The impact of intraoperative microbreaks with exercises on surgeons: A multi-center cohort study.

Recent literature has demonstrated ergonomic risk to surgeons in the operating room. One method used in other industries to mitigate these ergonomic risks is the incorporation of microbreaks. Thus, intraoperative microbreaks with exercises in a non-crossover design were studied. Fifty-six attending surgeons from 4 Medical Centers volunteered first in a day of their regular surgeries and then second day where there were microbreaks with exercises that could be performed in the sterile field, answering questions after each case, without significantly increasing the duration of their surgeries. Surgeons self-reported improvement or no change in their mental focus (88%) and physical performance (100%) for the surgical day incorporating microbreaks with exercises. Discomfort in the shoulders was significantly reduced while distractions and flow impact was minimal. Eighty-seven percent of the surgeons wanted to incorporate the microbreaks with exercises into their OR routine. Intraoperative microbreaks with exercises may be a way to mitigate work-related musculoskeletal fatigue, pain and injury.

Laparoscopic parastomal hernia repair using a nonslit mesh technique.

BACKGROUND: The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes. METHODS: A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence. RESULTS: A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence. CONCLUSION: On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Laparoscopic splenectomy in the elderly: a morbid procedure?

BACKGROUND: Laparoscopic splenectomy has emerged as the gold standard for elective splenectomy. Few reports have critically evaluated the results of laparoscopic splenectomy in elderly patients. METHODS: All laparoscopic splenectomies performed between August 19, 1998 and June 8, 2004 were reviewed retrospectively. RESULTS: Of 235 splenectomies, 188 were performed for patients younger than age 65 years (group 1), and 45 were performed for patients 65 years of age or older (group 2). The groups were demographically similar, except for the average age and the American Society of Anesthesiology (ASA) classification. Operative characteristics were similar, but the average length of hospital stay differed: 2.2 days for group 1 and 3.9 days for group 2 (p < 0.03). Complications occurred for 8.5% of group 1 and 17.8% of group 2, but the percentages were similar by ASA class. CONCLUSIONS: Elderly patients have a higher rate of complications after laparoscopic splenectomy. The complications are similar when matched for ASA class, but a larger percentage of elderly patients fall into higher ASA class ratings.

Development of a valid, cost-effective laparoscopic training program.

BACKGROUND: Practical programs for training and evaluating surgeons in laparoscopy are needed to keep pace with demand for minimally invasive surgery. METHODS: At the University of Kentucky five inexpensive simulations have been developed to train and assess surgical residents. Residents are videotaped performing laparoscopic procedures on models. Five surgeons assess the taped performances on 4 global skills. RESULTS: Creating mechanical models reduces training costs. Trainees agreed procedures were well represented by the simulations. Blinded assessment of performances showed high interrater agreement and correlated with the trainees' level of experience. Nonclinician evaluations on checklists correlated with evaluations by surgeons. CONCLUSIONS: Inexpensive simulations of laparoscopic appendectomy, cholecystectomy, inguinal herniorrhaphy, bowel enterotomy, and splenectomy enable surgical residents to practice laparoscopic skills safely. Obtaining masked, objective, and independent evaluations of basic skills in laparoscopic surgery can assist in reliable assessment of surgical trainees. The simulations described can anchor an innovative educational program during residency for training and assessment.

Multimedia article. Laparoscopic Ladd's procedure in two adults: malrotation and the minimally invasive approach.

Malrotation is an intestinal rotation anomaly rarely diagnosed in adults. In the adult patient, obstructing peritoneal bands may lead to nausea and abdominal distention. Familiarity with this presentation as well as the aberrant anatomy associated with the unusual problem facilitates surgical treatment. While the minimally invasive approach requires meticulous dissection due to this abnormal anatomy, laparoscopic treatment does provide the advantages of short convalescence and low morbidity. This video briefly reviews embryologic intestinal development, rotational anomalies and two laparoscopic Ladd's procedures.

Determinants of competency judgments by experienced laparoscopic surgeons.

