Adrian Anthony

Surgical simulation: a systematic review.

Objective:To evaluate the effectiveness of surgical simulation compared with other methods of surgical training. Summary Background Data:Surgical simulation (with or without computers) is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they operate on humans. Methods:Studies were identified through searches of MEDLINE, EMBASE, the Cochrane Library, and other databases until April 2005. Included studies must have been randomized controlled trials (RCTs) assessing any training technique using at least some elements of surgical simulation, which reported measures of surgical task performance. Results:Thirty RCTs with 760 participants were able to be included, although the quality of the RCTs was often poor. Computer simulation generally showed better results than no training at all (and than physical trainer/model training in one RCT), but was not convincingly superior to standard training (such as surgical drills) or video simulation (particularly when assessed by operative performance). Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training. Conclusions:While there may be compelling reasons to reduce reliance on patients, cadavers, and animals for surgical training, none of the methods of simulated training has yet been shown to be better than other forms of surgical training.

Endoscopic modified Lothrop procedure for the treatment of chronic frontal sinusitis: a systematic review

OBJECTIVE We sought to assess the safety and efficacy of the endoscopic modified Lothrop procedure (EMLP), performed either wholly intranasally or in combination with an external approach, against the osteoplastic flap (OPF) procedure with or without fat obliteration. METHODS All original, published studies on the EMLP and the OPF, with or without fat obliteration, were identified by searching Current Contents, Embase, MEDLINE, and The Cochrane Library. The search strategy for OPF was date-restricted to articles published after 1979 until February 2001. For both EMLP and OPF, only studies of patients diagnosed with chronic frontal sinusitis were included for review. English-language reports detailing randomized controlled trials, controlled clinical trials, case series, or case reports were included. RESULTS The limited comparative data suggested that EMLP caused fewer adverse postoperative outcomes but was more likely to generate a perioperative cerebrospinal fluid leak than OPF. However, none of the morbidity traditionally associated with OPF was evident after EMLP. EMLP appeared to have a shorter operative time and a lower perioperative blood loss than OPF, but little could be determined regarding the long-term efficacy and durability of EMLP because of the relatively short follow-up of the majority of the studies. CONCLUSION The evidence base for EMLP was deemed inadequate to assess its safety and efficacy, and an audit of the procedure was recommended. Additional clinical recommendations were made regarding the development and current practice of EMLP during this audit phase.

Liver electrolysis: pH can reliably monitor the extent of hepatic ablation in pigs

Electrolysis is a method of tissue ablation that creates chemical species and a pH gradient in response to direct current. Initial studies of electrolysis in animal models and humans have shown that it is a safe, predictable and effective process for destroying normal and tumour-bearing liver in a linear, dose-dependent manner. Presently, the amount of current that is applied (in coulombs) has to be calculated using historical data, with inherent inaccuracy. The present study tested whether pH could be used as a real-time monitor in order to predict more accurately the extent of necrosis. A total of 70 electrolytic lesions were created in 14 pigs, with pH monitoring of the lesion edge. The normal range of pH values was 6.5-8.7. A pH of less than 6 (at the anode) or more than 9 (at the cathode) reflected total cellular necrosis. When a pH value was recorded between 6.0 and 6.5 at the anode or between 8.7 and 9.0 at the cathode, the presence of necrosis was variable. In conclusion, during electrolytic ablation, pH measurement can monitor the extent of the induced necrosis.

Learning surgical communication, leadership and teamwork through simulation.

BACKGROUND In Australia and New Zealand, surgical trainees are expected to develop competencies across 9 domains. Although structured training is provided in several domains, there is little or no formal program for professionalism, communication, collaboration, and management and leadership. The Australian federal Department of Health and Aging funded a pilot course in simulation-based education to address these competencies for surgical trainees. This article describes the course and evaluation. METHODS Course development: Content and methods drew on best-evidence for teaching and learning these competencies from other disciplines. Course evaluation: Participants completed surveys using rating scales and free text comments to identify aspects of the course that worked well and those that needed improvement. RESULTS Eleven of 12 participants completed evaluation forms immediately after the course. Participants reported largely meeting learning objectives and valuing the educational methods. High levels of realism in simulations contributed to the ease with which participants immersed themselves in scenarios. CONCLUSIONS This study demonstrates that a course designed to teach competencies in communication, teamwork, leadership, and the encompassing professionalism to surgical trainees is feasible. Although participants valued the content and methods, they identified areas for development. Limitations of the evaluation are highlighted, and further areas for research are identified.

Use of electrolysis for the treatment of non‐resectable hepatocellular carcinoma

Beverley G. Fosh, J. Guy Finch, Adrian A. Anthony, Melissa M. Lea, Samantha K. Wong, Carin L. Black and Guy J. Maddern

A pilot training program in surgical communication, leadership and teamwork

risk factor disease states, for example, the definition of hypercholesterolemia, diabetes and hypertension, and the introduction of newer more effective drugs (e.g. clopidorel and statins). Analysis of medically treated patients over many years demonstrated a decrease in stroke rate over time with best medical therapy; the SMART study further demonstrated a continuation of the downward trend among patients receiving medical intervention for vascular disease, with the annual risk of stroke from asymptomatic carotid stenosis of less than 1%; and medical intervention alone was calculated to be at least 3 to 8 times more cost-effective in stroke prevention. While patients with symptomatic carotid artery stenoses benefit from intervention, improvements in medical therapy now mean that the same probably does not hold true for asymptomatic carotid stenoses with stroke rates of less than 1%. There has also not been a concurrent reduction in surgical risk, which in many centres exceed 2–3% for both CAS and CEA. It is also interesting that the magnetic resonance imaging changes after CAS is not considered in the same light as a troponin rise (indicating myocardial infarction) after CEA. When offering intervention to patients with asymptomatic carotid stenoses with marginal benefit at best, vascular interventionalists should adhere to evidence and guidelines as recently discussed in this journal. But it is perhaps time for surgeons to stop taking comfort from the relative risks of intervention, and historic studies of medical management, and instead look to future well-designed studies of modern medical management of asymptomatic carotid stenoses.

