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1.
Isr Med Assoc J ; 22(1): 13-16, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31927799

RESUMO

BACKGROUND: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring. OBJECTIVES: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes. METHODS: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts. RESULTS: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011). CONCLUSIONS: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.


Assuntos
Ginecologia/educação , Histerectomia Vaginal/educação , Curva de Aprendizado , Cirurgia Endoscópica por Orifício Natural/educação , Adulto , Idoso , Feminino , Humanos , Histerectomia Vaginal/métodos , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/métodos , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento
2.
BMC Surg ; 19(1): 88, 2019 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-31291917

RESUMO

BACKGROUND: No data are available to assess the learning curve for transvaginal natural orifice transluminal endoscopic hysterectomy for non-prolapsed uteri in benign gynecologic diseases. The lack of exposure to transvaginal natural orifice transluminal endoscopic hysterectomy during training, in addition to a poorly defined learning curve, further deters interested physicians from applying this technique to daily practice. The aim of this study was to evaluate the learning curve and perioperative outcome of transvaginal natural orifice transluminal endoscopic hysterectomy by an experienced endoscopist. METHODS: A total of 240 cases of transvaginal natural orifice transluminal endoscopic hysterectomies with or without adnexectomy for various benign gynecologic diseases were included. Demographic data and various perioperative parameters were reviewed from the prospectively collected database. Operative time was set as a surrogate marker for surgical competency. The learning curve was evaluated using the cumulative sum method. RESULTS: The overall mean operative time (OT) was 76.5 min ± 22.4. Four unique phases of the learning curve were derived using cumulative sum analysis: the mean OT of phase I (the initial learning curve of 20 cases) was 86.3 ± 23.7 min, phase II (acquisition of competence of 80 cases) was 71.0 ± 21.4 min, phase III (proficiency and plateau of 80 cases) was 76.0 ± 20.4 min, and phase IV (post-learning in which more challenging cases were managed) was 81.3 ± 23.6 min. No major complications were encountered. One case in phase III converted to laparoscopy due to difficulty in performing anterior colpotomy. CONCLUSION: Our data demonstrated four distinct phases of the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy. In a well-trained endoscopist, surgical competence in transvaginal natural orifice transluminal endoscopic hysterectomy can be reached after 20 cases.


Assuntos
Competência Clínica , Doenças dos Genitais Femininos/cirurgia , Histerectomia/métodos , Curva de Aprendizado , Cirurgia Endoscópica por Orifício Natural , Adulto , Idoso , Feminino , Humanos , Histerectomia/educação , Laparoscopia/métodos , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/educação , Duração da Cirurgia , Estudos Retrospectivos
3.
Laryngoscope ; 129(10): 2253-2257, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30843604

RESUMO

OBJECTIVE: A five-level training program was first proposed 10 years ago for surgeons learning endoscopic endonasal surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. METHOD: A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of surgery. RESULTS: Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. CONCLUSION: This study provides a three-phase validation of training levels for endoscopic skull base surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:2253-2257, 2019.


Assuntos
Cirurgia Endoscópica por Orifício Natural/educação , Procedimentos Neurocirúrgicos/educação , Base do Crânio/cirurgia , Cirurgiões/educação , Ensino/classificação , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Procedimentos Neurocirúrgicos/efeitos adversos , Nariz/cirurgia , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
4.
Auris Nasus Larynx ; 46(2): 272-278, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30170906