BACKGROUND: The definitive criteria for assessing competence remain elusive. In our study, we aimed to identify the determinants of competence assessment used by individual laparoscopic surgeons. METHODS: In a blinded fashion, five laparoscopic surgeons rated 27 subjects on three laparoscopic simulations in four skill categories: clinical judgment, dexterity, serial/simultaneous complexity, and spatial orientation. The raters then assessed overall subject competence for each procedure. Point-biserial correlational analyses and cluster analyses were performed to ascertain the relationships among the various scales. RESULTS: All of the correlations between the skills' ratings and competence judgments were statistically significant ( p <.05). No skill rating was consistently more highly correlated with the competence rating. There were no distinct patterns of correlations for each rater or each procedure. One factor emerged from each cluster analysis of the skills measures. CONCLUSIONS: The results suggest that the four skills scored in the study are highly correlated with each other and are important in determining competence. The cluster analyses revealed that the surgeon raters shared a common perception of competence.

Evaluating minimally invasive surgery training using low-cost mechanical simulations.

BACKGROUND: The goal of this study was to develop, test, and validate the efficacy of inexpensive mechanical minimally invasive surgery (MIS) model simulations for training faculty, residents, and medical students. We sought to demonstrate that trained and experienced MIS surgeon raters could reliably rate the MIS skills acquired during these simulations. METHODS: We developed three renewable models that represent difficult or challenging segments of laparoscopic procedures; laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), and laparoscopic inguinal hernia (LH). We videotaped 10 students, 12 surgical residents, and 1 surgeon receiving training on each of the models and again during their posttraining evaluation session. Five MIS surgeons then assessed the evaluation session performance. For each simulation, we asked them to rate overall competence (COM) and four skills: clinical judgment (respect for tissue) (CJ), dexterity (economy of movement) (DEX), serial/simultaneous complexity (SSC), and spatial orientation (SO). We computed intraclass correlation (ICC) coefficients to determine the extent of agreement (i.e., reliability) among ratings. RESULTS: We obtained ICC values of 0.74, 0.84, and 0.81 for COM ratings on LH, LC, and LA, respectively. We also obtained the following ICC values for the same three models: CJ, 0.75, 0.83, and 0.89; DEX, 0.88, 0.86, and 0.89; SSC, 0.82, 0.82, and 0.82; and SO, 0.86, 0.86, and 0.87, respectively. CONCLUSIONS: We obtained very high reliability of performance ratings for competence and surgical skills using a mechanical simulator. Typically, faculty evaluations of residents in the operating room are much less reliable. In contrast, when faculty members observe residents in a controlled, standardized environment, their ratings can be very reliable.

Changes in postural mechanics associated with different types of minimally invasive surgical training exercises.

BACKGROUND: Doctors who perform minimally invasive surgery commonly report upper extremity fatigue or joint and muscle pain. The goal of this study was to investigate the changes in postural parameters associated with different laparoscopic training tasks and graspers. METHODS: Three different training tasks (targeted object release, rope passing, and cable tying) were performed with three types of laparoscopic graspers. Joint angles were determined using video analysis, and centers of pressure (COP) were measured with force platforms. RESULTS: Cable tying proved to be the most challenging training task and involved greater joint angle excursions and COP excursions and velocities. Grasper 2 reduced shoulder and wrist flexion-extension over the selected tasks. CONCLUSION: Training tasks should be designed to simulate surgical procedures because different tasks require distinct combinations of joint rotations. Joint rotations and postural balance should be considered when an optimal grasper is selected for a particular training task.

The effect of using laparoscopic instruments on muscle activation patterns during minimally invasive surgical training procedures.

BACKGROUND: Many surgeons report pain as a result of muscle fatigue during laparoscopy. Therefore, determining how surgical task or instrument selection influences the duration of muscle activation may provide insight into the relationship between laparoscopic instrumentation and muscle fatigue. METHODS: Surface electromyography (EMG) electrodes were placed over the right deltoid, trapezius, bicep, pronator teres, flexor carpi ulnaris, and extensor digitorum superficialis muscles of four surgeons. These surgeons were then asked to perform a targeted grasp and release (T1), a simulated bowel inspection (T2), and a cable-tying exercise (T3) while using three different inline finger-looped graspers. The graspers included a nonratcheted handle with a single-action blunt-end effector (G1) and two models that had ratcheted handles with dual-action end effectors (G2, G3). Resting and maximal voluntary contraction EMG values for each muscle were used to normalize the data and to determine percentage of activation during each task. A multivariate analysis of variance (ANOVA) was used to compare EMG relative time of activation (RAT) patterns with grasper, task, and grasper and task interaction. RESULTS: In general, when grasper and task were considered individually, G1 and T3 demonstrated the highest RAT. Findings showed that RAT was most affected by the use of either G1 or G2 during T2 or T3. CONCLUSION: Task, grasper, and the interaction between grasper and task all appear to influence the RAT and therefore, to varying degrees, all three may play a role in influencing muscle fatigue.

