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AIMS: Training programs are essential to introduce new methods for bile duct clearance. Visual examination via cholangioscopy is ideal to diagnose and treat biliary tract diseases such as cancer and choledocholithiasis. However, surgeons rarely use cholangioscopes. Specific training is required to master laparoscopic and percutaneous cholangioscopy. This study aims to assess skill acquisition and retention during cholangioscopy training in the Image-Guided Therapies Masterclass. METHODS: This prospective study enrolled 17 physicians undergoing training in interventional treatments of biliary diseases. A novel disposable cholangioscope and access kit were used with a biliary tract model including two simulated common bile duct (CBD) stones. The curriculum required visualization of all critical structures before removal of one stone with a Dormia basket. After informed consent, demographic data and time to exercise completion were recorded on each of two subsequent training days. Task-specific questions were measured at the completion of training using a Likert scale (strongly disagree to strongly agree, 1-5 points). RESULTS: All participants successfully completed the task (6F/11 M, age 36 ± 5 years; 13 surgeons, 4 interventional radiologists; median experience with percutaneous procedures 2 years, range 0-20). Significant improvement in mean task completion time was observed (day 1: 172 ± 59 s, day 2: 89 ± 45 s; P < 0.0001). All task-specific questions were answered with a median rating of 5/5: "The platform facilitates cholangioscopy" and "This training method accelerates gain in proficiency and is useful for residents/fellows" (IQR 5-5), "This platform is useful to measure the proficiency level" and "There is an application for simulation in percutaneous surgery training" (IQR 4.5-5), "The platform is user-friendly" and "The model quality recreates realistic scenarios" (IQR 4-5). CONCLUSION: Cholangioscopic bile duct exploration and stone retrieval were achieved by all participants using a dedicated training program and physical simulator. Significant skill progress was observed during 2 days of dedicated training.
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Cálculos Biliares , Laparoscopía , Cirugía Asistida por Computador , Humanos , Adulto , Estudios Prospectivos , Endoscopía del Sistema Digestivo/métodos , Cálculos Biliares/cirugíaRESUMEN
INTRODUCTION: The role of impedance testing in selecting patients for antireflux surgery is poorly understood. The aim of this study was to compare the outcomes of patients that underwent antireflux surgery for GERD based on an abnormal pH/abnormal impedance test versus a normal pH/abnormal impedance test. METHODS: Records of patients who had an abnormal off-medication impedance test (≥ 48 total reflux events) who underwent antireflux surgery were reviewed and divided into two groups: normal [pH-] or abnormal [pH+] esophageal acid exposure (DeMeester score > 14.7). Symptom resolution was compared: scale 1 (no resolution) to 5 (complete resolution). RESULTS: Eighty-two patients met criteria: 44 [pH+] and 38 [pH-]. There were no differences in the demographics or indications for surgery. The frequencies of heartburn and regurgitation symptoms were significantly reduced by fundoplication in both groups. Complete resolution of heartburn was more common in the [pH+] group (90%) compared to the [pH-] group (67%) [p = 0.02]. Resolution of regurgitation was similar in both groups (90% in the [pH+] group vs 79% in the [pH-] group, p = 0.20). The mean dysphagia frequency score decreased for the [pH+] group, but increased in the [pH-] group. New-onset dysphagia was more common in [pH-] patients (23%) compared to [pH+] patients (5%), (p = 0.02). Continued use of PPI medications was significantly more likely in [pH-] group (42%) compared to the [pH+] group (21%). There was no difference in surgical satisfaction rates between groups. DISCUSSION: Patients with abnormal impedance and increased esophageal acid exposure had significantly better symptom resolution, less dysphagia, and less frequent PPI use with antireflux surgery versus those with normal pH. These findings urge caution in the use of abnormal impedance values with normal esophageal acid exposure for the selection of patients for an antireflux operation.
