Douglas Fenton-Lee

ASSESSMENT OF LAPAROSCOPIC PSYCHOMOTOR SKILLS IN INTERNS USING THE MIST VIRTUAL REALITY SIMULATOR: A PREREQUISITE FOR THOSE CONSIDERING SURGICAL TRAINING?

Selection for surgical training in Australia is currently based on assessment of a structured curriculum vitae, referral reports from selected clinicians and an interview. The formal assessment of laparoscopic psychomotor skill and ability to attain skills is not currently a prerequisite for selection. The aim of this study was to assess the innate psychomotor skills of interns and also to compare interns with an interest in pursuing a surgical career to interns with those with no interest in pursuing a surgical career. Twenty‐two interns were given the opportunity to carry out tasks on the Minimal Invasive Surgical Trainer, Virtual Reality (Mentice, Gothenburg, Sweden) Simulator. The candidates were required to complete six tasks, repeated six times each. Scores for each task were calculated objectively by the simulator software. Demographic data were similar between the two groups. Although some candidates who were interested in pursuing a surgical career performed poorly on the simulator, there was no significant difference when comparing the two groups. The Minimal Invasive Surgical Trainer, Virtual Reality (Mentice) Simulator provides an objective and comparable assessment of laparoscopic psychomotor skills. We can conclude that interns have varying inherent ability as judged by the simulator and this does not seem to have an influence on their career selection. There was no significant difference in the scores between the two groups. Interns with and without inherent abilities have aspirations to pursue surgical careers and their aptitude does not seem to influence this decision. Surgical colleges could use psychomotor ability assessments to recruit candidates to pursue a career in surgery. Trainees needing closer monitoring and additional training could be identified early and guided to achieve competency.

Biliary tract injury in laparoscopic cholecystectomy: results of a single unit.

Background:  Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them.

Pancreaticoduodenectomy - outcomes from an Australian institution.

Background:  Operative morbidity and mortality rates have improved markedly since the first single‐stage pancreaticoduodenectomy (PD) was performed by A. O. Whipple in 1940. There is a lack of published data regarding outcomes of PD from Australian centres. The aim of this study was primarily to establish post‐operative morbidity and mortality rates of an Australian unit, and secondly, to investigate the value of preoperative investigation with endoscopic ultrasound and laparoscopy upon tumour stage and survival following PD.

Localization of EGF receptors in frozen tissue sections by antibody and biotinylated EGF-based techniques.

We developed a sensitive EGF receptor detection method for frozen tissue sections using biotinylated EGF as the primary reagent. The method was directly compared with an immunohistochemical technique based on an anti-EGF receptor monoclonal antibody (MAb EGFR1) in normal human and rat tissues and in human tumors. The method was more sensitive than a previously published biotinylated EGF-based technique. In normal human tissues and in 37 of the 50 tumors, the binding pattern mirrored that of positive staining with EGFR1. Five further tumors showed weak immunoreactivity, but in these no binding of biotinylated EGF was detected. The remaining eight tumors were negative by both techniques. The discordant cases may reflect a lower level of sensitivity of the ligand-binding technique or, alternatively, abnormal receptors may have been expressed in these tissues. EGF receptors could be detected in rat liver with biotinylated EGF but not with the antibody, indicating the usefulness of the ligand-based technique in cross-species studies.

Colonic volvulus in the spinal cord injured patient

At the Prince Henry Hospital between 1970 and 1987, 8 cases of colonic volvulus were diagnosed in spinal cord injured (SCI) patients. This represents an incidence of 2.6% of SCI patients being treated at the hospital. The aetiology of volvulus is multifactorial and in these patients may be related to: neurological deficit; constipation as a result of immobility; and medications used for controlling muscle spasm, bladder and bowel function.Symptoms and signs are modified by the neurological deficit and awareness of the altered presentation will prevent delay and missed diagnoses. The effect of spinal cord injury and drugs on colonic motility needs further evaluation.

A series of complications after paraesophageal hernia repair with the used of Timesh: a case report.

