVIHR, P4HB-ST may be better suited for small defects. Caution is warranted when utilizing P4HB-ST in laparoscopic IPOM repair of larger defects until additional studies can further investigate outcomes.

Intraoperative Blood Pressure Lability Is Associated with Postoperative Hemorrhage after Uncomplicated Bariatric Surgery.

BACKGROUND: Postoperative hemorrhage is a rare complication in bariatric surgery. We aim to determine if differences in blood pressure or perioperative medication administration contribute to postoperative bleeding in patients who were hemodynamically stable intraoperatively. METHODS: This was a retrospective case-control study of all bariatric surgery patients from 2014 to 2017 at a high volume academic center. We identified controls based on age, gender, ethnicity, type of procedure, and pre-operative blood pressure. RESULTS: Patients with postoperative hemorrhage had a significantly lower MAP during the portion of the surgery in which the abdominal contents were inspected for leaks and bleeds. The timing of enoxaparin or ketorolac administration was not associated with bleeding. CONCLUSION: Blood pressure lability, but not enoxaparin or ketorolac administration, is associated with postoperative hemorrhage.

Safety and Feasibility of a Lower-Cost Stapler in Bariatric Surgery.

BACKGROUND: Laparoscopic staplers are integral to bariatric surgery. Their pricing significantly impacts the overall cost of procedures. An independent device company has designed a stapler handle and single-use reloads for cross-compatibility and equivalency with existing manufacturers, at a lower cost. OBJECTIVES: We aim to demonstrate non-inferior function and cross-compatibility of a newly introduced stapler handle and reloads compared to our institution's current stapling system in a large animal survival study. SETTING: University-affiliated animal research facility, USA. METHODS: Matched small bowel anastomoses were created in four pigs, one with each stapler (a total of two per animal). After 14 days, investigators blinded to stapler type evaluated the anastomoses grossly and microscopically. Each anastomosis was scored on multiple measures of healing. Individual parameters were added for a global "healing score." RESULTS: Clinical stapler function and gross quality of anastomoses were similar between stapler groups. Individual scores for anastomotic ulceration, reepithelialization, granulation tissue, mural healing, eosinophilic infiltration, serosal inflammation, and microscopic adherences were also statistically similar. The mean "healing scores" were equal. While this study was underpowered for subtle differences, safe and reliable performance in large animals still supports the feasibility of introducing new devices into human use. CONCLUSIONS: The new stapler system delivers a similar technical performance and is cross-compatible with currently marketed stapling devices. An equivalent quality device at a lower price point should enable case cost reduction, helping to maintain hospital case margin and procedure value in the face of potentially declining reimbursement. This device may provide a safe and functional alternative to currently used laparoscopic surgical staplers.

Gallbladder Agenesis: A Case Report.

Gallbladder agenesis (GA) is an extremely rare congenital entity. The incidence is around 1 per 6500 live births. The majority of patients, estimated between 50 to 70 percent, remain asymptomatic while those who are symptomatic report symptoms mimicking biliary colic. Initial workup for suspected gallbladder pathology such as right upper quadrant ultrasound (US) can be misleading or inconclusive. Furthermore, advanced diagnostic studies such as hepatobiliary iminodiacetic acid (HIDA) scan and endoscopic retrograde cholangio-pancreatography (ERCP) may report non-visualization of the gallbladder and erroneously lead providers to a diagnosis of cystic duct obstruction rather than GA. Consequently, some GA patients are only finally diagnosed intraoperatively. Surgery can be risky in these patients because unnecessary dissection while looking for the non-existent gallbladder can result in injury of the biliary tree, hepatic vasculature, or small bowel. Therefore, clinicians should keep GA on their differential diagnosis list and imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) should be obtained when other tests prove inconclusive. We report a 35-year-old female presenting with chronic symptoms consistent with biliary colic and an equivocal US reported as cholelithiasis. She underwent laparoscopy during which the absence of the gallbladder was noted. Postoperative MRCP confirmed the diagnosis of GA.