RESUMO

OBJECTIVES: To assess the perspectives of OHNS residents with regards to their training in the following advanced head and neck surgery techniques: transoral robotic surgery (TORS), transoral laser microsurgery (TLM), sialendoscopy, and surgeon-performed ultrasound (SP-US) for possible curricula development. METHODS: Cross-sectional survey. A 20-item questionnaire was electronically distributed to OHNS residency programs assessing volume of cases, training barriers, satisfaction, additional training preferences, and pertinence to future practice. RESULTS: One hundred thirty-one residents completed the questionnaire. Trainee satisfaction with advanced techniques did not vary significantly with level of training (PGY) or intent to pursue fellowship. Residents who participated in more TLM, sialendoscopy, and SP-US cases were significantly more likely to be satisfied with their training (all p<0.05). The most frequently reported limitation to training was low home institution procedure volume. Seventy-eight of 123 respondents (63.4%) indicated insufficient opportunity to participate in TORS, with most residents reporting that TORS was preferentially performed by attendings (59/78, 75.6%). Forty-five of 126 (35.7%) reported having adequate access to skills training in TORS, compared to 43.6%, 48.4%, and 54.8% for sialendoscopy, TLM, and SP-US, respectively. A vast majority expressed interest in home institution-sponsored training courses in SP-US (120/127, 94.5%) and sialendoscopy (105/129, 81.4%). Many anticipated using SP-US (63.3%) and sialendoscopy (49.6%) in their future practices. CONCLUSION: Greater resident participation in advanced head and neck surgical procedures is associated with higher trainee satisfaction. There is a possible need for additional home institution-sponsored training courses, especially in sialendoscopy and SP-US. LEVEL OF EVIDENCE: N/A.


Assuntos
Currículo , Internato e Residência , Otolaringologia/educação , Procedimentos Cirúrgicos Otorrinolaringológicos/educação , Adulto , Estudos Transversais , Endoscopia/educação , Feminino , Humanos , Terapia a Laser , Masculino , Microcirurgia/educação , Cirurgia Endoscópica por Orifício Natural/educação , Procedimentos Cirúrgicos Robóticos/educação , Ductos Salivares , Inquéritos e Questionários , Ultrassonografia
5.
Surg Laparosc Endosc Percutan Tech ; 28(6): 380-384, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30222694

RESUMO

BACKGROUND: For selected patients, endoscopic thyroidectomy via the oral-vestibular approach (ETOVA) can be used to achieve a very good esthetic effect. This study aimed to assess the learning curve for ETOVA and identify improvements. PATIENTS AND METHODS: This retrospective study evaluated the outcomes of 101 patients who underwent ETOVA by surgeons A and B. The patients were classified according to whether they had undergone surgery during the primary or advanced stage of the learning curve, respectively. Proficiency with the procedure in various types of cases and the operation time, operative blood loss, hospital stay length, and postoperative complications were analyzed. RESULTS: In total, 56 and 45 patients were treated by surgeons A and B, respectively. For both surgeons, the operation times decreased considerably after 20 cases. Statistically significant differences with respect to stage were observed in terms of operation time (P<0.05) and drainage tube reservation (P<0.05). By contrast, significant differences were not observed between stages in terms of operative blood loss (P>0.05) or postoperative hospital stay length (P>0.05). The total postoperative complication rate was low and comparable with that of open surgery. CONCLUSIONS: The specific learning curve identified for ETOVA suggests that surgeons with sufficient endoscopic surgery experience could achieve a stable proficiency after ∼20 cases. A standardized training program and exposure to more cases would reduce the learning curve.


Assuntos
Competência Clínica/normas , Curva de Aprendizado , Cirurgia Endoscópica por Orifício Natural/normas , Cirurgiões/normas , Tireoidectomia/normas , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Cirurgia Endoscópica por Orifício Natural/educação , Cirurgia Endoscópica por Orifício Natural/métodos , Duração da Cirurgia , Estudos Retrospectivos , Cirurgiões/educação , Tireoidectomia/educação , Tireoidectomia/métodos
6.
Vestn Otorinolaringol ; 83(3): 50-55, 2018.
Artigo em Russo | MEDLINE | ID: mdl-29953056

RESUMO

The objective of the present study was to upgrade the rhinological simulator employed as a tool for the teaching of the basic technical skills in endoscopic sinus surgery (ESS). The new ESS simulator providing a model of the nasal cavity consists of the replaceable cylinders and the adaptable table stand. It includes a set of 3D printed nasal models. Each of them is the elliptical tube of a specific size. The participants of the study performed different tasks depending on the structural properties of the tubes. A wide variety of surgical instruments and esndoscopes could be fitted to the simulator. 16 otorhinolaryngologists having no previous experience with ESS were recruited into the study to evaluate the effectiveness of the training procedures. After a brief tutorial, the participants practiced an one hour-long exercise per day during 5 days. The pre-training and post-training performances were videotaped. The task-performance time and the number of technical errors made by the operators were estimated immediately before and after the training session. To assess the subjective attitudes of the operators toward the new technology, the participants of the study were asked to complete the model questionnaire soon after the termination of the training course. The questionnaire contained 34 items. The correctness of the answers was assessed based on the 5-point Likert scale, with score 1 meaning 'totally disagree' and score 5 - 'totally agree'. The statistically significant reduction of the performance time and the number of technical mistakes was documented within the first 5 hours after the onset of teaching (p<0.05) which suggests the effectiveness of the training procedures. The questionnaire study has demonstrated the positive attitude of the trainees toward the proposed technology. The average score based on the Likert scale was higher than 3 for all kinds of questions. It is concluded that the results of this study give evidence of the positive assessment of the upgraded rhinological simulator as an effective tool for the teaching of the basic skills necessary to operate various surgical instruments and endoscopes by the novice surgeons in the field of endoscopic sinus surgery .