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Impedancia Eléctrica/uso terapéutico , Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Flexible endoscopy has evolved to the point that it includes many endoluminal procedures that once required open or laparoscopic surgery, for instance, antireflux surgery, pyloromyotomy, mucosal and submucosal tumor resections, and even full-thickness resection. However, these procedures remain technically demanding due to flexible technology issues: difficult imaging, limited energy devices, lack of staplers, unsatisfactory suturing abilities, and so on. Transgastric laparoscopy or hybrid laparoscopy/flex endoscopy has been described for almost two decades as an alternative to a pure endoluminal approach, mainly for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. The approach has never been widely adopted mostly due to cumbersome and difficult to maintain methods of gastric access. We propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed ports to replicate endoscopic procedures particularly in the difficult to access proximal stomach such as endoluminal antireflux surgery. Under general anesthesia, five female pigs (mean weight: 27.6 kg) had endoscopic placement of 3, 5 mm intragastric ports (Endo-TAGSS, Leakwood KS, USA) using a technique similar to percutaneous endoscopic gastrostomy. A 5-mm laparoscope was used for visualization. Laparoendoscopic-assisted plication of the gastroesophageal junction (GEJ) was performed using 3-0 interrupted sutures (Polysorb®, Covidien, Mansfield, MA, USA). A functional lumen imagine probe (EndoFLIP®, Crospon, Inc., Galway, Ireland) was used to measure diameter, cross sectional area (CSA), distensibility, and compliance of GEJ before and after intervention. Once the TAGSS ports were removed, the gastrotomies were closed by using endoscopic over-the-scope clips. At the end of the procedure, animals were euthanized. Five laparoendoscopic-assisted endoluminal plications were performed. The mean operative time was 65.6 min (Endoscopic evaluation: 3.2 min, TAGSS Insertion: 11 min, EndoFLIP evaluation + GEJ Plication: 43.25 min, gastric wall closure: 15 minutes). In all cases, this technique was effective and allowed to achieve an adequate GEJ plication by endoscopic grading and EndoFLIP measurements. Median pre-plication GEJ diameter (D) and median pre-plication GEJ cross-sectional area (CSA) were 11.42 mm (8.6-13.6 mm) and 104.8 mm2 (58-146 mm2). After the procedure, these values were decreased to 6.14 mm (5.7-6.6 mm) and 29.8 mm2 (25-34 mm2) respectively (p = 0.0079). Median pre-plication distensibility (d) and compliance (C) were 7.87 mm2/mmHg (2.4-22.69 mm2/mmHg) and 190.56 mm3/mmHg (70.9-502.8 mm3/mmHg). After the procedure, these values decreased to 1.5 mm2/mmHg (0.7-2.2 mm2/mmHg) and 52.17 mm3/mmHg (21.9-98.7 mm3/mmHg) respectively (p = 0.0317). No intraoperative events were observed. Endoscopically, all valves were felt to be transitioned from a Hill grade 3 (normal state for the animal model) to a Hill grade 1 at the procedure completion. A hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the intervention location limits the access to standard endoscopy or where endoscopic technology is inadequate. Further evaluation is planned in survival models and clinical trials.