Impact of preoperative wait time due to insurance-mandated medically supervised diets on weight loss after sleeve gastrectomy. Are patients losing momentum?

BACKGROUND: Few studies have examined whether preoperative period length, as defined by the amount of time from enrollment in a surgical weight loss program to the day of surgery, affects postoperative weight loss. OBJECTIVES: To identify associations between preoperative period length and postoperative weight loss. SETTING: Single surgeon at an academic medical center in the United States. METHODS: Retrospective chart review in 109 consecutive patients undergoing sleeve gastrectomy from 2014-2015. RESULTS: When patients were grouped based on postoperative percentage of total weight loss, greater weight loss was associated with shorter preoperative wait time. During the preoperative period, 72.2% of our patients achieved a net weight loss, but 34.6% had gained net weight until they started the preoperative "liver-shrinking" diet; 71.4±8.3% of the total preoperative weight loss occurred after initiating the preoperative diet, which accounted for approximately 15% of the whole preoperative period length. There was no correlation between the length of the preoperative diet and preoperative weight loss. CONCLUSIONS: Shorter preoperative periods and earlier initiation of liver reduction diets may increase postoperative weight loss, although ultimately there may be a limit to the weight loss that patients can achieve while adhering to highly restrictive lifestyle modifications.

Two-Port Laparoscopic Cholecystectomy: 18 Patients Human Experience Using the Dynamic Laparoscopic NovaTract Retractor.

OBJECTIVE: The concept of reducing the number of transabdominal access ports has been criticized for violating basic tenets of traditional multiport laparoscopy. Potential benefits of reduced port surgery may include decreased pain, improved cosmesis, less hernia formation, and fewer wound complications. However, technical challenges associated with these access methods have not been adequately addressed by advancement in instrumentations. We describe our initial experience with the NovaTract™ Laparoscopic Dynamic Retractor. METHODS: A retrospective review of all patients who underwent two-port laparoscopic cholecystectomy between 2013 and 2014 using the NovaTract retractor was performed. The patients were equally divided into three groups (Group A, B, C) based on the order of case performed. RESULTS: Eighteen consecutive patients underwent successful two-port laparoscopic cholecystectomy for symptomatic cholelithiasis. Mean age was 39.9 years and mean body mass index was 28.1 kg/m(2) (range 21-39.4). Overall mean operative time was 65 minutes (range 42-105), with Group A of 70 minutes, Group B of 65 minutes, and Group C of 58 minutes (P = .58). All cases were completed laparoscopically using the retraction system, without a need for additional ports or open conversion. No intra- or postoperative complications were seen. All patients were discharged on the same day of surgery. No mortality found in this series. CONCLUSIONS: The NovaTract laparoscopic dynamic retractor is safe and easy to use, which is reflected by acceptable operative time for a laparoscopic cholecystectomy using only two ports. The system allows surgical approach to mimic the conventional laparoscopic techniques, while eliminating or reducing the number of retraction ports.

Transvaginal cholecystectomy learning curve.

BACKGROUND: There are few surgeons in the United States, within private practice and academic centers, currently performing transvaginal cholecystectomies (TVC). The lack of exposure to TVC during residency or fellowship training, coupled with a poorly defined learning curve, further limits interested surgeons who want to apply this technique to their practice. This study describes the learning curve encountered during the introduction of TVC to our academic facility. METHODS: This study is an analysis of consecutive TVCs performed between August 14, 2009 and August 3, 2012 at an academic center. The TVC patients were divided into sequential quartiles (n = 15/16). The learning curve outcome was measured as the operative time of TVC patients and compared to the operative time of female laparoscopic cholecystectomy (LC) patients performed during the same time period. RESULTS: Sixty-one patients underwent a TVC with a mean age of 38 ± 12 years and mean BMI was 29 ± 6 kg/m(2). Sixty-seven female patients who underwent a LC with average age 41 ± 15 years and average BMI 33 ± 12 kg/m(2). The average operative time of LC patients and TVC patients was 48 ± 20 and 60 ± 17 min, respectively. Significant improvement in TVC operative times was seen between the first (n = 15 TVCs) and second quartiles (p = 0.04) and stayed relatively constant for third quartile, during which there was no statistically significant difference between the mean LC operative time for the second and third TVC quartiles CONCLUSIONS: The learning curve of a fellowship-trained surgeon introducing TVC to their surgical repertoire, as measured by improved operative times, can be achieved with approximately 15 cases.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES.