Assuntos
Cirurgia Endoscópica por Orifício Natural , Otolaringologia/educação , Treinamento por Simulação/métodos , Competência Clínica , Humanos , Cirurgia Endoscópica por Orifício Natural/educação , Cirurgia Endoscópica por Orifício Natural/métodos , Seios Paranasais/cirurgia , Melhoria de Qualidade , Inquéritos e Questionários
7.
Eur Arch Otorhinolaryngol ; 275(8): 2187-2192, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29858924

RESUMO

PURPOSE: Cerebrospinal fluid leakage is always the primary complication during the endoscopic endonasal skull base surgery. Dural suturing technique may supply a rescue method. However, suturing and knotting in such a deep and narrow space are difficult. Training in the model can improve skills and setting a stepwise curriculum can increase trainers' interest and confidence. METHODS: We constructed an easy model using silicone and acrylic as sphenoid sinus and using the egg-shell membrane as skull base dura. The training is divided into three steps: Step 1: extracorporeal knot-tying suture on the silicone of sphenoid sinus, Step 2: intra-nasal knot-tying suture on the same silicone, and Step 3: intra-nasal egg-shell membrane knot-tying suture. Fifteen experienced microneurosurgical neurosurgeons (Group A) and ten inexperienced PGY residents (Group B) were recruited to perform the tasks. Performance measures were time, suturing and knotting errors, and needle and thread manipulations. The third step was assessed through the injection of full water into the other side of the egg to verify the watertight suture. The results were compared between two groups. RESULTS: Group A finishes the first and second tasks in significantly less time (total time, 125.1 ± 10.8 vs 195.8 ± 15.9 min) and fewer error points (2.4 ± 1.3 vs 5.3 ± 1.0) than group B. There are five trainers in group A who passed the third step, this number in group B was only one. CONCLUSIONS: This low cost and stepwise training model improved the suture and knot skills for skull base repair during endoscopic endonasal surgery. Experienced microneurosurgical neurosurgeons perform this technique more competent.


Assuntos
Vazamento de Líquido Cefalorraquidiano/cirurgia , Currículo , Cirurgia Endoscópica por Orifício Natural/educação , Procedimentos Neurocirúrgicos/educação , Base do Crânio/cirurgia , Técnicas de Sutura/educação , Suturas , Análise Custo-Benefício , Humanos , Cirurgia Endoscópica por Orifício Natural/economia , Cirurgia Endoscópica por Orifício Natural/métodos , Procedimentos Neurocirúrgicos/economia , Nariz , Técnicas de Sutura/economia , Técnicas de Sutura/instrumentação
8.
Oper Neurosurg (Hagerstown) ; 14(2): 158-165, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29351688