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Endoscopía Gastrointestinal/métodos , Unión Esofagogástrica/cirugía , Laparoscopía/métodos , Animales , Endoscopía Gastrointestinal/instrumentación , Femenino , Gastrostomía/instrumentación , Gastrostomía/métodos , Humanos , Modelos Animales , Tempo Operativo , Instrumentos Quirúrgicos , Técnicas de Sutura/instrumentación , PorcinosRESUMEN
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Acalasia del Esófago/diagnóstico , Acalasia del Esófago/terapia , Adulto , Toxinas Botulínicas/uso terapéutico , Niño , Dilatación/métodos , Dilatación/normas , Manejo de la Enfermedad , Acalasia del Esófago/fisiopatología , Esofagoscopía/métodos , Esofagoscopía/normas , Medicina Basada en la Evidencia , Femenino , Humanos , Masculino , Miotomía/métodos , Miotomía/normas , Factores de Riesgo , Índice de Severidad de la Enfermedad , Evaluación de Síntomas/métodos , Evaluación de Síntomas/normasRESUMEN
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Humanos , Acalasia del Esófago , Acalasia del Esófago/diagnóstico , Acalasia del Esófago/terapiaRESUMEN
INTRODUCTION: Technological innovation in surgical science and healthcare is vital and calls for close collaboration between engineering and surgery. To meet this objective, BEST was designed as a free sustainable innovative teaching method for young professionals, combining surgery, engineering, and business in a multidisciplinary, high-quality, low-cost, and learning-by-doing philosophy. AIMS: This paper reviews the initial outcomes of the program and discusses lessons learned and future directions of this innovative educational method. METHODS: BEST educational method is delivered in two parts: the first component consisting of live streaming or pre-recorded online lectures, with an interdisciplinary profile focused on surgery, engineering, and business. The second component is an annual 5-day on-site course, organized at IRCAD-IHU, France. The program includes workshops in engineering, entrepreneurship team projects, and in-depth hands-on experience in laparoscopy, robotic surgery, interventional radiology, and flexible endoscopy with special emphasis on the interdisciplinary aspect of the training. A panel of surgeons, engineers, well-established entrepreneurs, and scientists assessed the team projects for potential patent application. RESULTS: From November 2011 till September 2013, 803 individual and institutional users from 79 different countries attended the online course. In total, 134 young professionals from 32 different countries applied to the onsite course. Sixty participants were selected each year for the onsite course. In addition, five participants were selected for a web-based team. Thirteen provisional patents were filed for the most promising projects. CONCLUSION: BEST proved to be a global talent incubator connecting students to high-quality education despite institutional and economical boundaries. Viable and innovative ideas arose from this revolutionary approach which is likely to spin-off significant technology transfer and lead the way for future interdisciplinary hybrid surgical education programs and career paths.
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Comercio/educación , Educación Médica/métodos , Ingeniería/educación , Cirugía General/educación , Adulto , Femenino , Francia , Humanos , Invenciones , Aprendizaje , Masculino , Evaluación de Programas y Proyectos de Salud , Adulto JovenRESUMEN
PURPOSE: Closure of the esophageal hiatus is an important step during laparoscopic antireflux surgery and hiatal hernia surgery. The aim of this study was to investigate the correlation between the preoperatively determined hiatal hernia size and the intraoperative size of the esophageal hiatus. METHODS: One hundred patients with documented chronic gastroesophageal reflux disease underwent laparoscopic fundoplication. All patients had been subjected to barium studies before surgery, specifically to measure the presence and size of hiatal hernia. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). HSA size >5 cm(2) was defined as large hiatal defect. Patients were grouped according to radiologic criteria: no visible hernia (n = 42), hernia size between 2 and 5 cm (n = 52), and >5 cm (n = 6). A retrospective correlation analysis between hiatal hernia size and intraoperative HSA size was undertaken. RESULTS: The mean radiologically predicted size of hiatal hernias was 1.81 cm (range 0-6.20 cm), while the interoperative measurement was 3.86 cm(2) (range 1.51-12.38 cm(2)). No correlation (p < 0.05) was found between HSA and hiatal hernia size for all patients, and in the single radiologic groups, 11.9 % (5/42) of the patients who had no hernia on preoperative X-ray study had a large hiatal defect, and 66.6 % (4/6) patients with giant hiatal hernia had a HSA size <5 cm(2). CONCLUSIONS: The study clearly demonstrates that a surgeon cannot rely on preoperative findings from the barium swallow examination, because the sensitivity of a preoperative swallow is very poor.