Laparoscopic pancreatic cystgastrostomy via the lesser sac approach.

Laparoscopic cystgastrostomy offers the benefits of a minimally invasive procedure while providing effective drainage for pancreatic pseudocysts. The lesser sac approach to laparoscopic cystgastrostomy provides adequate working space with excellent visualization. This assures meticulous hemostasis, debridement of the cyst, and wide internal drainage of the pancreatic pseudocyst. Additionally, the laparoscopic approach to this difficult problem can be augmented by other minimally invasive therapies. This video outlines the management of a patient with a pancreatic pseudocyst and concomitant splenic vein thrombosis treated with preoperative splenic embolization and laparoscopic cystgastrostomy via the lesser sac approach.

The treatment of pancreatic pseudocysts by laparoscopic drainage: endoluminal and lesser sac techniques.

A variety of approaches are now available to drain pancreatic pseudocysts (PP) when indicated. In addition to open surgery, endoscopic, laparoscopic, intra-luminal, and percutaneous techniques are available as therapeutic options to facilitate drainage of mature symptomatic PP. The laparoscopic lesser sac technique is appealing since it • relies on a secure stapled anastomosis, • provides an adequate sized cystgastrostomy to facilitate drainage, and • utilizes minimally invasive techniques to diminish operative morbidity and expedite return to normal activities. Short-term follow-up data suggest that this approach is feasible, effective and reproducible, Long-term studies demonstrating the efficacy of laparoscopic drainage of PP using the lesser sac technique are needed to validate these early favorable outcomes.

Transfer of training in acquiring laparoscopic skills.

BACKGROUND: Building on skills already learned in acquiring more complex or related skills is termed transfer of training (TOT). This study examined the TOT effects of previous open and laparoscopic surgical experience on a laparoscopic training module. STUDY DESIGN: Intracorporeal knot tying was chosen for evaluating TOT among three groups of surgical residents: interns (n = 11) with limited open and laparoscopic surgical experience, junior residents (n = 9) with recent and ongoing open and laparoscopic surgical experience, and senior residents (n = 8) with remote and limited laparoscopic experience but ongoing open surgical experience. After receiving a lecture, demonstration, and written instructions on three knot-tying techniques, residents rotated through three performance stations, one for each technique, over 2 days. After 15 minutes of practice, the residents were videotaped completing a test knot. Time to completion and economy of motion were recorded and analyzed. RESULTS: Junior residents had fewer performance errors than senior residents (reported as mean +/- standard error of the mean) and were significantly faster than interns. No significant differences between interns and senior residents for mean time or error performance were observed. Senior residents did not demonstrate TOT from open surgical experience to laparoscopic knot tying. No significant differences were obtained across the three sessions for errors or for time. CONCLUSION: No evidence was found for TOT from open surgical experience to newly introduced laparoscopic knot-tying techniques or from one skill training session to a different skill session at least 4 hours later. This study indicates that specific minimally invasive surgery training is needed to develop laparoscopic surgery skills.

Outpatient anterior cruciate ligament reconstruction: an analysis of charges and perioperative complications.

All outpatient anterior cruciate ligament (ACL) reconstructions using patellar tendon autograft performed at an accredited outpatient surgical center between 1994 and 1998 were prospectively studied. Hospital charges pertaining to the procedures were examined, and perioperative morbidities that might be attributed to an outpatient procedure were evaluated. The study group comprised 284 patients; average patient age at surgery was 28.7 years. Patients were subgrouped into group 1 (isolated ACL reconstructions; n=163), group 2 (ACL reconstructions and meniscal repair; n=48), and group 3 (ACL reconstructions and partial meniscectomy; n=73). Surgicenter facility charges, reoperation rate, complication rate, motion, pain management, hospital emergency room visits, hospital admission, and outpatient surgical facility visits were analyzed. Historical controls from our hospital and our initial outpatient pilot study (May 1994 through November 1995) were used as financial controls. The average surgical center charge for all patients was $3,443. On average, there was a $600 increase for all subgroups from May 1994 through November 1995 compared to December 1995 through August 1998. In the latter time interval, the fixed facility charges were $3,150, $4,075, and $4,275 for groups 1, 2, and 3, respectively. Overall, 19 (7%) patients required a reoperation including 7 (2.5%) patients who required arthroscopic debridement for symptomatic motion deficits. This study expands on our initial published report regarding hospital charges pertaining to an outpatient ACL reconstruction. Extended over another 4 years, we noted slight increases reflective of regional inflationary increases. Compared to our initial inpatient study (1988-1993), significant charge reductions were maintained. This study demonstrated a low complication rate and high patient subjective satisfaction level.

