Byron F. Santos

Single-incision laparoscopic surgery (SILS™) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator

BackgroundSingle-incision laparoscopic surgery (SILS™) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILS™ may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS™ technique.MethodsMedical students, surgical residents, and attending physicians were recruited and divided into inexperienced (IE), laparoscopy-experienced (LE), and SILS™-experienced (SE) groups. Each subject performed standardized tasks from FLS, including peg transfer, pattern cutting, placement of ligating loop, and intracorporeal suturing using a standard three-port FLS box-trainer with standard laparoscopic instruments. For SILS™, the subjects used an FLS box-trainer modified to accept a SILS Port™ with two working ports for instruments and one port for a 30° 5-mm laparoscope. SILS™ tasks were performed with instruments capable of unilateral articulation. SILS™ suturing was performed both with and without an articulating EndoStitch™ device. Task scores, including cumulative laparoscopic FLS score (LS) and cumulative SILS™ FLS score (SS), were calculated using standard time and accuracy metrics.ResultsThere were 27 participants in the study. SS was inferior to LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups. SILS™ suturing using the articulating suturing device was superior to the use of a modified needle driver technique.ConclusionsSILS™ is more technically challenging than standard laparoscopic surgery. Using currently available SILS™ platforms and instruments, even surgeons with SILS™ experience are unable to match their overall LAP performance. Specialized training curricula should be developed for inexperienced surgeons who wish to perform SILS™.

Natural orifice translumenal endoscopic surgery: Progress in humans since white paper

Since the first description of the concept of natural orifice translumenal endoscopic surgery (NOTES), a substantial number of clinical NOTES reports have appeared in the literature. This editorial reviews the available human data addressing research questions originally proposed by the white paper, including determining the optimal method of access for NOTES, developing safe methods of lumenal closure, suturing and anastomotic devices, advanced multitasking platforms, addressing the risk of infection, managing complications, addressing challenges with visualization, and training for NOTES procedures. An analysis of the literature reveals that so far transvaginal access and closure appear to be the most feasible techniques for NOTES, with a limited, but growing transgastric, transrectal, and transesophageal NOTES experience in humans. The theoretically increased risk of infection as a result of NOTES procedures has not been substantiated in transvaginal and transgastric procedures so far. Development of suturing and anastomotic devices and advanced platforms for NOTES has progressed slowly, with limited clinical data on their use so far. Data on the optimal management and incidence of intraoperative complications remain sparse, although possible factors contributing to complications are discussed. Finally, this editorial discusses the likely direction of future NOTES development and its possible role in clinical practice.

Effect of training and instrument type on performance in single-incision laparoscopy: Results of a randomized comparison using a surgical simulator

PurposeSingle-incision laparoscopy (SIL) is potentially less invasive compared with standard laparoscopic surgery (LAP); however, it may be more technically challenging and have a longer learning curve. A two-phase study was conducted to examine the performance of standardized tasks on a surgical simulator by novices during a distributed training period. Phase 1 examined the effect of LAP-specific or SIL-specific training on skill acquisition for both techniques. Phase 2 compared the effectiveness and learning curves of additional instrument types for SIL (straight [STR] vs. dynamic articulating [D-ART]).MethodsMedical students without previous surgical experience were randomized to LAP-specific training or SIL-specific training, using static articulating instruments [S-ART] for SIL. LAP and SIL scores on the peg transfer (PEG) and pattern cutting (CIRCLE) tasks from the Fundamentals of Laparoscopic Surgery (FLS) were measured at baseline and after four training sessions. In phase 2, a new group of subjects were randomized to SIL training using STR or D-ART instruments, with similar baseline and post-training testing. FLS task scores were calculated and compared according to training regimen and instrument type.ResultsForty-five subjects completed the study. All scores improved significantly during the training period. Improvement in LAP score was similar between LAP-trained and SIL-trained groups. Improvement of SIL score was better for the SIL-trained group. Final scores were better and the learning curve was shorter for LAP versus SIL technique, with no differences in SIL scores according to instrument type.ConclusionsLAP technique results in superior task performance with a shorter learning curve compared with SIL technique during a standardized training period. SIL-specific simulator training is better than LAP training alone to improve SIL performance. Neither S-ART nor D-ART instruments for SIL are associated with improved performance or shorter learning curve compared with STR instruments.

452 Analysis of a Single-Series Learning Curve for PerOral Esophageal Myotomy (POEM)

Background: Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. The operator learning curve for POEM and patient factors associated with operative difficulty are not known. Methods: A single-institution prospective POEM outcomes database was analyzed. All POEM procedures were performed conjointly by the same two surgeons. Associations between preoperative patient variables (series case number, gender, age, BMI, ASA class, prior treatment with dilation or Botox, symptom duration, manometric pressures, achalasia subtype) and operative outcomes (procedure time, tunnel length, myotomy length, number of clips used for closure, EBL, mucosal perforation, need to decompress pneumoperitoneum) were tested using bivariate linear correlation. To assess for changes in efficiency over the course of the series, the total procedure time and the time required for each individual procedural step (submucosal access, tunnel creation, myotomy, and mucosal closure) were tested for best fit to linear, logarithmic, and exponential regression curves using case number as the dependent variable. A subgroup analysis of treatment-naive patients was secondarily performed. Results: 30 patients underwent POEM, of which 26 were treatment-naive. Preoperative symptom duration was positively associated with increased operative time (r^2=.55, p,.01). Prior achalasia treatment and EGJ resting pressure were both positively associated with operative time at a trend level (p=.08 for both). Case number correlated negatively with the number of clips required for closure (r^2=-.51, p ,.01), whereas duration of symptoms was positively correlated with clip number (r^2=.40, p,.05). Case number correlated negatively, whereas duration of symptoms correlated positively, with occurrence of a mucosal perforation, both at a trend level (p=.06 and .07). Myotomy length proximal to the EGJ increased over the course of the series (r^2=.44, p=.02), whereas there was no change in myotomy length distal to the EGJ. Total procedure time and time to perform tunnel creation, myotomy and mucosal closure did not change over the course of the series. Submucosal access time decreased over the course of the series (r^2=.22, p,.01) with best fit to a logarithmic curve. In treatment-naive patients only, mucosal closure time decreased over the series (r^2=.17, p=.03) with best fit to an exponential curve. Conclusions: In this POEM series, the time needed to access the submucosa and the number of clips required to close the mucosotomy both decreased with experience. Myotomy length proximal to the EGJ increased with experience. Total procedure time did not change over the course of the series, and may not be an important marker of procedural skill for POEM. Longer symptom duration and prior endoscopic treatment may result in increased operative difficulty.

12. Other Devices for Tissue Approximation

Techniques and instruments for tissue approximation have evolved dramatically since the dawn of surgical history. For millennia, surgical needles and thread were some of the only tools available to surgeons for approximating tissues and closing wounds. While these basic tools still occupy a crucial role in current surgical practice, modern surgeons have a variety of additional sophisticated tissue approximation devices at their disposal. This chapter presents an overview of currently available and frequently used laparoscopic tissue approximation devices including linear and circular staplers, tissue fastener devices, clip appliers, ligating loops, and tissue glues. Considerations for the proper selection and use of these devices, as well as common pitfalls, are discussed.