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Diafragma/cirugía , Reflujo Gastroesofágico/cirugía , Hernia Hiatal/cirugía , Adulto , Diafragma/diagnóstico por imagen , Femenino , Fundoplicación , Reflujo Gastroesofágico/diagnóstico por imagen , Hernia Hiatal/diagnóstico por imagen , Humanos , Periodo Intraoperatorio , Laparoscopía , Masculino , Persona de Mediana Edad , Periodo Preoperatorio , Radiografía , Estudios RetrospectivosRESUMEN
Sliding Type-I hiatal hernia is commonly diagnosed using upper endoscopy, barium swallow or less commonly, esophageal manometry. Current data suggest that endoscopy is superior to barium swallow or esophageal manometry. Recently, high-resolution manometry has become available for the assessment of esophageal motility. This novel technology is capable of displaying spatial and topographic pressure profiles of gastroesophageal junction and crural diaphragm in real time. The objective of the current study was to compare the specificity and sensitivity of high-resolution manometry and endoscopy in the diagnosis of sliding hiatal hernia in patients with gastroesophageal reflux disease. Data were analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ± 13.2 years) with objective gastroesophageal reflux disease who were considered for laparoscopic antireflux surgery between January 2006 and January 2009 and had preoperative high-resolution manometry and endoscopy. Manometrically, hiatal hernia was defined as separation of the gastroesophageal junction >2.0 cm from the crural diaphragm. Intraoperative diagnosis of hiatal hernia was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Forty-two patients were found to have a Type-I sliding hiatal hernia (>2 cm) during surgery. Twenty-two patients had manometric criteria for a hiatal hernia by high-resolution manometry, and 36 patients were described as having a hiatal hernia by preoperative endoscopy. False positive results were significantly fewer (higher specificity) with high-resolution manometry as compared with endoscopy (4.88% vs. 31.71%, P= 0.01). There were no significant differences in the false negative results (sensitivity) between the two diagnostic modalities (47.62% vs. 45.24%, P= 0.62). Analysis of likelihood ratios of a positive and negative test demonstrated that high-resolution manometry is better than endoscopy both to rule out and rule in a hiatal hernia. A significant discordance was also observed between the two tests (P= 0.033). High-resolution manometry has better specificity and ability to rule out an overt Type-I sliding hiatal hernia (greater likelihood ratio of a positive test) in patients with GERD. Because of high false negative results, both high-resolution manometry and endoscopy are unreliable for ruling in a hiatal hernia. Negative result for a hiatal hernia by either modality mandates additional testing.
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Endoscopía del Sistema Digestivo/métodos , Hernia Hiatal/diagnóstico , Manometría/métodos , Adulto , Anciano , Estudios de Cohortes , Intervalos de Confianza , Femenino , Hernia Hiatal/cirugía , Humanos , Funciones de Verosimilitud , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
INTRODUCTION: Incarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes. METHODS: From the 2005-2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1 day of admission (early) or >1 day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities. RESULTS: Of 224 patients, 149 (67%) were early and 75 (33%) were interval, with mean 3.6 days. Repairs were 89% transabdominal, 9% included fundoplication, and 18% gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31% (p = 0.2) and mortality 5.4 versus 4% (p = 0.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13%, p = 0.002) and length of stay was shorter (5 vs. 11 days, p < 0.001) for early vs. interval patients. On adjusted analysis, the early group had an 80% reduction in sepsis (95% confidence interval (CI), 0.05-0.6, p = 0.005). Odds of overall or other morbidity or mortality were statistically similar between groups. CONCLUSIONS: Patients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.
