Virtual reality simulation training can improve technical skills during laparoscopic salpingectomy for ectopic pregnancy.

OBJECTIVES: To assess the first commercially available virtual reality (VR) simulator to incorporate procedural modules for training of inexperienced gynaecological surgeons to perform laparoscopic salpingectomy for ectopic pregnancy. DESIGN: Prospective cohort study. SETTING: Departments of surgery and gynaecology in central London teaching hospitals. SAMPLE: Thirty gynaecological surgeons were recruited to the study, and were divided into novice (<10 laparoscopic procedures), intermediate (20-50) and experienced (>100) groups. METHODS: All subjects were orientated to the VR simulator with a basic skills task, followed by performing ten repetitions of the virtual ectopic pregnancy module, in a distributed manner. MAIN OUTCOME MEASURES: Operative performance was assessed by the time taken to perform surgery, blood loss and total instrument path length. RESULTS: There were significant differences between the groups at the second repetition of the ectopic module for time taken (median 551.1 versus 401.2 versus 249.2 seconds, P = 0.001), total blood loss (median 304.2 versus 187.4 versus 123.3 ml, P = 0.031) and total instrument path length (median 17.8 versus 8.3 versus 6.8 m, P = 0.023). The learning curves of the experienced operators plateaued at the second session, although greater numbers of sessions were necessary for intermediate (seven) and novice (nine) surgeons to achieve similar levels of skill. CONCLUSIONS: Gynaecological surgeons with minimal laparoscopic experience can improve their skills during short-phase training on a VR procedural module. In contrast, experienced operators showed nonsignificant improvements. Thus, VR simulation may be useful for the early part of the learning curve for surgeons who wish to learn to perform laparoscopic salpingectomy for ectopic pregnancy.

Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature.

This pilot case-control study was carried out to determine the value of intraperitoneal irrigation with a long-acting local anaesthetic agent in reducing postoperative analgesic requirements following gynaecological operative laparoscopy. Twenty women undergoing gynaecological laparoscopic surgery were recruited to receive dilute bupivacaine instilled into the peritoneal cavity at the completion of surgery. Analgesic requirements were assessed during the first 10 hours, and pain scores at 4 and 24 hours. Analgesic requirements were then compared with historical controls. Our results revealed that the total parenteral opioid requirement after bupivacaine was significantly less than in the control group (0.50 mg vs. 7.17 mg, P=0.006). Oral analgesic requirements were not significantly different between the two groups. Pain scores in the bupivacaine group showed no difference at 4 and 24 hours postoperatively. Intraperitoneal irrigation with dilute bupivacaine at the end of gynaecological laparoscopic surgery appears to reduce early postoperative analgesic requirements in this pilot study.

Mass closure: a new technique for closure of the vaginal vault at vaginal hysterectomy.

A variety of methods of management of the vaginal vault have been described, all of which maintain certain principles. In techniques that advocate closure of the vault, the peritoneum and vaginal epithelium are treated with separate sutures. This leaves a potential space above the vaginal closure. We describe a simple technique of mass closure which obliterates this space and incorporates the pedicles to provide support for the vault. This method may hold potential advantages in terms of haemostasis, risk of vault haematoma, and post-operative vaginal cuff infections.

Laparoscopic myomectomy.

Fibroids are common tumors that present with a variety of symptoms for whom medical treatment is generally unsatisfactory. Laparoscopic myomectomy was described nearly 20 years ago. Since then several hundred procedures have been described in the literature. With increasing experience it has become apparent that the technique is both technically demanding and time consuming. It is also not clear whether laparoscopic surgical outcome is improved compared with laparotomy. At present these factors limit the application of laparoscopic myomectomy.