BACKGROUND: NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy. METHODS: Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps. RESULTS: At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy. CONCLUSION: As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods-combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

Perceptions, training experiences, and preferences of surgical residents toward laparoscopic simulation training: a resident survey.

INTRODUCTION: Simulation training for surgical residents can shorten learning curves, improve technical skills, and expedite competency. Several studies have shown that skills learned in the simulated environment are transferable to the operating room. Residency programs are trying to incorporate simulation into the resident training curriculum to supplement the hands-on experience gained in the operating room. Despite the availability and proven utility of surgical simulators and simulation laboratories, they are still widely underutilized by surgical trainees. Studies have shown that voluntary use leads to minimal participation in a training curriculum. Although there are several simulation tools, there is no clear evidence of the superiority of one tool over the other in skill acquisition. The purpose of this study was to explore resident perceptions, training experiences, and preferences regarding laparoscopic simulation training. Our goal was to profile resident participation in surgical skills simulation, recognize potential barriers to voluntary simulator use, and identify simulation tools and tasks preferred by residents. Furthermore, this study may help to inform whether mandatory/protected training time, as part of the residents' curriculum is essential to enhance participation in the simulation laboratory. METHODS: A cross-sectional study on general surgery residents (postgraduate years 1-5) at Yale University School of Medicine and the University of Toronto via an online questionnaire was conducted. Overall, 67 residents completed the survey. The institutional review board approved the methods of the study. RESULTS: Overall, 95.5% of the participants believed that simulation training improved their laparoscopic skills. Most respondents (92.5%) perceived that skills learned during simulation training were transferrable to the operating room. Overall, 56.7% of participants agreed that proficiency in a simulation curriculum should be mandatory before operating room experience. The simulation laboratory was most commonly used during work hours; lack of free time during work hours was most commonly cited as a reason for underutilization. Factors influencing use of the simulation laboratory in order of importance were the need for skill development, an interest in minimally invasive surgery, mandatory/protected time in a simulation environment as part of the residency program curriculum, a recommendation by an attending surgeon, and proximity of the simulation center. The most preferred simulation tool was the live animal model followed by cadaveric tissue. Virtual reality simulators were among the least-preferred (25%) simulation tools. Most residents (91.0%) felt that mandatory/protected time in a simulation environment should be introduced into resident training protocols. CONCLUSIONS: Mandatory and protected time in a simulation environment as part of the resident training curriculum may improve participation in simulation training. A comprehensive curriculum, which includes the use of live animals, cadaveric tissue, and virtual reality simulators, may enhance the laparoscopic training experience and interest level of surgical trainees.

A comparison of NOTES transvaginal and laparoscopic cholecystectomy procedures based upon task analysis.

