Integration of laparoscopic virtual-reality simulation into gynaecology training.

Surgery carries the risk of serious harm, as well as benefit, to patients. For healthcare organisations, theatre time is an expensive commodity and litigation costs for surgical specialities are very high. Advanced laparoscopic surgery, now widely used in gynaecology for improved outcomes and reduced length of stay, involves longer operation times and a higher rate of complications for surgeons in training. Virtual-reality (VR) simulation is a relatively new training method that has the potential to promote surgical skill development before advancing to surgery on patients themselves. VR simulators have now been on the market for more than 10 years and, yet, few countries in the world have fully integrated VR simulation training into their gynaecology surgical training programmes. In this review, we aim to summarise the VR simulators currently available together with evidence of their effectiveness in gynaecology, to understand their limitations and to discuss their incorporation into national training curricula.

Objective assessment of surgical competence in gynaecological laparoscopy: development and validation of a procedure-specific rating scale.

OBJECTIVE: The purpose of this study was to develop a global- and a procedure-specific rating scale based on a well-validated generic model (objective structured assessment of technical skills) for assessment of technical skills in laparoscopic gynaecology. Furthermore, we aimed to investigate the construct validity and the interrater agreement (IRA) of the rating scale. We investigated both the gamma coefficient (Kendall's rank correlation), which is a measure of the strength of dependence between observations, and the kappa value for each of the ten individual items included in the rating scale. DESIGN: Prospective cohort, observer-blinded study. SETTING: Departments of Obstetrics and Gynaecology in Zealand, Denmark. POPULATION: Twenty one gynaecologists or gynaecological trainees. MATERIAL AND METHODS: Twenty-one video recordings of right side laparoscopic salpingectomies were collected prospectively, eight from novices (defined as <10 procedures), seven from intermediate experienced (20-50 procedures) and six from experts (> 200 procedures). All operations were performed by the same operative principles and using a standardised technique. The recordings were analysed by two independent, blinded observers. MAIN OUTCOME MEASURES: Construct validity of the rating scale based on operative performance (median of total score) and interrater reliability. RESULTS: There were significant differences between the three groups: median score of novices 24.00 versus intermediate 29.50 versus expert 39.50, P < 0.003) The IRA was 0.83 overall. The gamma correlation coefficient was 0.91. The kappa values varied from 0.510-0.933 for each of the individual items of the rating scale. CONCLUSIONS: The procedure-specific rating scale for laparoscopic salpingectomy is a valid and reliable tool for assessment of technical skills in gynaecological laparoscopy.

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.

Objective assessment of gynecologic laparoscopic skills using the LapSimGyn virtual reality simulator.

BACKGROUND: Safe realistic training and unbiased quantitative assessment of technical skills are required for laparoscopy. Virtual reality (VR) simulators may be useful tools for training and assessing basic and advanced surgical skills and procedures. This study aimed to investigate the construct validity of the LapSimGyn VR simulator, and to determine the learning curves of gynecologists with different levels of experience. METHODS: For this study, 32 gynecologic trainees and consultants (juniors or seniors) were allocated into three groups: novices (0 advanced laparoscopic procedures), intermediate level (>20 and <60 procedures), and experts (>100 procedures). All performed 10 sets of simulations consisting of three basic skill tasks and an ectopic pregnancy program. The simulations were carried out on 3 days within a maximum period of 2 weeks. Assessment of skills was based on time, economy of movement, and error parameters measured by the simulator. RESULTS: The data showed that expert gynecologists performed significantly and consistently better than intermediate and novice gynecologists. The learning curves differed significantly between the groups, showing that experts start at a higher level and more rapidly reach the plateau of their learning curve than do intermediate and novice groups of surgeons. CONCLUSION: The LapSimGyn VR simulator package demonstrates construct validity on both the basic skills module and the procedural gynecologic module for ectopic pregnancy. Learning curves can be obtained, but to reach the maximum performance for the more complex tasks, 10 repetitions do not seem sufficient at the given task level and settings. LapSimGyn also seems to be flexible and widely accepted by the users.