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Descompresión Quirúrgica/métodos , Hernia Hiatal/cirugía , Resucitación/métodos , Enfermedad Aguda , Anciano , Descompresión Quirúrgica/mortalidad , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/mortalidad , Femenino , Fundoplicación/mortalidad , Fundoplicación/estadística & datos numéricos , Gastrostomía/mortalidad , Gastrostomía/estadística & datos numéricos , Hernia Hiatal/complicaciones , Hernia Hiatal/mortalidad , Humanos , Tiempo de Internación , Masculino , Resucitación/mortalidad , Estudios Retrospectivos , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
BACKGROUND AND STUDY AIMS: Gastrointestinal stents have become an important therapeutic option for several indications. However, migration in up to 40â% of cases represents a significant drawback, especially when covered prostheses are used. We hypothesized that a novel endoscopic suturing device could enable endoluminal stent fixation, which might increase attachment and thereby potentially reduce migration. PATIENTS AND METHODS: In an initial ex vivo porcine model, stents were attached to the esophageal wall with either endoscopic hemoclips or by endoscopic suture stent fixation (ESSF). The distal tension force required to induce dislocation was measured in Newtons (N) by a digital force gauge and was compared with conventional stent placement. ESSF was then performed clinically in five patients, in whom self-expanding metal stents were sutured in place for endoscopic treatment of gastrointestinal fistulas or strictures. RESULTS: Esophageal ESSF was achieved in all experiments and significantly increased the force needed to displace the stent (nâ=â12; mean force 20.4 N; 95â% confidence interval [CI]: 15.4â-â25.4; Pâ<â0.01) compared with clip fixation (nâ=â8; mean 6.1 N; 95â%CI 4.7â-â7.6) or stent placement without fixation (nâ=â16; mean 4.8 N; 95â%CI 4.0â-â5.6). All clinical cases of ESSF were performed successfully (5â/5) and took a median of 15 minutes. Elective stent removal was achieved without complications. One stent migration (1â/5) due to sutures being placed too superficially was observed. More loosely tied sutures remained intact, with the stent attached in place. CONCLUSION: Endoscopic suture fixation of gastrointestinal stents provided significantly enhanced migration resistance in an ex vivo setting. In addition, early clinical experience found ESSF to be technically feasible and easy to accomplish.
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Materiales Biocompatibles Revestidos/uso terapéutico , Esofagoscopía/métodos , Enfermedades Gastrointestinales/cirugía , Stents , Técnicas de Sutura , Adulto , Anciano , Animales , Fenómenos Biomecánicos , Intervalos de Confianza , Constricción Patológica/diagnóstico , Constricción Patológica/cirugía , Modelos Animales de Enfermedad , Diseño de Equipo , Seguridad de Equipos , Unión Esofagogástrica/patología , Unión Esofagogástrica/cirugía , Femenino , Enfermedades Gastrointestinales/patología , Humanos , Masculino , Persona de Mediana Edad , Falla de Prótesis , Muestreo , Sensibilidad y Especificidad , Porcinos , Resistencia a la TracciónAsunto(s)
Disección/métodos , Mucosa Gástrica/cirugía , Gastroscopía/métodos , Animales , Disección/instrumentación , Gastroscopios , Suturas , PorcinosRESUMEN
BACKGROUND: Mediastinal surgery most often is performed via a transthoracic or transabdominal approach; however, the pre- and paratracheal mediastinum can be readily accessed with a transcervical approach. The purpose of this study was to evaluate the feasibility, safety, and success rate of using a transcervical approach and flexible endoscopes to perform mediastinal surgery also in the retro- and paraesophageal mediastinum. METHODS: Mediastinal operations on four live pigs and one human cadaver were performed using standard endoscopes through a small cervical incision. The procedure involved marking of four mediastinal lymph nodes using endoscopic ultrasound (EUS). The esophagus was dissected to the phrenoesophageal junction by creating connective tissue tunnels with balloon dilatation and low-pressure CO(2) insufflation. Heller myotomy was performed followed by sequential identification and removal of the marked nodes. Success rate of esophageal dissection to the diaphragm, Heller myotomy, directed mediastinal lymph node harvest, and complication rates were evaluated. RESULTS: Dissection of the esophagus to the diaphragm was achieved in 100% of attempts. Distal esophageal myotomy was performed in all cases. Harvest of marked lymph nodes (ln) was successful in 100% of animals (16/16 ln) and cadavers (2/2 ln). One major complication was recorded in the pig group (tension pneumomediastinum). CONCLUSIONS: The entire visceral mediastinum can be successfully accessed through a transcervical incision using flexible endoscopes. Directed lymph node harvest and esophageal myotomy is feasible with a high success rate. Connective tissue tunnels are safe, atraumatic, and a promising concept for targeted mediastinal exploration. With refinement in technology, this approach may be useful for a variety of mediastinal surgeries.
