Asuri Krishna

A Prospective Randomized Controlled Blinded Study to Evaluate the Effect of Short-Term Focused Training Program in Laparoscopy on Operating Room Performance of Surgery Residents (CTRI /2012/11/003113)

INTRODUCTION Laparoscopic surgery requires certain specific skills. There have been several attempts to minimize the learning curve with training outside the operation room. Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Several randomized controlled trials and systematic reviews have demonstrated that the technical skills learned on these simulators transfer to the operating room. Currently, however, the integration of these simulated models into formal residency training curricula is lacking. In our institute, we have adopted the Tuebingen Trainer devised by Professor GF Buess from Germany. The purpose of this study was to evaluate the training of surgical residents on an ex vivo phantom model for basic laparoscopic skill acquisition and its transferability to the OR performance. MATERIALS AND METHODS Seventeen general surgery residents were randomized into 2 groups: Laparoscopic Training Group (n = 9, Group A) and Standard Training Group (n = 8, Group B). Group A underwent training in the Minimally Invasive Surgery Training Centre on the porcine phantom model and did 10 laparoscopic cholecystectomies, whereas Group B did not undergo training in the Minimally Invasive Surgery Training Centre. All the participants performed a laparoscopic cholecystectomy in the operation theater in the presence of a consultant who was blinded to the training status of the participants. The performance of the residents in both groups in the operation theater was assessed using GOALS criteria, surgical performance assessment parameters, task-specific checklists, and visual analog scale for gallbladder perforation difficulty and overall competence. RESULTS The Laparoscopic Training Group had better performance than the Standard Training Group regarding operation time, GOALS criteria, and Task-specific checklists. Although the surgical performance assessments, i.e. cystic duct and artery identification scores, gallbladder perforation scores, and liver injury scores, were better in the Laparoscopic Training Groups, they were not statistically significant. The overall difficulty of the surgery was comparable in both the groups. The Laparoscopic Training Group exhibited significant overall competence on visual analog scale scores. CONCLUSION Our study has clearly shown that training on the Tuebingen Trainer with integrated porcine organs results in a statistically significant improvement in the operating room performance of surgical residents as compared with the nontrained residents, thereby indicating a transfer of skills from training to the operating room.

Learning Curve in Laparoscopic Inguinal Hernia Repair: Experience at a Tertiary Care Centre

One of the major reasons for laparoscopy not having gained popularity for repair of groin hernia is the perceived steep learning curve. This study was conducted to assess the learning curve and to predict the number of cases required for a surgeon to become proficient in laparoscopic groin hernia repair, by comparing two laparoscopic surgeons. The learning curve evaluation parameters included operative time, conversions, intraoperative complications and postoperative complications, and these were compared between the senior and the junior surgeon. One hundred thirty-eight cases were performed by the senior surgeon, and 63 cases by the junior surgeon. Both were comparable in terms of intraoperative and postoperative complications. Using the moving average method, minimum of 13 laparoscopic hernia repairs are required to reach at par the operating time of an experienced surgeon. For total extraperitoneal (TEP) repair, the number of cases was 14; and for transabdominal preperitoneal (TAPP) repair, this number was 13.

Nonoperative Management of Traumatic Chylothorax

Chylothorax is known for its rarity, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional, and immunologic disorders, can result from chylothorax. Management of chylothorax is challenging. It can either be managed nonoperatively or surgically. Surgical treatment is required in cases of persistent or high output fistulae. We report here in three cases of blunt trauma chest following road traffic crash associated with chylothorax. All of them were successfully managed nonoperatively with inter costal tube drainage and supportive treatment sans need of any operative intervention.

Technical challenges in laparoscopic cholecystectomy in situs inversus.

Laparoscopic cholecystectomy in patients with situs inversus can be a technically challenging procedure. Although laparoscopic cholecystectomy has been described in patients with situs inversus, no standard technique has been described. We are presenting our experience of laparoscopic cholecystectomy in two patients with situs inversus and discuss the problems encountered during surgery and likely remedies.

A prospective randomised controlled trial comparing chronic groin pain and quality of life in lightweight versus heavyweight polypropylene mesh in laparoscopic inguinal hernia repair.

Background: The aim of our study was to compare chronic groin pain and quality of life (QOL) after laparoscopic lightweight (LW) and heavyweight (HW) mesh repair for groin hernia. Materials and Methods: One hundred and forty adult patients with uncomplicated inguinal hernia were randomised into HW mesh group or LW mesh group. Return to activity, chronic groin pain and recurrence rates were assessed. Short form-36 v2 health survey was used for QOL analysis. Results: One hundred and thirty-one completed follow-up of 3 months, 66 in HW mesh group and 65 in LW mesh group. Early post-operative convalescence was better in LW mesh group in terms of early return to walking (P = 0.01) and driving (P = 0.05). The incidence of early post-operative pain, chronic groin pain and QOL and recurrences were comparable. Conclusion: Outcomes following laparoscopic inguinal hernia repair using HW and LW mesh are comparable in the short-term as well as long-term.

Comparison TAPP vs. TEP: Which Technique Is Better?