New animal model for the study of postmenopausal coronary and cerebral artery function: the Watanabe heritable hyperlipidemic rabbit fed on a diet avoiding phytoestrogens.

OBJECTIVE: To evaluate the effect of estrogen replacement therapy (ERT) on the functional characteristics of coronary and cerebral arteries in a new rabbit model for postmenopausal vascular function. METHODS: Female ovariectomized Watanabe heritable hyperlipidemic (WHHL) rabbits were randomized to treatment for 16 weeks with either 17 beta-estradiol or placebo. The chow used was semi-synthetic, thereby avoiding the influence of phytoestrogens. Ring segments of cerebral and coronary arteries were mounted for isometric tension recordings in myographs. The passive and active length-tension relationships for electromechanical (high potassium), pharmacomechanical (histamine) and combined electro- and pharmacomechanical (high potassium plus histamine) contraction were evaluated. RESULTS: Treatment with 17 beta-estradiol significantly changed the active length-tension relationship for the electromechanical response in the proximal coronary arteries. No changes were observed for the passive length-tension relationships. CONCLUSIONS: Long-term treatment with 17 beta-estradiol lowered the electromechanical tonus of atherosclerotic coronary arteries proximally, where the atherosclerosis is most developed. This could be one of the mechanisms behind the putative protective effect of hormone replacement therapy against ischemic heart disease. The study presents a promising new animal model for the investigation of postmenopausal coronary and cerebral artery function. The data correspond well with epidemiological observations in postmenopausal women.

Seminal vesicle cyst with ipsilateral renal agenesis.

OBJECTIVE: The purpose of this study was to review the clinical symptoms and imaging features of a seminal vesicle cyst associated with renal agenesis. CONCLUSION: Patients with seminal vesicle cysts associated with renal agenesis may present with symptoms of bladder irritation or obstruction and with an abdominal or pelvic mass revealed on physical examination. Differentiation of a seminal vesicle cyst from other pelvic cystic masses may be determined with a spectrum of imaging techniques including excretory urography, sonography, CT, and MR imaging.

CT-appearance of intraluminal duodenal diverticulum. The "halo" sign.

The barium appearance of intraluminal duodenal diverticulum has been classically described as a "windsock" appearance. However, the CT-scan appearance of this abnormality has not been well documented. A case report of a patient with intraluminal duodenal diverticulum is presented. The authors believe the CT-scan findings in the patient are virtually pathognomonic for this lesion and propose the term "halo" sign be applied to this previously undescribed finding.

Regression of large pelvic desmoid tumor by tamoxifen and sulindac.

A 54-year-old man was evaluated for symptoms of bladder outlet obstruction. Evaluation revealed a 10 by 9.8-cm tumor composed of bland, fibroblastic, poorly cellular material adjacent to the prostate. Administration of a course of antiestrogen (tamoxifen) and a nonsteroidal anti-inflammatory agent (sulindac) resulted in prompt relief of symptoms and a slow decrease in the size of the tumor as measured by computed tomography. After 54 months of therapy, the tumor was undetectable clinically and dramatically reduced in size as seen on computed tomography. Data on the natural history of desmoid tumors and the efficacy of various therapeutic strategies are reviewed.

Suppurative pylephlebitis and pylethrombosis: the role of anticoagulation.

Suppurative thrombophlebitis of the portal vein resulting from inflammatory intra-abdominal conditions is a rare complication that may result in pylethrombosis and portal hypertension. A case is presented with documented pylethrombosis caused by diverticulitis. Color flow Doppler scanning was used to establish the diagnosis. Systemic anticoagulation therapy was added to the antibiotic regimen because of postoperative propagation of the clot. Anticoagulation therapy prompted resolution of the episode. Long-term follow-up studies demonstrated recanalization of the portal vein. Anticoagulation should be instituted with documented acute pylethrombosis caused by inflammatory disease of the abdomen.

Lumbar herniation of the spleen.