RESUMO

BACKGROUND: Variations on the endoscopic transsphenoidal approach present unique surgical techniques that have unique effects on surgical outcomes, extent of resection (EOR), and anatomical complications. OBJECTIVE: To analyze the learning curve and perioperative outcomes of the 3-hand endoscopic endonasal mononostril transsphenoidal technique. METHODS: Prospective case series and retrospective data analysis of patients who were treated with the 3-hand transsphenoidal technique between January 2007 and May 2015 by a single neurosurgeon. Patient characteristics, preoperative presentation, tumor characteristics, operative times, learning curve, and postoperative outcomes were analyzed. Volumetric EOR was evaluated, and a logistic regression analysis was used to assess predictors of EOR. RESULTS: Two hundred seventy-five patients underwent an endoscopic transsphenoidal surgery using the 3-hand technique. One hundred eighteen patients in the early group had surgery between 2007 and 2010, while 157 patients in the late group had surgery between 2011 and 2015. Operative time was significantly shorter in the late group (161.6 min) compared to the early group (211.3 min, P = .001). Both cohorts had similar EOR (early group 84.6% vs late group 85.5%, P = .846) and postoperative outcomes. The learning curve showed that it took 54 cases to achieve operative proficiency with the 3-handed technique. Multivariate modeling suggested that prior resections and preoperative tumor size are important predictors for EOR. CONCLUSION: We describe a 3-hand, mononostril endoscopic transsphenoidal technique performed by a single neurosurgeon that has minimal anatomic distortion and postoperative complications. During the learning curve of this technique, operative time can significantly decrease, while EOR, postoperative outcomes, and complications are not jeopardized.


Assuntos
Cirurgia Endoscópica por Orifício Natural , Neuroendoscopia , Adenoma/diagnóstico por imagem , Adenoma/patologia , Adenoma/cirurgia , Estudos de Coortes , Feminino , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Análise Multivariada , Cirurgia Endoscópica por Orifício Natural/educação , Cirurgia Endoscópica por Orifício Natural/métodos , Neuroendoscopia/educação , Neuroendoscopia/métodos , Duração da Cirurgia , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/patologia , Neoplasias Hipofisárias/cirurgia , Procedimentos Cirúrgicos Reconstrutivos , Reoperação , Base do Crânio/diagnóstico por imagem , Base do Crânio/cirurgia , Resultado do Tratamento , Carga Tumoral
9.
Surg Endosc ; 32(7): 3046-3054, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29380066

RESUMO

BACKGROUND: Per oral endoscopic myotomy (POEM) has emerged as a promising option for the treatment of achalasia. This study assessed POEM training process, outcomes, and improvement in quality of life after POEM performed by an interventional endoscopist (mentor) with trainees. METHODS: We performed a retrospective review of data for patients who underwent POEM with involvement of trainees. Trainees were trained in performing mucosotomy, submucosal dissection, creating submucosal tunnel, identifying gastroesophageal junction, myotomy, and closure of mucosal incision in a step-by-step fashion. Trainees' performance on each step was evaluated by the mentor based on several key points in each step. The short form 36 (SF36) was obtained before and certain times after the primary POEM procedure was performed. RESULTS: Sixty-two patients, 26 males and 36 females with a mean age of 59 years, who underwent POEM were enrolled. A checklist included all related items for each step was established. All trainees obtained competence within 6 cases for each step. 61/62 (98.3%) patients had a significant improvement in the Eckardt's score post POEM: 9.3 ± 1.5 prior to POEM and 2.6 ± 1.2 after the POEM (P = 0.001) and a decrease in mean lower esophageal sphincter pressure (LES): pre- and post-procedure mean LES pressures were 28.5 ± 11.4 and 12.1 ± 4.5 mmHg, respectively (P = 0.001). The SF-36 questionnaire demonstrated a significant improvement in quality of life and comparable with those without trainees in other studies. CONCLUSION: This preliminary study showed for the first time that training for POEM can be performed in a step-by-step fashion, learning mucosal incision, submucosal dissection, myotomy, and mucosal incision closure from an expert interventional endoscopist without increasing adverse events. The checklist for each step could be used as an important guide in training POEM. The outcomes of POEM in this study were similar to those reported by others without trainees. Further multiple center studies are needed to verify this training process and to establish a formal training protocol.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Ressecção Endoscópica de Mucosa/métodos , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Qualidade de Vida , Adulto , Idoso , Idoso de 80 Anos ou mais , Ressecção Endoscópica de Mucosa/educação , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/psicologia , Esofagoscopia/métodos , Feminino , Gastroenterologia/educação , Humanos , Masculino , Pessoa de Meia-Idade , Miotomia/educação , Cirurgia Endoscópica por Orifício Natural/educação , Estudos Retrospectivos , Fatores de Tempo
10.
Surg Endosc ; 32(3): 1414-1421, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28916889

