Impedance planimetry during per-oral endoscopic myotomy is associated with decreased inadvertent capnoperitoneum.

BACKGROUND: Per-oral endoscopic myotomy (POEM) has become an accepted minimally invasive alternative to Heller myotomy for the treatment of achalasia and other disorders of esophageal dysmotility. One associated adverse event is the inadvertent creation of capnoperitoneum. A proposed mechanism is that extension of the submucosal tunnel below the esophageal hiatus and onto the gastric wall leads to transmural perforation. We hypothesized that the use of impedance planimetry with the endoscopic functional luminal imaging probe (EndoFLIP) more accurately identifies the esophagogastric junction and helps to better define the myotomy's ideal limits, thus lowering the incidence of inadvertent capnoperitoneum. METHODS: This is a single-center, retrospective review of consecutive POEM cases from 06/11/2011 to 08/08/2022, with EndoFLIP introduced in 2017. Patient and procedural characteristics, including the incidence of clinically significant capnoperitoneum and decompression, were analyzed using univariate and multivariable linear regression statistics. RESULTS: There were 140 POEM cases identified, 74 (52.9%) of which used EndoFLIP. Clinically significant capnoperitoneum was encountered in 26 (18.6%) cases, with no differences in patient characteristics between those who had capnoperitoneum and those who did not. There was a decreased incidence of capnoperitoneum in cases using EndoFLIP compared to those without (n = 6, 23% vs n = 20, 77%, p = 0.001), with zero instances in the final 56 cases. After adjusting for potentially confounding factors, EndoFLIP use was associated with a - 15.93% (95% confidence interval - 30.68%, - 1.18%) decrease in procedure duration. CONCLUSIONS: The routine use of EndoFLIP during POEM was associated with decreased incidence of clinically significant capnoperitoneum, potentially due to improved myotomy tailoring and decreased duration of insufflation with shorter procedure times.

Expert laparoscopist performance on virtual reality simulation tasks with and without haptic features.

BACKGROUND: Virtual reality (VR) simulation for laparoscopic training is available with and without haptic feedback features. Currently, there is limited data on haptic feedback's effect on skill development. Our objective is to compare expert laparoscopists' skills characteristics using VR delivered laparoscopic tasks via haptic and nonhaptic laparoscopic surgical interfaces. METHODS: Five expert laparoscopists performed seven skills tasks on two laparoscopic simulators, one with and one without haptic features. Tasks consisted of 2-handed instrument navigation, retraction and exposure, cutting, electrosurgery, and complicated object positioning. Laparoscopists alternated platforms at default difficulty settings. Metrics included time, economy of movement, completed task elements, and errors. Progressive change in performance for the final three iterations were determined by repeated measures ANOVA. Iteration quartile means were determined and compared using paired t-tests. RESULTS: No change in performance was noted in the last three iterations for any metric. There were no significant differences between platforms on the final two quartiles for most metrics except avoidance of over-stretch error for retraction; and cutting task was significantly better with haptics on all iteration quartiles (p < 0.03). Economy of movement was significantly better with haptics for both hands for clip application (p < 0.01) and better for right hand on complex object positioning (p < 0.05). Accuracy was better with haptics for retraction and cutting (p < 0.05) and clip application (p < 0.05). CONCLUSION: Results showed higher performance in accuracy, efficient instrument motion, and avoidance of excessive traction force on selected tasks performed on VR simulator with haptic feedback compared to those performed without haptics feedback. Laparoscopic surgeons interpreted machine-generated haptic cues appropriately and resulted in better performance with VR task requirements. However, our results do not demonstrate an advantage in skills acquisition, which requires additional study.