Laparoscopic pancreatic cystgastrostomy: the lesser sac technique.

Management of pancreatic pseudocysts has remained largely unchanged during the past century. Excision and drainage procedures remain the mainstay of therapy for large, persistent, or symptomatic pseudocysts. Laparoscopic approaches to the management of pancreatic pseudocysts have been previously described. The lesser sac approach is an effective means of creating a hemostatic cystgastrostomy through a single posterior gastrotomy. This procedure is performed by creating a cystotomy and posterior wall gastrotomy through which an endoscopic stapler is applied. The cystotomy-gastrotomy is closed using laparoscopically placed sutures. An endoscope is inserted into the stomach and pseudocyst at the conclusion of the procedure to ensure an airtight anastomosis. The lesser sac approach to pancreatic cystgastrostomy allows for a minimally invasive approach to the management of pancreatic pseudocysts using a single gastrotomy.

Laparoscopic dissecting instruments.

The authors provide an overview of laparoscopic dissecting instruments and discuss early development, surgical options, and special features. End effectors of different shapes and functions are described. A comparison of available energy sources for laparoscopic instruments includes discussion of thermal dissection, ultrasonic dissection, and water-jet dissection. The ergonomic risks and challenges inherent in the use of current laparoscopic instruments are outlined, as well as ergonomic issues for the design of future instruments. New directions that laparoscopic instrumentation may take are considered in connection with developing technology in robotics, haptic feedback, and MicroElectroMechanical Systems.

Immersive virtual reality used as a platform for perioperative training for surgical residents.

Perioperative preparations such as operating room setup, patient and equipment positioning, and operating port placement are essential to operative success in minimally invasive surgery. We developed an immersive virtual reality-based training system (REMIS) to provide residents (and other health professionals) with training and evaluation in these perioperative skills. Our program uses the qualities of immersive VR that are available today for inclusion in an ongoing training curriculum for surgical residents. The current application consists of a primary platform for patient positioning for a laparoscopic cholecystectomy. Having completed this module we can create many different simulated problems for other procedures. As a part of the simulation, we have devised a computer-driven real-time data collection system to help us in evaluating trainees and providing feedback during the simulation. The REMIS program trains and evaluates surgical residents and obviates the need to use expensive operating room and surgeon time. It also allows residents to train based on their schedule and does not put patients at increased risk. The method is standardized, allows for repetition if needed, evaluates individual performance, provides the possible complications of incorrect choices, provides training in 3-D environment, and has the capability of being used for various scenarios and professions.

Obesity and laparoscopic repair of ventral hernias.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) is gaining acceptance and compares favorably with open repair. Patients who are morbidly obese (MO) traditionally have been considered poor surgical candidates for ventral hernia repair because of their associated comorbidities and risk of postoperative wound infection and hernia recurrence. In this study we evaluated our experience with LVHR in patients who are obese and those who are morbidly obese. METHODS: All 64 patients undergoing LVHR at the University of Kentucky between September 1997 and October 2000, representing 66 hernias, were entered prospectively into a database. Data before, during, and after surgery were collected as well as follow-up data. Patients were divided into three groups on the basis of body mass index (BMI): normal to overweight (BMI < or = 29); obese (BMI 30-39), and MO (BMI > or = 40). RESULTS: There were 16 patients in the MO group, most of them women. The mean BMI was 43.9 (range, 40-60), and the mean age was 45.6 years (range, 25-68 years). The location of defects was similar among the groups, as were the number of prior repairs. The operative time and length of stay for the MO group tended to be longer than for the other two groups. Five minor complications occurred in the MO group. During a follow-up period ranging from 1 to 35 months, there were no recurrences. CONCLUSION: Laparoscopic repair of ventral hernias in patients who are morbidly obese is both safe and feasible, and can be performed with minimal morbidity. At this writing, there have been no recurrences, but long-term follow-up evaluation is required.