BACKGROUND: A virtual reality-based simulator for natural orifice translumenal endoscopic surgery (NOTES) procedures may be used for training and discovery of new tools and procedures. Our previous study (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013) shows that developing such a simulator for the transvaginal cholecystectomy procedure using a rigid endoscope will have the most impact on the field. However, prior to developing such a simulator, a thorough task analysis is necessary to determine the most important phases, tasks, and subtasks of this procedure. METHODS: 19 rigid endoscope transvaginal hybrid NOTES cholecystectomy procedures and 11 traditional laparoscopic procedures have been recorded and de-identified prior to analysis. Hierarchical task analysis was conducted for the rigid endoscope transvaginal NOTES cholecystectomy. A time series analysis was conducted to evaluate the performance of the transvaginal NOTES and laparoscopic cholecystectomy procedures. Finally, a comparison of electrosurgery-based errors was performed by two independent qualified personnel. RESULTS: The most time-consuming tasks for both laparoscopic and NOTES cholecystectomy are removing areolar and connective tissue surrounding the gallbladder, exposing Calot's triangle, and dissecting the gallbladder off the liver bed with electrosurgery. There is a positive correlation of performance time between the removal of areolar and connective tissue and electrosurgery dissection tasks in NOTES (r = 0.415) and laparoscopic cholecystectomy (r = 0.684) with p < 0.10. During the electrosurgery task, the NOTES procedures had fewer errors related to lack of progress in gallbladder removal. Contrarily, laparoscopic procedures had fewer errors due to the instrument being out of the camera view. CONCLUSION: A thorough task analysis and video-based quantification of NOTES cholecystectomy has identified the most time-consuming tasks. A comparison of the surgical errors during electrosurgery gallbladder dissection establishes that the NOTES procedure, while still new, is not inferior to the established laparoscopic procedure.

Complications of transvaginal natural orifice transluminal endoscopic surgery: a series of 102 patients.

OBJECTIVE: To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date. BACKGROUND: TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain. METHODS: All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus. RESULTS: A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue. CONCLUSIONS: As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Comparison of immediate postoperative pain after transvaginal versus traditional laparoscopic cholecystectomy.

BACKGROUND: Transvaginal cholecystectomy (TVC) is the most common natural orifice transluminal surgery (NOTES) performed in women, yet there is a paucity of data on intraoperative and immediate postoperative pain management. Previous studies have demonstrated that NOTES procedures are associated with less postoperative pain and faster recovery times. This study analyzes intraoperative and postoperative opioid use for TVC compared with traditional four-port laparoscopic cholecystectomies (LCs). METHODS: This is a retrospective analysis of consecutive TVC and LC female patients between August 2009 and August 2012 in an academic institution. We compared demographics, intraoperative and postoperative opioid use and times in the operating room (OR) and in the post anesthesia care unit (PACU). RESULTS: A total of 68 TVC and 67 LC patients were included in this study. The TVC and LC groups were similar in terms of age (both 41 years) and body mass index (29 and 31 kg/m2, respectively). The intraoperative preparation, surgical, and emergence times were significantly longer for the TVC than for the LC (p ≤ 0.01). Compared with the LC group, the intraoperative opioid requirement was significantly greater (TVC 27 mg vs. LC 25 mg; p = 0.003), but after adjusting for anesthesia time, the difference in OR opioid consumption became non-significant (p = 0.08). The PACU opioid requirement (TVC 2.5 vs. LC 5 mg; p = 0.04) was significantly lower for the TVC group, and a greater proportion of patients did not need any pain medications (TVC 38 % vs. LC 21 %; p = 0.04), compared with the LC group. The average PACU pain scores were not significantly different between the groups (p = 0.45). CONCLUSION: TVC patients did not experience more pain than LC patients. Although the average pain scores of TVC patients did not differ from those of the LC patients, TVC patients did require less pain medication in the PACU.

Pure transvaginal ventral hernia repair in humans.

INTRODUCTION: Transvaginal natural orifice transluminal endoscopic surgery procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain. We aim to demonstrate a novel technique of pure transvaginal laparoscopic ventral hernia repair in a series of patients performed in our institution. TECHNIQUE DESCRIPTION: The patient was placed in lithotomy position and steep Trendelenburg. A 2-cm transverse colpotomy incision was made and a SILS port was introduced. One 12-mm trocar and two 5-mm trocars were placed through the SILS port and standard straight laparoscopic instruments were used. An appropriately sized round mesh was deployed within a specimen retrieval bag into the peritoneal cavity. Complete anterior circumferential fixation of the mesh was achieved using an AbsorbaTack device. The colpotomy incision was closed. RESULTS: There were a total of 6 pure transvaginal ventral hernia repair procedures performed in our institution between November 2010 and February 2012. The first case was converted to an open procedure after a rectal injury was recognized and repaired. Two patients had transient urinary retention that resolved after 24 hours. One patient had vaginal wound granulation noted at 2 months postoperatively. No long-term complications or recurrences were noted with a median follow-up of 9 months. The mean operative time was 107 minutes. CONCLUSION: Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible, safe, and associated with improved cosmetic results.

