Transference of skills in robotic vs. laparoscopic simulation: a randomized controlled trial.

BACKGROUND: Elucidating how robotic skills are best obtained will enable surgeons to best develop future robotic training programs. We perform a randomized controlled trial to assess the performance of robotic compared to laparoscopic surgery, transference of pre-existing skills between the two modalities, and to assess the learning curve between the two using novice medical students. METHODS: Forty students were randomized into either Group A or B. Students practiced and were tested on a peg transfer task in either a laparoscopic simulator (LS) and robotic simulator (RS) in a pre-defined order. Performance, transference of skills and learning curve were assessed for each modality. Additionally, a fatigue questionnaire was issued. RESULTS: There was no significant difference between overall laparoscopic scores (219 ± 19) and robotic scores (227 ± 23) (p = 0.065). Prior laparoscopic skills performed significantly better on robotic testing (236 ± 12) than without laparoscopic skills (216 ± 28) (p = 0.008). There was no significant difference in scores between students with prior robotic skills (223 ± 16) than without robotic skills (215 ± 22) (p = 0.162). Students reported no difference in fatigue between RS and LS. The learning curve plateaus at similar times between both modalities. CONCLUSION: Novice medical students with laparoscopic skills performed better on a RS test than students without laparoscopic training, suggesting a transference of skills from laparoscopic to robotic surgery. These results suggest laparoscopic training may be sufficient in general surgery residencies as the skills transfer to robotic if used post-residency.

Laparoscopic Simulation in Reverse and Side Alignment Impact on Forward Alignment Performance: A Randomized Controlled Trial.

BACKGROUND: The influence of visual-spatial discordance during training on laparoscopic skills is poorly understood. It has been proposed that training in visual-spatial discordant situations can improve performance in the forward alignment, which was the basis of our hypothesis. Our study's aim was to conduct a randomized control trial to explore the impact of simulated training in visual-spatial discordant situations on forward alignment performance. METHODS: The participants were 80 medical students who were randomized into four groups. Group A served as the control and performed all peg transfers in the forward alignment. Groups B, C, and D experienced varied rounds of either increasing or decreasing sensorimotor discordance. The students were trained and tested using the peg transfer task used in the Fundamentals of Laparoscopic Surgery curriculum. Based on the group, each student performed 10 peg transfer practice rounds in their assigned alignment. After each practice session, each student was tested and scored in forward alignment performance. A baseline test, followed by three practice sessions, and three tests were done. RESULTS: Group A (control) demonstrated a statistically significant overall increase in scoring of 37.1% from baseline when compared to the final test. Groups B, C, and D showed improvements of 3.7%, 27.1%, and 19.3%, respectively, between baseline and the final test, yet none demonstrated consistent linear improvements. On multi-variate analysis, students who practiced in the side or reverse alignment positions scored 25 and 37 points lower, respectively, than students who practiced in the forward alignment. CONCLUSION: Our study suggests that training in visual-spatial discordant conditions does not lead to the development of forward alignment laparoscopic skills. This could have important implications when developing future laparoscopic skills training curriculums. To our knowledge, this is the largest study to date assessing the impacts of training in visual-spatial discordance situations on performance in the forward alignment.

Primary signet ring cell carcinoma of the pancreatic head: A case report.

Pancreatic SRCC is a rare, aggressive tumor. Given limited evidence and the risk of side effects, physicians may elect to withhold chemotherapy in select patients, with the exception of neoadjuvant chemotherapy use to facilitate resectability.

Hernia recurrence and infection rate in elective complex abdominal wall repair using biologic mesh.

BACKGROUND: Elective complex ventral hernia repairs, done using synthetic mesh in patients with comorbidities, can result in mesh related complications such as hernia recurrence or infection. We studied hernia recurrence and surgical site occurrences after elective complex repairs in predominately clean cases using biologic mesh and examined the impact of several comorbidities. METHODS: A retrospective chart review was completed on patients who underwent elective repair with biologic mesh in clean/clean-contaminated settings between 2012 and 2015 with a minimum of 1-year follow-up. Multiple comorbid conditions, including diabetes, chronic obstructive pulmonary disease, steroid use, smoking history and previous hernia repairs were identified. Post-operative complications including recurrence and infections were ruled out by computed tomography, clinical exam, and/or by telephone survey. RESULTS: 40 patients were identified. 85% (n = 34) had class 1 wounds. 25% (n = 10) experienced a hernia recurrence. 10% (n = 4) of patients developed postoperative infection, none required mesh explantation or re-operation. No statistically significant association was found between the comorbidities assessed and recurrence/infection rates. CONCLUSIONS: We present the first study analyzing clinical outcomes of complex ventral hernia repairs using biologic mesh in predominately clean settings. This study being non-comparative limits definitive conclusions, but our aim is to add to the growing literature on biologic mesh to help future researchers performing comparative trials of synthetic versus biologic meshes.

Adrenocortical oncocytic neoplasm: A systematic review.