RESUMO

INTRODUCTION: With the increasing adoption of peroral endoscopic myotomy (POEM) as a first-line therapy for achalasia as well as a growing list of other indications, it is apparent that there is a need for effective training methods for both endoscopists in training and those already in practice. We present a hands-on-focused with pre- and post-testing methodology to teach these skills. METHODS: Six POEM courses were taught by 11 experienced POEM endoscopists at two independent simulation laboratories. The training curriculum included a pre-training test, lectures and discussion, mentored hands-on instruction using live porcine and ex-plant models, and a post-training test. The scoring sheet for the pre- and post-tests assessed the POEM performance with a Likert-like scale measuring equipment setup, mucosotomy creation, endoscope navigation, visualization, myotomy, and closure. Participants were stratified by their experience with upper-GI endoscopy (Novices <100 cases vs. Experts ≥100 cases), and their data were analyzed and compared. RESULTS: Sixty-five participants with varying degrees of experience in upper-GI endoscopy and laparoscopic achalasia cases completed the training curriculum. Participants improved knowledge scores from 69.7 ± 17.1 (pre-test) to 87.7 ± 10.8 (post-test) (p < 0.01). POEM performance increased from 15.1 ± 5.1 to 25.0 ± 5.5 (out of 30) (p < 0.01) with the greatest gains in mucosotomy [1.7-4.4 (out of 5), p < 0.01] and equipment (3.4-4.7, p < 0.01). Novices had significantly lower pre-test scores compared with Experts in upper-GI endoscopy (overall pre-score: 11.9 ± 5.6 vs. 16.3 ± 4.6, p < 0.01). Both groups improved significantly after the course, and there were no differences in post-test scores (overall post-score: 23.9 ± 6.6 vs. 25.4 ± 5.1, p = 0.34) between Novices and Experts. CONCLUSIONS: A multimodal curriculum with procedural practice was an effective curricular design for teaching POEM to practitioners. The curriculum was specifically helpful for training surgeons with less upper-GI endoscopy experience.


Assuntos
Currículo , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/educação , Cirurgiões/educação , Adulto , Avaliação Educacional , Acalasia Esofágica/cirurgia , Feminino , Humanos , Masculino
11.
J Clin Neurosci ; 42: 209-216, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28511971

RESUMO

The endoscopic endonasal approach is considered an alternative minimally invasive approach for suprasellar craniopharyngiomas. However, the complicated surgical manipulations required by this approach have limited its application. We evaluate whether the approach features a learning curve. Thirty-three patients were retrospectively reviewed and grouped as early (17 patients) and late (16 patient) groups. The operation time, extent of removal, ophthalmology, endocrinology, reconstruction and modifications of standard technique were evaluated. Between the two groups, the operation time decreased from 201.1±105.3min in the early group to 107.6±90.0min in the late group (p<0.05). Regarding clinical outcomes, non-significantly increasing trends toward the rate of gross total resection, visual improvement and (from 76.5% to 87.5%, 73.3% to 93.3%), significantly decreasing trends toward the rate of tumor recurrence (from 23.5% to 0% p<0.05) and non-significantly decreasing trends toward the rate of hypopituitarism recovery (26.7% to 0%) were observed between the two groups. With respect to complications, non-statistically significant decreasing trends toward transient cranial nerve paralysis (from 5.9% to 0%) and non-statistically significant increasing trends toward rate of CSF leakage, meningitis and new hypothyroidism (from 11.8% to 25%, 11.8% to 31.3%, 0 to 3%) were observed. We identified a learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. The exact number of patients necessary to establish a significant improvement in the clinical outcomes and decrease in the complications warrants further investigation. The outcomes of tumor recurrence may be associated with duration of follow-up. The CSF leakage represented the most common complication.