TEP and TAPP are the two standard techniques for laparoscopic repair of groin hernia. There have been many studies comparing TEP and TAPP in terms of safety and efficacy; however, there are conflicting reports of advantages of one over the other. TAPP has been reported to be easier to learn but has a higher incidence of visceral injury, postoperative pain, and longer operative time [1]. On the other hand, TEP avoids violation of the peritoneal cavity but is associated with a longer learning curve and a lesser incidence of vascular and visceral injury [1]. The recent guidelines for laparoscopic groin hernia repair published by the International Endo Hernia Society (IEHS) also could not answer the question of which of the two techniques is better [2]. There have been many systematic analyses comparing TEP and TAPP repairs, and the major differences between the two techniques are as follows: 1. Access-related complications

Complications, Pitfalls and Prevention of Complications of Laparoscopic Incisional and Ventral Hernia Repair and Comparison to Open Repair

LeBlanc and Booth in 1993 [1] first reported laparoscopic repair of a ventral and incisional hernia (LIVHR). With the development of newer prosthetic devices and fixation devices, laparoscopic repair has found its applicability not only in primary ventral and incisional hernia repair but also in parastomal and parapubic hernias. According to the recent IEHS guidelines, laparoscopic repair is considered the standard of care for management of patients with ventral and incisional hernia [2]. LIVHR is a very safe procedure and provides patients all the benefits of laparoscopic surgery like early return to activity and shorter hospital stay. However, unlike other laparoscopic procedures, although pain is less in open repair, it still is associated with considerable pain in the postoperative period because of the use of mesh fixation devices like tackers. Like all procedures laparoscopic repair is associated with certain intraoperative and postoperative complications which are important to be diagnosed and managed [2].

Komplikationen und deren Prävention bei der laparoskopischen Operation von Bauchwand- und Narbenhernien

Das Kapitel beschreibt die haufigsten Komplikationen der laparoskopischen Operation von primaren und sekundaren Hernien der vorderen Bauchwand (Darmverletzung, Wundinfektion, Netzinfektion, Serom, chronischer Schmerz, Rezidiv sowie die moglichen allgemeinen Komplikationen), ihre Ursachen, Therapie und Vorbeugung. Daruber hinaus werden ausfuhrlich die Ergebnisse der wissenschaftlichen Publikationen zusammengetragen, auf ihre Evidenz gepruft und entsprechende Empfehlungen ausgesprochen.

TAPP versus TEP – welche Technik ist besser?

Beide Techniken, TAPP und TEP, haben sich heute fest im Therapiespektrum bei der Leistenhernie weltweit etabliert. Beide Techniken sind standardisiert, auch von jungen Chirurgen durchfuhrbar und mit einer niedrigen Komplikations- und Rezidivrate belastet. Die Unterschiede zwischen den Ergebnissen, wie sie in den verschiedensten Publikationen berichtet werden, sind allerdings gros, sodass eine verlassliche Vergleichbarkeit schwierig ist. Mithilfe einer umfassenden Literaturanalyse und tabellarischer Darstellung der Ergebnisse wird im vorliegenden Kapitel versucht, die Evidenz zu ermitteln und Empfehlungen fur die Praxis zu geben. Grundsatzlich zeigt der Vergleich spezifische Starken und Schwachen der beiden minimalinvasiven Operationsverfahren, wobei insgesamt jedoch keine Uberlegenheit einer Technik nachgewiesen werden kann. Allgemein zu empfehlen ist daher, die Technik einzusetzen, in der der Chirurg ausgebildet wurde und seine besten Erfahrungen gemacht hat. Die Lernkurve fur die TAPP scheint im Vergleich zur TEP allerdings kurzer und das Indikationsspektrum weiter zu sein. Auch der mogliche Einsatz einer roboterassistierten Operation gewahrt der TAPP einen moglichen Vorteil.

The prevalence of new onset diabetes mellitus after renal transplantation in patients with immediate posttransplant hyperglycemia in a tertiary care centre

Objectives: This study aimed to determine the prevalence of immediate posttransplant hyperglycemia and new onset diabetes after renal transplantation (NODAT). It also aims at answering whether posttransplant hyperglycemia per se is a risk factor for future development of NODAT. Methods: A retrospective study was conducted among patients undergoing kidney transplantation under a single surgical unit in a tertiary care hospital in the past 5 years. All known patients with diabetes were excluded from the study. Immediate postoperative hyperglycemia was defined as random blood sugar (RBS) ≥200 mg/dl or requirement of insulin. NODAT was defined as fasting plasma glucose ≥126 mg/dl or RBS ≥200 mg/dl or if the patient is receiving therapy for glycemic control at 6 weeks or 3 months posttransplantation. Results: The study population included 191 patients. The overall prevalence of posttransplant hyperglycemia and NODAT was 31.4% and 26.7%, respectively. NODAT developed in 28 patients (46.7%) of those who had posttransplant hyperglycemia. Thus, posttransplant hyperglycemia was associated with a fourfold increased risk of NODAT (P = 0.000). Posttransplant hyperglycemia was associated with increased infections (P = 0.04) and prolonged hospital stay (P = 0.0001). Increased age was a significant risk factor for NODAT (P = 0.000), whereas gender, acute rejection episodes, cadaveric transplant, hepatitis C virus status, human leukocyte antigen mismatch, and high calcineurin levels were not significantly associated with the future development of NODAT. Conclusion: The significant risk of NODAT posed by posttransplant hyperglycemia makes it prudent to follow up these patients more diligently in a resource-limited setting wherein routine monitoring in all patients is cumbersome.