Vascular and bowel complications during retroperitoneal laparoscopic surgery

Comparing technical dexterity of sleep-deprived versus intoxicated surgeons

Background:

The evidence on the effect of sleep deprivation on the cognitive and motor skills of physicians in training is sparse and conflicting, and the evidence is nonexistent on surgeons in practice. Work-hour limitations based on these data have contributed to challenges in the quality of surgical education under the apprentice model, and as a result there is an increasing focus on competency-based education. Whereas the effects of alcohol intoxication on psychometric performance are well studied in many professions, the effects on performance in surgery are not well documented. To study the effects of sleep deprivation on the surgical performance of surgeons, we compared simulated the laparoscopic skills of staff gynecologists “under 2 conditions”: sleep deprivation and ethanol intoxication. We hypothesized that the performance of unconsciously competent surgeons does not deteriorate postcall as it does under the influence of alcohol.

Methods:

Nine experienced staff gynecologists performed 3 laparoscopic tasks in increasing order of difficulty (cup drop, rope passing, pegboard exchange) on a box trainer while sleep deprived (<3 hours in 24 hours) and subsequently when legally intoxicated (>0.08 mg/mL blood alcohol concentration). Three expert laparoscopic surgeons scored the anonymous clips online using Global Objective Assessment of Laparoscopic Skills criteria: depth perception, bimanual dexterity, and efficiency. Data were analyzed by a mixed-design analysis of variance.

Results:

There were large differences in mean performance between the tasks. With increasing task difficulty, mean scores became significantly (P < .05) poorer. For the easy tasks, the scores for sleep-deprived and intoxicated participants were similar for all variables except time. Surprisingly, participants took less time to complete the easy tasks when intoxicated. However, the most difficult task took less time but was performed significantly worse compared with being sleep deprived. Notably, the evaluators did not recognize a lack of competence for the easier tasks when intoxicated; incompetence surfaced only in the most difficult task.

Conclusions:

Being intoxicated hinders the performance of more difficult simulated laparoscopic tasks than being sleep deprived, yet surgeons were faster and performed better on simple tasks when intoxicated.

A surgical virtual reality simulator distinguishes between expert gynecologic laparoscopic surgeons and perinatologists

BACKGROUND

Concern regarding the quality of surgical training in obstetrics and gynecology residency programs is focusing attention on competency based education. Because open surgical skills cannot necessarily be translated into laparoscopic skills and with minimally invasive surgery becoming standard in operative gynecology, the discrepancy in training between obstetrics and gynecology will widen. Training on surgical simulators with virtual reality may improve surgical skills. However, before incorporation into training programs for gynecology residents the validity of such instruments needs to first be established. We sought to prove the construct validity of a virtual reality laparoscopic simulator, the SurgicalSim(TM), by showing its ability to distinguish between surgeons with different laparoscopic experience.

METHODS

Eleven gynecologic surgeons (experts) and 11 perinatologists (controls) completed 3 tasks on the simulator, and 10 performance parameters were compared.

RESULTS

The experts performed faster, more efficiently, and with fewer errors, proving the construct validity of the SurgicalSim.

CONCLUSIONS

Laparoscopic virtual reality simulators can measure relevant surgical skills and so distinguish between subjects having different skill levels. Hence, these simulators could be integrated into gynecology resident endoscopic training and utilized for objective assessment. Second, the skills required for competency in obstetrics cannot necessarily be utilized for better performance in laparoscopic gynecology.

Intraoperative complications of laparoscopic adrenalectomy

A laparoscopic or retroperitoneoscopic access to the adrenal gland is the standard of care for adrenalectomy in most cases. Although in laparoscopic adrenalectomy the approach is minimally invasive, the procedure is challenging. This is reflected in the scope of possible complications. The surgeon must consider complications related to the anatomical topography of the adrenal gland, which typically encompasses the complications known from open surgery and complications related to the minimal invasive access. In this topic paper we will address the most frequently encountered complications of adrenalectomy: vascular injuries, injuries of the bowel, pleural tears, and injuries to the liver, spleen and pancreas. Fortunately, these complications occur rarely. However, many of these complications can have devastating consequences. Therefore, it's the surgeon's obligation to be aware of the possible complications he might encounter during laparoscopic adrenalectomy. This awareness is essential for their prevention and it helps the laparoscopic surgeon to identify complications intraoperatively.

Learning curve in human laparoscopic surgery

Laparoscopic urology has gained considerable popularity since the first laparoscopic nephrectomy was performed. However, the rapid application of the technique in urologic practice has led to increased reports of complications, even in the hands of surgeons who are well experienced in open surgical techniques, often early in a surgeon's laparoscopic experience. The lack of translation of open surgical skills into laparoscopic results has led us to reappraise the learning curves relevant to open and laparoscopic surgery, to understand the differences, and enable us to make changes in the curriculum and the training to acquire laparoscopic skills.

Taking the side of transperitoneal access for surgery in upper urinary tract

Laparoscopic surgery has become a preferred treatment option for the management of upper urinary tract pathology. Large series of complex urologic operations have been published, with favorable outcomes. Although the early experience with urologic laparoscopy consisted almost exclusively of transperitoneal procedures, some surgeons prefer the retroperitoneal approach. The debate of retroperitoneal versus transperitoneal laparoscopy for upper tract pathology is complex because comparative and randomized studies are lacking. In contrast to the retroperitoneal approach, transperitoneal laparoscopic procedures allow for a larger working space, adequate maneuverability, and the presence of familiar anatomic landmarks. This article highlights our experiences and approaches to major laparoscopic upper urinary tract surgery for benign and malignant conditions. A summary of the published literature as it pertains to the transperitoneal approach also is presented.