Assuntos
Rinorreia de Líquido Cefalorraquidiano/etiologia , Craniofaringioma/cirurgia , Curva de Aprendizado , Cirurgia Endoscópica por Orifício Natural/educação , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Rinorreia de Líquido Cefalorraquidiano/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/métodos , Nariz , Complicações Pós-Operatórias/epidemiologia
12.
Surg Endosc ; 31(2): 987-994, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27495340

RESUMO

BACKGROUND: Novel, less invasive approaches such as single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery require preclinical evaluation and training. Therefore, there is a need for an experimental model closely mimicking the clinical situation. The aim of our study was to create an experimental model of calculous cholecystitis in a large laboratory animal and test its feasibility for the evaluation of different techniques of cholecystectomy. METHODS: In 11 laboratory pigs, gallstones were placed inside the gallbladder laparoscopically. Levels of inflammatory markers-leucocytes (WBC), C-reactive protein (CRP) and interleukin 6 (IL-6)-were monitored on the postoperative days (POD) 1, 2, 3, 7 and 30. Abdominal ultrasound was performed 2 and 4 weeks after the operation. Four weeks after the lithiasis induction, laparoscopic cholecystectomy was performed. The control group consisted of ten healthy animals in which a cholecystectomy was performed. The pigs were monitored for 30 days after surgery. All removed gallbladders were assessed histologically. RESULTS: The induction of lithiasis took 42 (35-52) min with no morbidity and mortality. The values of WBC, CRP and IL-6 increased significantly (vs. baseline) on POD 1, 2 and 3 (p < 0.05) and then normalised. Ultrasonography confirmed the presence of chronic calculous cholecystitis in all cases after 4 weeks. Laparoscopic cholecystectomy was significantly longer in animals with lithiasis, 63 (42-91) versus 46 (31-62) min (p = 0.018). Perioperative gallbladder wall perforation was significantly more frequent in the model group (8/11 vs. 1/10; p = 0.04). In contrast to healthy animals, all gallbladders with stones showed histological signs of chronic inflammation. CONCLUSIONS: A new animal model of calculous cholecystitis was created. Laparoscopic cholecystectomy was more technically difficult compared to operating on a healthy gallbladder. This model may be a suitable tool for effective preclinical training and also for the evaluation of different techniques of cholecystectomy.


Assuntos
Colecistectomia Laparoscópica/educação , Colecistolitíase/cirurgia , Cirurgia Endoscópica por Orifício Natural/educação , Animais , Colecistectomia Laparoscópica/métodos , Modelos Animais de Doenças , Procedimentos Cirúrgicos Minimamente Invasivos , Cirurgia Endoscópica por Orifício Natural/métodos , Suínos , Resultado do Tratamento
13.
Surg Endosc ; 31(6): 2566-2572, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27670649

RESUMO

BACKGROUND: Esophageal bougination is a worldwide standard endoscopic procedure. Clinical methods and recommendations are based on clinical experiences only. Mechanical properties have never been described. Aim of the study was to establish a realistic ex vivo training model. Therefore, detailed assessment of relevant mechanical features of esophageal bougination should be evaluated ex vivo and in patient setting and correlated against. PATIENTS AND METHODS: A three-step concept was used to evaluate mechanical properties at stenosis level. First, insertion forces were evaluated in an ex vivo linear single stenosis model during steady mechanical insertion. Second, adding friction and properties of the pharynx and upper esophagus, the model was integrated in an artificial endoscopic training model (ELITE training model). Third, in vivo measurements were taken to correlate ex vivo data with parameters of a realistic patient setting. RESULTS: With the presented setup, we were able to assess insertion force and pressure levels in an artificial stricture using different sizes of commercially available standard bougies. In all models, there was a relevant increase in insertion force with higher stricture pressure levels. Insertion force levels in the ELITE model show higher levels compared to the linear stenosis model. Having regard to the maximum forces in patients, there is also a constant increase in mean insertion force according to higher bougie sizes, but lower forces were measured as in the ELITE model. DISCUSSION: The applied models are suitable to appraise mechanical properties of esophageal bougination in an ex vivo model and patient setting. Forces could be constituted reliable, significant increase was documented according to stenosis level and results were comparable to patient data. This was comparable to patient data. Further clinical evaluation in different kinds of stenosis is necessary.


