Curva de aprendizaje para el acceso con trocar óptico en cirugía pélvica laparoscópica: estudio prospectivo / Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

Introducción El acceso con trocar óptico (ATO) es una técnica modificada de laparoscopia cerrada cuyo objetivo es minimizar el riesgo de lesiones vasculares o intestinales y reducir la posible fuga de gas. Se ha analizado el efecto de la curva de aprendizaje (CA) para el ATO, considerando n=30 procedimientos como umbral para definir un nivel aceptable de experticia. Nuestro objetivo es evaluar el impacto de la CA en los primeros 30 casos de ATO realizados por un aprendiz. Métodos Se trata de un estudio prospectivo aleatorizado en 60 pacientes planificadas para cirugía ginecológica laparoscópica. Las pacientes fueron seleccionadas aleatoriamente para el ATO realizado por un cirujano sin entrenamiento previo en la técnica o por un cirujano experto. La CA se evaluó mediante: 1) tiempo hasta lograr el acceso; 2) número de correcciones hechas por el experto; 3) número de veces en que la punta del trocar se detuvo en la capa preperitoneal; 4) errores al realizar la incisión en la piel; 5) veces en que la punta del trocar termina bajo el epiplón; 6) complicaciones. Para analizar el CA en los 30 primeros casos, se estratificaron los procedimientos en 3 grupos (casos 1-10; 11-20; 21-30) tanto para el aprendiz como para el experto y se compararon las variables de la CA. Resultados De forma global, el tiempo medio de inserción para el ATO fue de 56s. No se registraron complicaciones intraoperatorias ni postoperatorias graves. El tiempo medio de inserción fue estadísticamente más largo para el aprendiz en comparación con el experto en los 10 primeros casos (91s frente a 33s, respectivamente, p=0,01). En los casos 11-20 y 21-30, la ventaja de tiempo del cirujano experto se hizo menos evidente (p=0,05). El número de veces que la punta del trocar se detuvo en la capa preperitoneal fue similar entre los grupos, así como las veces que la punta del trocar llegó por debajo del epiplón. Conclusiones La técnica de ATO es rápida y reproducible . ... (AU)

Introduction The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n=30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. Methods This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. Results Overall, mean OTA insertion time was 56s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33s respectively, p=0.01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (p=0.05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. Conclusions OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC. (AU)

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study.

INTRODUCTION: The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. METHODS: This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. RESULTS: Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. CONCLUSIONS: OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

Balloon tamponade for prevention and treatment of vaginal hemorrhages in gynecology.

The preliminary experience of balloon tamponade in planned vaginal surgery and in emergency vaginal bleeding using a new device (Vagistop) is reported. The results shows the advantages of the system in comparison with vaginal gauze packing.

Minimally invasive vaginal hysterectomy using bipolar vessel sealing: preliminary experience with 500 cases.

The objective of our study was to evaluate surgical outcome of minimally invasive vaginal hysterectomy (MIVH), using the bipolar vessel sealing system (BVSS; BiClamp®). The design was a retrospective analysis (Canadian Task-force Classification II-3). The setting was a secondary care hospital. Records of patients who underwent vaginal hysterectomy for benign indications in our centre between November 2005 and March 2011 were reviewed. The demographic patients' data, indications for surgery, patient history with regard to previous surgery, duration of surgery, blood loss (postoperative hemoglobin drop '∆Hb'), perioperative complications, and length of inpatient stay were collected from the medical records. The intervention was vaginal hysterectomy using BVSS (BiClamp®). Results showed that the mean duration of surgery was 48.9 ± 15.3 min (95% CI, 49.2-52.5). The mean duration of hospital stay was 3.2 ± 1.2 days (95% CI, 2.8-3.2). The mean ∆Hb was 1.4 ± 1.8 g/dl. Overall, conversion to laparotomy was required in three cases (0.6%). Only one haemoperitoneum occurred (0.2%) and this is the only case who required blood transfusion. The main indication for VH was uterine prolapse in 52.0% (n = 260) of cases; uterine fibroids in 37.4% (n = 187); adenomyosis uteri in 4.2% (n = 21); cervical dysplasia in 22 patients (4.4%) and in 2% (n = 10) of patients, endometrial hyperplasia and other pathologies were the indications for VH. It was concluded that electrosurgical bipolar vessel sealing by (BiClamp®) can provide a safe and feasible alternative to sutures in vaginal hysterectomy, resulting in reduced operative time and blood loss, with acceptable surgical outcomes.

Transmigrated intrauterine device discovered 17 years after its insertion.

We present the case of an intraperitoneal IUD incidentally noted on lumbar spine X-rays and confirmed by CT. This was secondary to asymptomatic uterine perforation occurred at the time of insertion 17 years before.