Transvaginal cholecystectomy: effect on quality of life and female sexual function.

IMPORTANCE: Transvaginal cholecystectomy (TVC) is the leading natural orifice transluminal endoscopic surgery to date and has the potential to offer improved cosmesis, less pain, and shorter recovery times for female patients. OBJECTIVE: To investigate quality of life and female sexual function in our patients undergoing TVC. DESIGN: A prospective cohort study from August 14, 2009, to June 12, 2012, of TVCs performed at our institution to date. SETTING: Tertiary academic referral center. PARTICIPANTS: The first 47 consecutive female patients (aged 18-65 years) who received a TVC by a single surgeon. INTERVENTIONS: A hybrid TVC was performed by a 5-mm umbilical trocar and a 12-mm transvaginal trocar with standard laparoscopic instruments. MAIN OUTCOMES AND MEASURES: Quality-of-life index (36-Item Short Form Health Survey) and female sexual function (Female Sexual Function Index) scores. RESULTS: A total of 47 TVCs were performed, with a mean age of 39 years, mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 31, and mean operative time of 65 minutes. No difference was noted in overall female sexual function from preoperatively to 1 and 3 months postoperatively. When comparing quality of life preoperatively vs 1 and 3 months postoperatively, there were significant improvements in physical function (P = .02), energy and fatigue (P = .001), emotional well-being (P = .01), pain (P < .001), and general health (P = .03). No significant changes were noted in physical limitations (P = .18), emotional problems (P = .72), and social function (P = .12). CONCLUSIONS AND RELEVANCE: In our experience to date, female sexual function is unchanged and quality of life either is unchanged or improves at 1 and 3 months following TVC. Undergoing TVC does not appear to negatively affect female sexual function or quality of life in the short term.

Pure transvaginal umbilical hernia repair.

BACKGROUND: Transvaginal natural orifice transluminal endoscopic surgery (NOTES) procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain [1, 2]. Most transvaginal procedures are performed as hybrid procedures [3]. To our knowledge, this is the first video depiction of a pure transvaginal umbilical hernia repair in a human. METHODS: This is a 38-year-old woman, body mass index 36.4 kg/m(2), with a symptomatic port site hernia in the umbilical region after a previous laparoscopic cholecystectomy. The patient was positioned in stirrups in a steep Trendelenburg position. Sterilization of vaginal cavity was performed with 10 % povidone-iodine solution. A 2 cm transverse incision at the posterior fornix was made, and a SILS port (Covidien, North Haven, CT) was introduced. One 12 mm trocar and two 5 mm trocars were placed through SILS port. Standard straight laparoscopic instruments were used. A 12 cm round Parietex mesh (Covidien) was placed in a specimen retrieval bag and deployed into the peritoneal cavity. The mesh was extracted, unfolded in the abdominal cavity, and circumferentially fixated to the abdominal wall with an AbsorbaTack device (Covidien). The colpotomy incision was closed with a running absorbable suture. RESULTS: The procedure lasted 103 min and was performed on an outpatient basis. No intraoperative complications occurred. The patient was doing well and had no pain or recurrence at 2, 6, and 9 months' follow-up. CONCLUSIONS: Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible and safe. This approach may improve cosmesis and decrease the risk of future ventral hernias. Potential cons may include a longer operative time, mesh infection, and risk of visceral injury with a pure transvaginal approach. As transvaginal surgery evolves, techniques and devices will become increasingly refined to tackle these challenges.

Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese.