Assuntos
Competência Clínica , Estenose Esofágica/cirurgia , Cirurgia Endoscópica por Orifício Natural/educação , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Anatômicos
14.
Surg Innov ; 24(1): 55-65, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27671036

RESUMO

The goal of this study was to establish face, content, and construct validity of NOViSE-the first force-feedback enabled virtual reality (VR) simulator for natural orifice transluminal endoscopic surgery (NOTES). Fourteen surgeons and surgical trainees performed 3 simulated hybrid transgastric cholecystectomies using a flexible endoscope on NOViSE. Four of them were classified as "NOTES experts" who had independently performed 10 or more simulated or human NOTES procedures. Seven participants were classified as "Novices" and 3 as "Gastroenterologists" with no or minimal NOTES experience. A standardized 5-point Likert-type scale questionnaire was administered to assess the face and content validity. NOViSE showed good overall face and content validity. In 14 out of 15 statements pertaining to face validity (graphical appearance, endoscope and tissue behavior, overall realism), ≥50% of responses were "agree" or "strongly agree." In terms of content validity, 85.7% of participants agreed or strongly agreed that NOViSE is a useful training tool for NOTES and 71.4% that they would recommend it to others. Construct validity was established by comparing a number of performance metrics such as task completion times, path lengths, applied forces, and so on. NOViSE demonstrated early signs of construct validity. Experts were faster and used a shorter endoscopic path length than novices in all but one task. The results indicate that NOViSE authentically recreates a transgastric hybrid cholecystectomy and sets promising foundations for the further development of a VR training curriculum for NOTES without compromising patient safety or requiring expensive animal facilities.


Assuntos
Colecistectomia/educação , Simulação por Computador , Feedback Formativo , Cirurgia Endoscópica por Orifício Natural/educação , Treinamento por Simulação , Adulto , Competência Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Interface Usuário-Computador
15.
J Craniomaxillofac Surg ; 44(11): 1800-1805, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27713053

RESUMO

PURPOSE: Endoscope-assisted surgery has widely been adopted as a basic surgical procedure, with various training systems using virtual reality developed for this procedure. In the present study, a basic training system comprising virtual reality for the removal of submandibular glands under endoscope assistance was developed. The efficacy of the training system was verified in novice oral surgeons. MATERIAL AND METHODS: A virtual reality training system was developed using existing haptic devices. Virtual reality models were constructed from computed tomography data to ensure anatomical accuracy. Novice oral surgeons were trained using the developed virtual reality training system. RESULTS: The developed virtual reality training system included models of the submandibular gland and surrounding connective tissues and blood vessels entering the submandibular gland. Cutting or abrasion of the connective tissue and manipulations, such as elevation of blood vessels, were reproduced by the virtual reality system. A training program using the developed system was devised. Novice oral surgeons were trained in accordance with the devised training program. CONCLUSIONS: Our virtual reality training system for endoscope-assisted removal of the submandibular gland is effective in the training of novice oral surgeons in endoscope-assisted surgery.


Assuntos
Instrução por Computador , Cirurgia Endoscópica por Orifício Natural/educação , Glândula Submandibular/cirurgia , Simulação por Computador , Instrução por Computador/instrumentação , Humanos , Cirurgia Endoscópica por Orifício Natural/instrumentação , Interface Usuário-Computador
16.
Best Pract Res Clin Gastroenterol ; 30(3): 397-408, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27345648

RESUMO

Advanced endoscopy has evolved from diagnostic ERCP to an ever-increasing array of therapeutic procedures including EUS with FNA, ablative therapies, deep enteroscopy, luminal stenting, endoscopic suturing and endoscopic mucosal resection among others. As these procedures have become increasingly more complex, the risk of potential complications has also risen. Training in advanced endoscopy involves more than obtaining a minimum number of therapeutic procedures. The means of assessing a trainee's competence level and ability to practice independently continues to be a matter of debate. The use of quality indicators to measure performance levels may be beneficial as more advanced techniques and procedures become available.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Educação Médica Continuada/organização & administração , Endoscopia Gastrointestinal/educação , Endossonografia , Cirurgia Endoscópica por Orifício Natural/educação , Competência Clínica , Humanos , Indicadores de Qualidade em Assistência à Saúde
17.
Surg Endosc ; 30(12): 5529-5536, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27129546