Hernias of the lumbar region are rare but have been reported to occur after trauma, flank surgery, iliac bone grafting, spontaneously, or as a result of congenital abnormality of musculoskeletal development. The acquired type is more common than the congenital type. The contents of the hernia most commonly are retroperitoneal fat, kidney, and bowel. We report a case of an asymptomatic postincisional lumbar herniation of a spleen that was diagnosed by computed tomography.

Idiopathic segmental thrombosis of the corpus cavernosum as a cause of partial priapism.

Idiopathic segmental thrombosis of the corpus cavernosum as a cause for partial priapism is an uncommon event. Diagnosis and treatment in the past have principally involved invasive methods. We present a case in which both conventional invasive methods and noninvasive imaging were used.

Multiple retroperitoneal schwannomas: case report and review of the literature.

We report a rare case of multiple retroperitoneal schwannomas, initially believed to be an adrenal carcinoma with metastasis. These benign tumors were discovered in a patient presenting with vague back pain. Preoperative radiographic and endocrine evaluations suggested a nonfunctioning adrenal tumor. The final diagnosis and its juxta-adrenal origin were confirmed by histological and immunohistochemical studies. A review of the literature on retroperitoneal schwannoma is included.

Bilateral obturator hernias: case report, radiographic characteristics, and brief review of literature.

Obturator hernia is a rare cause of intestinal obstruction, and bilateral obturator hernias are even rarer. Early diagnosis can decrease the morbidity and mortality associated with these lesions. We present the case of a patient with bilateral obturator hernias, discuss the radiographic findings, and briefly review the literature.

Computerized tomographic appearance of hernias of the bladder.

Herniation of the bladder is not uncommon and it can occur with any type of hernia in the groin. Most bladder hernias are discovered unexpectedly during herniorrhaphy, and serious complications can result from intraoperative injury to the bladder. The appearance of hernias on excretory urography and cystography has been described extensively but experience with computerized tomography (CT) has been limited. We describe the appearance of 8 bladder hernias on CT: 2 incisional, 2 femoral, 3 small direct inguinal, and 1 massive direct inguinal hernia with bladder necrosis and perforation. Appearance on CT is characteristic, and this modality may be useful for preoperative evaluation.

Is magnetic resonance imaging alone accurate enough in staging renal cell carcinoma?

A patient with renal cell carcinoma extending into the inferior vena cava presented to our institution. Magnetic resonance imaging demonstrated the superior extent of the thrombus to be at the level of the hepatic veins. Preoperative venacavography showed extension into the right atrium. The need for both studies in evaluating patients with Stage 3A disease is reviewed.

Acute pyelonephritis after transrectal ultrasonographically guided biopsy of the prostate: diagnosis by computed tomography.

Acute pyelonephritis developed in a 67-yr-old man after transrectal ultrasonographically guided biopsy of the prostate. The clinical presentation and results of excretory urography were nondiagnostic. Diagnosis was made by computed tomography, which was delayed 12 h after i.v. administration of contrast medium.

Gastrosplenic fistula: complication of adenocarcinoma of stomach.

Penetration of the spleen by an adenocarcinoma of the stomach is described in a patient undergoing chemotherapy. The diagnosis was made by computed tomography.

Computed tomographic evaluation of spigelian hernia.

Spigelian hernia is an uncommon hernia of the anterior abdominal wall. Because of its insidious nature and at times nonspecific physical findings associated with it, the diagnosis of this hernia is often not made. Typically, the hernial orifice is small, and strangulation of the contents of the hernial sac can occur. Computed tomography permits the distinction between spigelian hernia and other anterior abdominal wall or intra-abdominal masses. When a spigelian hernia is found, CT is useful in establishing contents of the hernial sac and defects in the fascial plane.

Computed tomographic findings of giant intestinal pseudopolyposis.

The cases of 3 patients with giant intestinal pseudopolyposis are presented. Giant pseudopolyposis complicated chronic ulcerative colitis in 2 patients and granulomatous colitis in 1 patient. Each patient was evaluated with either barium or Gastrografin enema as well as with computed tomography (CT) after administration of oral contrast material. The unique manifestations of this unusual lesion as demonstrated by computed tomography are described.