BACKGROUND: The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients. METHODS: One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m(2). These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19-62 years) and average BMI of 38.9 kg/m(2) (range 35.2-44.9 kg/m(2)). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments. RESULTS: The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered. CONCLUSIONS: NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.

Laparoscopic iliac and iliofemoral lymph node resection for melanoma.

Regional lymphadenectomy in the iliac and groin, originally devised by Basset in 1912, is performed for the treatment of melanoma metastatic to this lymphatic basin. Laparoscopic iliac node dissection may be a valuable management option because it allows performance of the same procedure as in open surgery but with significant benefits such as decreased operative morbidity due to decreased surgical trauma, less violation of the abdominal muscles or the inguinal ligament, reduced postoperative pain, and increased patient satisfaction with the cosmetic appearance. The authors' approach makes use of a laparoscopic technique to offer an alternative to traditionally described lymph node dissection for melanoma. A review of the literature showed few laparoscopic approaches in this context. Jones et al. do not perform the resection en bloc and do not address the iliofemoral lymph node dissection with a combined retroperitoneal technique such as the current authors use. Two authors in the literature use laparoscopy through a transperitoneal approach, with a piecemeal removal of nodes. Delman et al. limit their technique to the inguinal and high femoral basin alone. The video demonstrates the novel use of a laparoscopic method to harvest iliac lymph nodes in combination with a minimally invasive approach to groin dissection for metastatic melanoma. After a laparoscopic resection of these nodes, the authors deliver the iliac nodal contents through the groin using a minimally invasive approach. This approach is highly beneficial to the patient. He is able to leave the hospital significantly earlier than he would have after a traditional open procedure. He can return to his job as a car mechanic within 1 week and is metastasis free at the 9-month follow-up assessment without evidence of lymphocele formation. The authors do not believe that this technique has any significant implication for lymphocele formation compared with an open procedure because in essence, the same resection is being performed. A larger prospective series is necessary to determine lymphocele outcomes.

Construct and face validity of a virtual reality-based camera navigation curriculum.

INTRODUCTION: Camera handling and navigation are essential skills in laparoscopic surgery. Surgeons rely on camera operators, usually the least experienced members of the team, for visualization of the operative field. Essential skills for camera operators include maintaining orientation, an effective horizon, appropriate zoom control, and a clean lens. Virtual reality (VR) simulation may be a useful adjunct to developing camera skills in a novice population. No standardized VR-based camera navigation curriculum is currently available. We developed and implemented a novel curriculum on the LapSim VR simulator platform for our residents and students. We hypothesize that our curriculum will demonstrate construct and face validity in our trainee population, distinguishing levels of laparoscopic experience as part of a realistic training curriculum. METHODS: Overall, 41 participants with various levels of laparoscopic training completed the curriculum. Participants included medical students, surgical residents (Postgraduate Years 1-5), fellows, and attendings. We stratified subjects into three groups (novice, intermediate, and advanced) based on previous laparoscopic experience. We assessed face validity with a questionnaire. The proficiency-based curriculum consists of three modules: camera navigation, coordination, and target visualization using 0° and 30° laparoscopes. Metrics include time, target misses, drift, path length, and tissue contact. We analyzed data using analysis of variance and Student's t-test. RESULTS: We noted significant differences in repetitions required to complete the curriculum: 41.8 for novices, 21.2 for intermediates, and 11.7 for the advanced group (P < 0.05). In the individual modules, coordination required 13.3 attempts for novices, 4.2 for intermediates, and 1.7 for the advanced group (P < 0.05). Target visualization required 19.3 attempts for novices, 13.2 for intermediates, and 8.2 for the advanced group (P < 0.05). Participants believe that training improves camera handling skills (95%), is relevant to surgery (95%), and is a valid training tool (93%). Graphics (98%) and realism (93%) were highly regarded. CONCLUSIONS: The VR-based camera navigation curriculum demonstrates construct and face validity for our training population. Camera navigation simulation may be a valuable tool that can be integrated into training protocols for residents and medical students during their surgery rotations.