RESUMO

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical paradigm, where peritoneal access is achieved through one of the natural orifices of the body. It is being reported as a safe and feasible surgical technique with significantly reduced external scarring. Virtual Translumenal Endoscopic Surgical Trainer (VTEST™) is the first virtual reality simulator for the NOTES. The VTEST™ simulator was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the VTEST™ simulator underwent face validation at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. This manuscript outlines the results of the subsequent evaluation study, performed in order to assess the face and content validity of the latest VTEST™ simulator. METHODS: Twelve subjects participated in an institutional review board-approved study that took place at the 2014 NOSCAR summit. Six of the 12 subjects, who are experts with NOTES experience, were used for face and content validation. The subjects performed the hybrid transvaginal NOTES cholecystectomy procedure on VTEST™ that included identifying the Calot's triangle, clipping and cutting the cystic duct/artery, and detaching the gallbladder. The subjects then answered five-point Likert scale feedback questionnaires for face and content validity. RESULTS: Overall, subjects rated 12/15 questions as 3.0 or greater (60 %), for face validity questions regarding the realism of the anatomical features, interface, and the tasks. Subjects also highly rated the usefulness of the simulator in learning the fundamental NOTES technical skills (3.50 ± 0.84). Content validity results indicate a high level of usefulness of the VTEST™ for training prior to operating room experience (4.17 ± 0.75).


Assuntos
Colecistectomia/educação , Colecistectomia/métodos , Cirurgia Endoscópica por Orifício Natural/educação , Treinamento por Simulação/métodos , Colecistectomia/instrumentação , Feminino , Humanos , Cirurgia Endoscópica por Orifício Natural/instrumentação , Cirurgia Endoscópica por Orifício Natural/métodos , Estados Unidos , Interface Usuário-Computador , Vagina/cirurgia
18.
Artigo em Inglês | MEDLINE | ID: mdl-27046543

RESUMO

Natural orifice translumenal endoscopic surgery (NOTES) procedures are rapidly being developed in diverse surgical fields. We are developing a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™) built on a modularized platform that facilitates rapid development of virtual reality (VR) NOTES simulators. Both the hardware interface and software components consist of independent reusable and customizable modules. The developed modules are integrated to build a VR-NOTES simulator for training in the hybrid transvaginal NOTES cholecystectomy. The simulator was demonstrated and evaluated by expert NOTES surgeons at the 2015 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit.


Assuntos
Instrução por Computador/métodos , Cirurgia Endoscópica por Orifício Natural/educação , Cirurgia Endoscópica por Orifício Natural/métodos , Treinamento por Simulação/métodos , Cirurgia Assistida por Computador/métodos , Interface Usuário-Computador , Instrução por Computador/instrumentação , Desenho de Equipamento , Análise de Falha de Equipamento , Cirurgia Endoscópica por Orifício Natural/instrumentação , Software , Cirurgia Assistida por Computador/instrumentação
19.
Gastrointest Endosc Clin N Am ; 26(2): 385-400, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27036904

RESUMO

Natural orifice translumenal endoscopic surgery (NOTES) is an intense area of research, and is arguably the most significant endoscopic innovation of this decade. Training for new NOTES is a relatively long, encompassing advanced endoscopy training, mastery of endoscopic dexterity within the narrow submucosal or "third space" with an in-depth understanding of the tissue planes. Proficiency with new closure and hemostatic devices is also essential. Few institutions worldwide can provide all the cognitive and technical elements essential to train new NOTES trainees. Trainees may need to spend time across several institutions to ensure safe and effective practice of new NOTES.


Assuntos
Endoscopia Gastrointestinal/educação , Cirurgia Endoscópica por Orifício Natural/educação , Desenvolvimento de Programas , Humanos , Técnicas de Sutura/educação
20.
Gastrointest Endosc Clin N Am ; 26(2): 401-412, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27036905

RESUMO

Natural orifice transluminal endoscopic surgery (NOTES) is a newer field of endoscopic surgery that allows for scarless treatment of pathologic entities, using novel transluminal approaches. There has been a shift of focus from a clinical and research standpoint from the development and dissemination of "first-generation" NOTES procedures to "new NOTES" procedures that traverse the mucosa of luminal structures, yet do not stray far into the peritoneal cavity. It has been a challenge to find appropriate and effective ways to train gastroenterologists and surgeons in these novel approaches. We review the importance of simulation in training and discuss available simulation options.


Assuntos
Simulação por Computador , Endoscopia Gastrointestinal/educação , Cirurgia Endoscópica por Orifício Natural/educação , Treinamento por Simulação/métodos , Humanos
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