Should high-frequency electrosurgery be discouraged during laparoscopic surgery?

Surgeons know that they don't know about the safe use of surgical energy: an international study reveals that the knowledge gap persists

INTRODUCTION

The rate of electrosurgery complications is 0.1-2.1%. More than 10 years ago, SAGES pioneered a well-structured educational program (FUSE) aimed to teach about the safe use of electrosurgery. This inspired the development of similar training programs around the globe. Still, the knowledge gap persists among surgeons, possibly due to the lack of judgment.

AIM

To investigate factors affecting the level of expertise in electrosurgical safety and their correlation with self-assessment scores among surgeons and surgical residents.

MATERIALS AND METHODS

We conducted an online survey consisting of 15 questions that could be thematically broken down into 5 blocks. We analyzed how the objective scores were correlated with the self-assessment scores, professional experience, past participation in training programs, and work at a teaching hospital.

RESULTS

A total of 145 specialists took part in the survey, including 111 general surgeons and 34 s-year surgical residents from Russia, Belarus, Ukraine, and Kirgizia. Only 9 (8.1%) surgeons scored "excellent," 32 (28.8%) scored "good," and 56 (50.4%) scored "fair." Of all surgical residents participating in the study, only 1 (2.9%) scored "excellent," 9 (26.5%) scored "good," and 11 (32.4%) scored "fair." The test was failed by 14 surgeons (12.6%) and 13 (38.2%) residents. The difference between the trainees and the surgeons was statistically significant. Our multivariate logistic model identified 3 significant factors predisposing to successful performance on the test: past training in the safe use of electrosurgery, professional experience, and work at a teaching hospital. Of all study participants, those with no past training in the safe use of electrosurgery, and non-teaching surgeons were the most realistic about their competencies.

CONCLUSION

We have identified alarming gaps in the knowledge of electrosurgical safety among surgeons. Faculty staff and experienced surgeons scored higher, but past training was the most influential factor in improving knowledge of electrosurgical safety.

Detection of adverse events leading to inadvertent injury during laparoscopic cholecystectomy using convolutional neural networks

Uncontrolled movements of laparoscopic instruments can lead to inadvertent injury of adjacent structures. The risk becomes evident when the dissecting instrument is located outside the field of view of the laparoscopic camera. Technical solutions to ensure patient safety are appreciated. The present work evaluated the feasibility of an automated binary classification of laparoscopic image data using Convolutional Neural Networks (CNN) to determine whether the dissecting instrument is located within the laparoscopic image section. A unique record of images was generated from six laparoscopic cholecystectomies in a surgical training environment to configure and train the CNN. By using a temporary version of the neural network, the annotation of the training image files could be automated and accelerated. A combination of oversampling and selective data augmentation was used to enlarge the fully labeled image data set and prevent loss of accuracy due to imbalanced class volumes. Subsequently the same approach was applied to the comprehensive, fully annotated Cholec80 database. The described process led to the generation of extensive and balanced training image data sets. The performance of the CNN-based binary classifiers was evaluated on separate test records from both databases. On our recorded data, an accuracy of 0.88 with regard to the safety-relevant classification was achieved. The subsequent evaluation on the Cholec80 data set yielded an accuracy of 0.84. The presented results demonstrate the feasibility of a binary classification of laparoscopic image data for the detection of adverse events in a surgical training environment using a specifically configured CNN architecture.

Thermal Processes in Bile Ducts During Laparoscopic Cholecystectomy with Monopolar Instruments. Experimental Study Using Real-Time Intraluminal and Surface Thermography

Introduction. A significant rate of complications during laparoscopic cholecystectomy (LC) occurs due to thermal injury caused by monopolar electrosurgery (MES) equipment. Most of them manifest weeks and months after surgery with the common bile duct (CBD) and large duodenal papilla strictures, some in the early postoperative period with bile leaks. Objective. To study thermal processes occurring in the lumen and on the surface of the bile ducts during monopolar coagulation in a porcine model of LC. Methods. The temperature of the bile ducts was measured using instrumentation consisted of biliary stent with temperature sensors, which was inserted in the porcine CBD, signal amplifier, and current sense transformer. Surface temperature was measured with a scientific grade thermal camera. Cholecystectomy was performed using a standard "critical view of safety" (CVS) approach with 5 mm monopolar laparoscopic instruments. Results. Application of MES caused significant tissue heating. Lateral thermal spread and the rate of tissue heating depended on the duration of energy application and the initial tissue temperature. In 5 out of 6 experiments, the intraluminal temperature rose up to the critical threshold, and the exposure time ranged from 54 to 560 seconds. A sensor positioned at the papilla site was heated in all the experiments but still below the cell damage inducing threshold. The analysis of thermographic charts revealed the presence of the "current channeling" effect and the pedicle effect. Conclusion. There is a possibility of a direct and delayed thermal injury to the bile ducts during LC.

Minilaparoscopy For Inguinal Hernia Repair

BACKGROUND AND OBJECTIVES

Inguinal hernia repair is among the most common procedures performed worldwide and the laparoscopic totally extraperitoneal (TEP) approach is a recognized and effective surgical technique. Although technically advantageous because of the option of no mesh fixation and no need for creation of a peritoneal flap resulting, in less postoperative pain and faster recovery, TEP has not achieved the popularity it deserves, mainly because of its complexity and steep learning curve. Minilaparoscopy was first described in the 1990s and has recently gained significantly from better instrumentation that may increase TEP's effectiveness and acceptance. We performed a prospective study, to analyze the outcomes of minilaparoscopy in pain and operative time when compared to the conventional laparoscopic technique in hernia repair.

METHODS

Fifty-eight laparoscopic inguinal hernia repairs were performed: 36 by traditional laparoscopic technique and 22 by minilaparoscopic instruments (mini). A study protocol was applied prospectively for data collection. Variables analyzed were early postoperative pain (at hour 6 after procedure), pain at discharge, use of on-demand analgesics, and operative time.

RESULTS

The mini group presented reduced early postoperative pain and operative time. The present study also suggests less postoperative pain at discharge with mini procedures, although this difference was not statistically significant. No difference between the groups regarding on-demand use of analgesics was found.

CONCLUSIONS

This study corroborates findings in previously published papers that have shown the feasibility of minilaparoscopy in laparoscopic TEP hernia repair and its benefits regarding postoperative pain, operative time, and aesthetic outcomes.