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Tejido Conectivo , Escisión del Ganglio Linfático/métodos , Ganglios Linfáticos/cirugía , Mediastinoscopía/métodos , Mediastino/cirugía , Animales , Cadáver , Cateterismo , Endosonografía , Esófago/cirugía , Estudios de Factibilidad , Humanos , Ganglios Linfáticos/diagnóstico por imagen , Masculino , Mediastinoscopios , Mediastinoscopía/instrumentación , Porcinos , Resultado del TratamientoAsunto(s)
Endoscopía/métodos , Cavidad Abdominal/cirugía , Animales , Colecistectomía Laparoscópica/métodos , Hemodinámica , Humanos , Inhalación/fisiología , Mediastinoscopía , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Modelos Animales , Neumoperitoneo Artificial , Estómago/cirugía , Porcinos , ToracoscopíaRESUMEN
The placement of mesh in the crural closure of paraesophageal hiatal hernia repairs has been shown to decrease hernia recurrence rates. Typical synthetic mesh are easy to use but have high rate of erosion into the esophagus. Alternatively, biologic mesh decrease the risk of erosion, but are more difficult to manipulate, and there is currently no well-described method for securing them. Current fixation techniques of mesh are difficult, cumbersome, incur extra expense, and are not without complications. A method that requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure is presented.
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Hernia Hiatal/cirugía , Mallas Quirúrgicas , Humanos , Laparoscopía , Técnicas de SuturaRESUMEN
Natural orifice transluminal endoscopic surgery (NOTES) is a largely theoretical but potentially exciting evolution of minimally invasive surgical care. Using technology borrowed from current diagnostic and therapeutic flexible endoscopy, the idea is to replicate current laparoscopic procedures in an "incisionless" manner. It is widely recognized that for NOTES to become a practical reality, many issues need to be resolved, both methodologic and political. One critical element of development will be the design of appropriate instrumentation for NOTES. This is currently happening and involves a complex collaboration between industry and clinicians both to adapt current equipment and to design and create new tools to enable the performance of transluminal procedures. This article describes the current process of such technology development as well as the resulting instrumentation that enables the performance of NOTES. The issues of access and platform stability, laparoscopic-like instruments, and secure tissue approximation are described, and the devices to solve these issues are detailed.
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Endoscopía del Sistema Digestivo/instrumentación , Tecnología de Fibra Óptica/instrumentación , Gastroscopios , Gastroscopía/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Endoscopía del Sistema Digestivo/tendencias , Endoscopía Gastrointestinal/métodos , Diseño de Equipo , Seguridad de Equipos , Femenino , Predicción , Humanos , Masculino , Sensibilidad y Especificidad , Instrumentos Quirúrgicos , Evaluación de la Tecnología BiomédicaRESUMEN
BACKGROUND: Complex laparoscopic tasks require collaboration of surgeons as a surgical team. Conventionally, surgical teams are formed shortly before the start of the surgery, and team skills are built during the surgery. There is a need to establish a training simulation to improve surgical team skills without jeopardizing the safety of surgery. The Legacy Inanimate System for Laparoscopic Team Training (LISETT) is a bench simulation designed to enhance surgical team skills. The reported project tested the construct validity of LISETT. The research question was whether the LISETT scores show progressive improvement correlating with the level of surgical training and laparoscopic team experience or not. METHODS: With LISETT, two surgeons are required to work closely to perform two laparoscopic tasks: peg transportation and suturing. A total of 44 surgical dyad teams were recruited, composed of medical students, residents, laparoscopic fellows, and experienced surgeons. The LISETT scores were calculated according to the speed and accuracy of the movements. RESULTS: The LISETT scores were positively correlated with surgical experience, and the results can be generalized confidently to surgical teams (Pearson's coefficient, 0.73; p = 0.001). To analyze the influences of individual skill and team dynamics on LISETT performance, team quality was rated by team members using communication and cooperation characters after each practice. The LISETT scores are positively correlated with self-rated team quality scores (Pearson's coefficient, 0.39; p = 0.008). CONCLUSIONS: The findings proved LISETT to be a valid system for assessing cooperative skills of a surgical team. By increasing practice time, LISETT provides an opportunity to build surgical team skills, which include effective communication and cooperation.