Surgical rotations in provincial South Australia: The trainees' perspective

Background:  Rural general surgery is faced with a shortage of resident surgeons in many parts of Australia. Although it is accepted that an undergraduate rural exposure favourably influences graduates to undertake rural practice, it is not known whether postgraduate terms exert a similar effect.

Developing a mesh-tissue integration index and mesh registry database: the next step in the evolution of hernia repair: Perspectives

The use of mesh in incisional hernia repair has been paramount in reducing recurrence rates when compared with suture closure only. Factors influencing early efficacy of hernia repair include adequate closure of the defect, the size and strength (weight) of mesh, and type and security of fixation. Long-term efficacy is dependent on tissue incorporation into the mesh scaffold. The degree of meshtissue ingrowth affects recurrence rate and tissue flexibility, which relates to functional outcome and resistance to mesh infection. There is a ‘Goldilocks’ state to be achieved in mesh-tissue integration (MTI) which is key to an adequate, durable and functional repair. Excessive tissue response results in dense fibrosis, mesh shrinkage, seromas and chronic pain. Inadequate response can result in infection and recurrence (Fig. 1). Numerous intrinsic and extrinsic factors are known to affect MTI. Hydrophilic mesh is favourable as it allows rapid tissue ingrowth. Microporous filaments (>10 μm) allow white blood cells to infiltrate, and macropore (>1.5 mm) components allow penetration of blood vessels and avoid coalescing of fibrotic capsule, resulting in a flexible and functional repair. Preserving macroporosity by ensuring technical factors during mesh placement, such as avoiding overstretching or folding of the mesh, is important. Patient factors such as tissue vascularity and systemic conditions determined by diabetes, smoking, obesity, steroids and genetics, influence tissue integration. Theoretically, adjuncts such as growth factors, fibrin and autologous leucocyte platelet-rich fibrin may enhance MTI. There are over 150 mesh products available that have Food and Drug Administration (United States) and/or Therapeutic Goods Administration (Australia) approval. There is no requirement for manufacturers to provide MTI data. By only reporting the compositional safety profile of meshes, surgeons choose a mesh based primarily on its physical characteristics and technical ease of insertion. While there are a number of papers about tissue response to mesh, the lack of evidence around MTI precludes adopting a more holistic and tailored approach to hernia surgery. Tailoring surgery to optimize outcomes in hernia repair requires a greater understanding of the biological response elicited by any given mesh and how this response may be manipulated. Broadening this understanding will challenge existing assumptions about how mesh products help achieve successful outcomes. We propose developing a standardized, numerical MTI index for meshes placed in the subrectus and intraperitoneal position. The purpose is to assist surgeons in selecting a mesh according to its tissue ingrowth characteristics, matched to the individual patient to achieve an optimal outcome. Devising an MTI index will involve measuring the rate and extent of tissue ingrowth in an animal model based on macroscopic (including visual integration, mesh shrinkage, number of adhesions and T-Peel testing), microscopic (including cell population, and proportion of immune cells, growth cells and mature collagen) and biologic (protein quantification of vascular endothelial growth factor, transforming growth factor-beta and platelet-derived growth factors) assessments at 1, 4, 8, 12 and 24 weeks post-surgery. By examining a number of time points, we can assess the rate of tissue ingrowth, which is lacking from published data. The index will range from 1 to 5. Meshes with an index of 1 will have poor tissue integration while those with an index of 5 will have excellent vascularized tissue ingrowth and adequate fixation within 4 weeks of insertion. A fibrosis sub-index (F) will define meshes according to foreign body reaction. The fibrosis sub-index will range from 1 to 5, with 5 indicating negligible amounts of giant cell infiltration and 1 indicating an excessive foreign body reaction. A mesh with an F-index of 5 will be flexible with minimal shrinkage, whilst a mesh with an F-index of 1 may have a high incidence of rigidity and marked shrinkage. For meshes placed intraperitoneally, an adhesion sub-index (A) will be calculated adapted from previous studies. The adhesion index will range from 1 to 5, with 5 indicating minimal or no adhesions and 1 indicating dense adhesions. Accordingly, the preferred mesh will display an MTI index of 5, an F-index of 5 and an A-index of 5, equating to a fully incorporated and fixed mesh within 4 weeks, with excellent flexibility and no shrinkage, rigidity or adhesions. The indices will require validation. It is simplistic to believe that indices based on animal studies will translate to predictable patient outcomes considering the diversity and complexity of patients. To fully appreciate the significance of MTI, a longitudinal database that records mesh indices and patient characteristics against outcomes is pivotal in progressing hernia management towards a truly holistic and tailored approach (Fig. 1). A well-designed and resourced database will allow systematic assessment and refinement of the use of mesh products in hernia surgery. It may then be possible to understand not only the predictors of successful outcomes but also the factors associated with failures. This in turn may allow surgeons to assess the role of adjuvant growth factors in subpopulations of patients to improve MTI or indeed adjuvant agents to downregulate excessive tissue response to mesh. Incisional hernia surgery is undergoing a conceptual shift from a ‘mechanical approach’ (e.g. component separation, huge mesh overlap) to a ‘biological approach’. A biological paradigm is multifaceted. It may involve preoperative optimization of the patient by use of botulinum toxin for muscle relaxation and appropriate selection of mesh, with growth factor adjuncts, with the aim to reduce