Mini-laparoscopic splenectomy.

BACKGROUND AND PURPOSE: Since the introduction of mini-laparoscopic instruments (2- to 3-mm diameter), their utility and safety have been questioned. Their application in cholecystectomy has recently been documented. This study determined the adequacy and safety of these minimally invasive instruments in laparoscopic splenectomy. METHODS: Retrospective review of all 16 mini-laparoscopic splenectomies performed by the authors was carried out. Diagnoses included immune thrombocytopenia (5), spherocytosis (6), and beta-thalassemia, sickle-cell disease, splenic mass, cyst, and splenomegaly in 1 case each. The average age of the patients was 20.1 years (range 4-70 years); seven patients were adults. Ten of the patients were female. The patients' body mass index ranged from 17 to 25 kg/m2. Splenomegaly (at least two times normal size: 100-200 g for children, 400-600 g for adults) was present in each case. A three-trocar technique was used in 15 patients, and a fourth trocar was required in only one case. RESULTS: The average operative time and blood loss were 114 minutes (range 60-195 minutes) and 44 mL (range 10-150 mL), respectively. There were no intraoperative complications, and no patient required transfusion. Conversion to standard laparoscopy or laparotomy did not occur. The mean hospital stay was 1.4 days (range 1-2 days). With an average 20-month follow-up, no wound, septic, or other complications have been identified. All patients or their families (in the case of children) graded the cosmetic outcome as excellent. CONCLUSION: The use of mini-laparoscopic instruments for splenectomy is safe and effective in children and adults with a normal body mass index, even in the case of splenomegaly. Operative times are reasonable, and hospital stays are brief. The postoperative cosmetic appearance is excellent.

Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases.

BACKGROUND: In this study of laparoscopic splenectomy (LS), we evaluate prospectively gathered perioperative patient data and review lessons learned in the evolution of this procedure. METHODS: At 2 university medical centers between November 1993 and March 2000, there were 203 patients (122 female patients and 81 male patients) who underwent LS after preoperative evaluation. RESULTS: LS was successfully completed in 197 patients (97%). The mean operative time was 145.5 minutes and the length of stay averaged 2.7 days with 143 (70.4%) staying less than 48 hours. The most common indication was idiopathic thrombocytopenic purpura (ITP). Six patients required conversion to open splenectomy (OS), with only 2 conversions in the last 163 cases. No deaths were attributed to the procedure. Complications occurred in 19 patients (9.3%). Thirty accessory spleens were identified in 25 patients (12.3%). Seventeen patients (8.4%) underwent concomitant procedures, most commonly cholecystectomy. CONCLUSIONS: LS by the lateral approach is both safe and feasible in patients of all ages.

Minilaparoscopically assisted placement of ventriculoperitoneal shunts.

BACKGROUND: Ventriculoperitoneal (VP) shunting remains the preferred treatment for hydrocephalus. Laparoscopic techniques to aid in the placement of the peritoneal portion of the catheter have been reported previously. We describe a minilaparoscopic VP shunt (MLVPS) insertion technique that facilitates directed placement of the peritoneal portion of the catheter in most patients, including those with obese abdomens previously subjected to surgery. In this study we review our experience with MLVPS placement. METHODS: All cases of MLVPS insertions at the University of Kentucky Medical Center and Lexington VA Hospital performed between February 1998 and March 1999 were reviewed retrospectively. A total of 27 patients (13 males and 14 females) ranging in age from 4 to 81 years (mean, 41 years) underwent VP shunting. The MLVPS insertion was performed via a 2-mm laparoscope and a separate 2-mm incision for catheter insertion using a venous introducer kit. In patients who had prior abdominal surgery, a 5-mm direct-view trocar was used. RESULTS: The MLVPS procedure was successful in 27 patients (100%). The mean number of prior shunts was 2 (range, 0-28). Of the 27 patients, 16 (59%) had undergone previous abdominal surgery. The mean operative time was 76 min (range, 19-155 min). There were no intra- or postoperative complications, and no mortalities. The follow-up period extended from 1 to 12 months. CONCLUSIONS: Findings show MLVPS placement to be safe and feasible. It allows accurate, directed placement of the VP shunt with a 2-mm laparoscope and a second 2-mm incision for shunt insertion. The procedure is associated with reduced trauma to the abdominal wall and minimal postoperative ileus. Long-term follow-up assessment of shunt function is planned.