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Competencia Clínica , Instrucción por Computador , Educación Médica , Endoscopía/educación , Grupo de Atención al Paciente/organización & administración , Diseño de Equipo , Humanos , Destreza Motora , Simulación de PacienteRESUMEN
BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, may offer advantages over open and laparoscopic surgery. Most investigations to date have focused on small end-organ resections, and none have described en bloc regional lymphadenectomy. This study aimed to describe a method of anal transcolonic sigmoid colon resection. METHODS: A fresh frozen then thawed cadaver model was used. Three male human cadavers were subjected to transanal sigmoid colon mobilization, high vascular ligation, en bloc lymphadenectomy, and stapled end-to-end anastomosis performed by a single operator using transanal endoscopic microsurgery instrumentation. RESULTS: The findings showed that NOTES sigmoid colon resection with en bloc lymphadenectomy and primary anastomosis can be performed successfully. The critical steps of the procedure were (1) luminal suture occlusion of the sigmoid colon, (2) transrectal bowel division, (3) entry through the mesorectum into the presacral space, (4) en bloc mobilization of the sigmoid colon mesentery off of the retroperitoneum, (5) high ligation of the superior hemorrhoidal artery, (6) transanal delivery of the intact sigmoid colon specimen, (7) extracorporeal division of the colon, and (8) creation of a stapled end-to-end colorectal anastomosis. Postprocedure laparotomy confirmed adequate lymphadenectomy and anastomosis with no untoward events. CONCLUSIONS: It is possible to complete the critical steps of a NOTES sigmoid resection, en bloc lymphadenectomy, primary anastomosis, and retrieval of an intact specimen without any incisions using transanal endoscopic microsurgery instrumentation.
Asunto(s)
Colectomía/métodos , Colon Sigmoide/cirugía , Colonoscopía/métodos , Microcirugia , Cadáver , Estudios de Factibilidad , Humanos , MasculinoRESUMEN
BACKGROUND: To assess team collaboration in the context of laparoscopic surgery, laparoscopic cutting tasks performed by single operators and dyad teams were observed. Our previous work suggested that the anticipatory movement performed by a teammate may lead to a shorter total task time than for a single bimanual operator. This report further explores this phenomenon by quantifying the frequency of anticipatory movements and discussing their significance to team collaboration. METHODS: Subjects were required to reach, grasp, and cut a piece of thread using a laparoscopic grasper and scissors. The task was performed by either 8 individual subjects bimanually or 16 paired subjects unimanually (using their preferred hands). The performances were video recorded. The total task time, the time used for thread grasping and cutting, and the number of anticipatory movements were computed and compared between the single operator and the dyad team group. In this report, anticipatory movement is defined as movements of the scissors before the completion of grasping and holding the thread. RESULTS: Shorter durations of total task time were shown for the dyad than for the bimanual group. Anticipatory movements were counted significantly more often when the scissors were controlled by a teammate on the dyad team (96%) than when they were controlled by the preferred hand of the operator (45%). The number of anticipatory movements increased with practice, but no significant difference was shown among practice phases. CONCLUSION: Higher frequency of anticipatory movement was observed in the dyad team, which led to superior performance for team collaboration, as compared with that of the single operator. Performance of anticipatory movements in the dyad team was explained by a shared mental model, which postulates combined capacity for information processing among team members. Results have implications for surgical education, team training, and error prevention in the performance of laparoscopic surgery.