BACKGROUND: Adrenocortical oncocytic neoplasms are rare tumors, generally regarded as benign and hormonally nonfunctional. We performed a systematic review to update the literature on adrenocortical oncocytic neoplasms by reviewing patient and tumor characteristics, as well as management trends, because the literature is composed of predominately single-case reports. METHODS: A systematic search was performed in PubMed, Embase, and Cochrane Library through June 2017. Malignant potential was determined by applying the Lin-Weiss-Bisceglia criteria to cases. RESULTS: Included for analysis were 84 citations describing 140 adrenocortical oncocytic neoplasms, including our own case. These were diagnosed predominantly in females (66%), on the left side (64%), and were nonfunctional (66%). Average age at diagnosis was 44 years (2.5-77), and median tumor size was 80 mm (16-285). A total of 35% of adrenocortical oncocytic neoplasms were benign, 41% borderline, and 24% malignant. Male patients were more likely to have a malignant tumor compared with females (36% versus 18%, P = .035). The 5-year overall survival for benign adrenocortical oncocytic neoplasms was 100%, borderline 88%, and malignant 47%. Hormonal function did not discriminate malignant from benign lesions. Adrenocortical oncocytic neoplasms that stained positive for synaptophysin (50%, P < .001) and negative for vimentin (62%, P = .009) are more often benign. CONCLUSION: We found that the majority of adrenocortical oncocytic neoplasms (65%) were either malignant or had malignant potential, contrary to the previous literature. The Lin-Weiss-Bisceglia criteria are useful in identifying those patients for whom closer surveillance is warranted, because their prognosis is dependent on the Lin-Weiss-Bisceglia diagnosis.

Lymphoepithelial cysts of the pancreas. Can preoperative imaging distinguish this benign lesion from malignant or pre-malignant cystic pancreatic lesions?

CONTEXT: Lymphoepithelial cysts of the pancreas are rare true benign cystic tumors of the pancreas of uncertain etiology. Cystic neoplasms of the pancreas present a significant diagnostic dilemma in differentiating benign from premalignant or malignant variants. Since the first description of lymphoepithelial cysts in 1985, 109 cases have been reported in the literature. We describe 6 cases of this rare tumor, the preoperative imaging results, and a review the literature. PATIENTS: Five males and one female ranging in age from 47 to 76 years underwent resection for lymphoepithelial cysts. Five patients presented with abdominal pain related to the lesion and in one patient the lesion was discovered incidentally. Four patients had elevated serum CA 19-9 levels. Pre-operative imaging with a CT scan and MRI of the abdomen typically revealed a well defined hypodense mass with Hounsfield units (HU) in the range of 15 to 20. One patient had papillary projections into the lesion. The mean size was 3.3 cm (ranging from 1.8 cm to 4 cm). All lesions were exophytic off the pancreatic parenchyma (1 cyst was located in the head of the pancreas, 2 were in the body, and 3 were in the tail region). Pre-operative EUS-guided/CT-guided needle aspiration, when performed, was not diagnostic. All patients underwent resection (one pancreaticoduodenectomy, five left pancreatectomies) to remove these cystic neoplasms. Pathology revealed a cyst lined by non-dysplastic squamous cells surrounded by sheets of benign lymphocytes. No evidence of malignancy was found. CONCLUSION: Lymphoepithelial cysts of the pancreas are rare and are characteristically seen in men. While a hypodense mass (less than 20 HU) with papillary projections should be considered suspicious for lymphoepithelial cyst, a definitive diagnosis cannot be made solely based on preoperative imaging. EUS-guided biopsy coupled with biochemical/tumor marker studies are increasingly being used as a diagnostic tool to help differentiate between the various types of cystic pancreatic neoplasms. Imaging findings of lymphoepithelial cysts are non-specific and hence surgical resection is often required to rule out the presence of a malignant or pre-malignant cystic pancreatic lesion. In true lymphoepithelial cysts, malignant transformation is not seen and patients who have these cysts are not at increased risk of developing a pancreatic malignancy.

Mesothelioma as a rapidly developing Giant Abdominal Cyst.

The benign cystic mesothelioma of the peritoneum is a rare lesion and is known for local recurrence. This is first case report of a rapidly developing massive abdominal tumor with histological finding of benign cystic mesothelioma (BCM). We describe a BCM arising in the retroperitoneal tis[sue on the right side, lifting ascending colon and cecum to the left side of abdomen. Patient was an active 58-year-old man who noticed a rapid abdominal swelling within a two month time period with a weight gain of 40 pounds. Patient had no risk factors including occupational (asbestos, cadmium), family history, social (alcohol, smoking) or history of trauma. We will discuss the clinical, radiologic, intra-operative, immunohistochemical, pathologic findings, and imaging six months after surgery. Patient has no recurrence and no weight gain on follow up visits and imaging.

Routine drain placement in Roux-en-Y gastric bypass: an expanded retrospective comparative study of 755 patients and review of the literature.

Routine drain use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons. After a patient in our program experienced intestinal obstruction secondary to a drain, we reevaluated our practice and hypothesized drains would be of no benefit and potentially harmful after LRYGB. Retrospective record review of all patients undergoing LRYGB from August 2005 to August 2009 was performed. As we changed our practice in December 2006, we have two comparable groups: one with a drain placed at surgery and one without. All operations were otherwise performed in an identical fashion by three fellowship-trained university surgeons. We compared outcomes between the two groups, particularly regarding gastrojejunal (GJ) leaks. Jejunojejunal (JJ) leaks, unlikely to be captured by these drains, were not studied. A total of 755 LRYGBs were performed during the study period, the first 272 patients with routine drains and the subsequent 483 without. Demographics were statistically similar between the two groups. There were four GJ leaks in the drain group (1.47%) and three in the nondrain group (0.62%). Among the drain patients, two required operation and two were treated nonoperatively. Among the nondrain patients, two required operation and one was treated nonoperatively. The leak and reoperation rates between the groups were not statistically different (p = 0.154 and p = 0.514). Routine drains likely have no benefit after LRYGB. Clinical parameters such as tachycardia, fever, oliguria, and increasing abdominal pain should guide further investigation for and treatment of a leak.