Early dysphagia with nonresorbable mesh usage after laparoscopic hiatal hernia repair is not uncommon. This was thought to be the result of excessive scaring induced by the mesh. The presenting symptoms associated with mesh complications are dysphagia 41%, chest pain 26%, heartburn 19%, weight loss 8%, epigastric pain 4%, fever 2%. These can be troublesome and severely affect the patient’s quality-of-life. A 73-year-old female patient was referred to us for the management of ongoing symptoms of retrosternal pain, dysphagia, regurgitation, eructation, and abdominal bloating. Three years earlier, she had undergone a laparoscopic Toupet fundoplication to repair her paraesophageal hernia at an outside hospital. At that time a posterior hiatal repair was carried out with 0-Ethibond sutures and reinforcement with Timesh. Postoperatively she developed epigastric pain and nausea when eating and a barium meal showed a mediastinal leak. Subsequently, an esophageal stent was inserted. Her symptoms stabilized and her stent was removed 2 months later with the resolution of the leak. However, her symptoms had continued and gradually worsened. A computed tomography (CT) of the thorax carried out showed recurrence of her hiatus hernia with a significant proportion of the stomach in the chest. Gastroscopy confirmed a paraesophageal hiatus hernia with suture material protruding into the fundus of the stomach but showed no evidence of mesh erosion into the stomach or oesophagus. Laparoscopy was carried out to assess feasibility of a laparoscopic approach and a laparoscopic redo Nissen fundoplication was carried out. There were adhesions around the stomach to the liver and crura. The Timesh mesh was densely adherent to the surrounding tissue and was not possible to be removed and was left in situ as shown in Figure 1. The stomach, which was wedged in the hiatus, was reduced into the abdomen after dividing the Timesh. There was no evidence of shortening of the oesophagus. The wrap, which was seen to have unravelled, was taken down. A posterior crural repair was carried out again with 0-Prolene (Ethicon Inc, Somerville, NJ) continuous sutures incorporating Timesh and the right crural limbs. Surgisis (Cook Medical, Bloomington, IN) mesh was placed over the crura and secured with AbsorbaTacks (Covidien, Mansfield, MA). A 360 degree floppy Nissen fundoplication was constructed using 0-Ethibond sutures and two coronal sutures placed in the right crura and one coronal suture in the left crura to complete the repair as shown in Figure 2. A gastrografin follow-through carried out the next day showed no contrast extravasation or obstruction. The patient had an uneventful postoperative course. At 6 weeks followup she reported relief of her symptoms. She no longer experience reflux, retrosternal pain, or dysphagia. The use of mesh to reinforce the cruroplasty during the repair of large hiatus hernia was pioneered by Frantzides et al in 2002. Their prospective randomized control trail had demonstrated a reduction of recurrences from 22% to 0% during a follow-up of 3.3 years. These promising results have led to renewed interest in the use of synthetic mesh in the repair of large hiatal hernias. Consequently new types of complications related to synthetic mesh placement at the esophageal hiatus have been reported which include esophageal stenosis owing to mesh fibrosis and scarification, esophageal mesh erosion, cardiac tamponade secondary to tack fixation, hiatal fibrosis, penetration of the cardial lumen. Since these reports surgeons have endeavored to evaluate different types of mesh to find the best type of mesh.

The management of hydatid disease of the liver: part 1

Figure 1 . Hepatic resection INTRODUCTION Hydatid disease most commonly affects the liver when man becomes the accidental intermediate host in the life cycle of the cestode Echinococcus. There are two main forms of the disease dependent upon infection with either the Echinococcus granulosus or Echinococcus multilocularis species. E.chinococcus multilocularis is geographically isolated and less prevalent which is fortunate as it generally has a more fulminant clinical course1~2. The management of E. granulosus will therefore constitute the main part of this review. Evaluation of the clinical efficacy of several chemotherapeutic compounds of the benzoimidazole carbonates group has taken place over the past decade with encouraging results. Despite the improvements in the efficacy of chemotherapy, particularly for E. granulosus, surgical resection remains the mainstay of treatment. The aims of hydatid surgery are: (1 ) the total removal of all infective components of the cysts; (2) the avoidance of spillage of cyst contents at the time of surgery; (3) management of communications between cyst and adjacent structures; (4) management of the residual cavity; and ( 5 ) minimize risk of operation.

Duodenal obstruction from a secondary aortoduodenal fistula

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Aberrant cholecystohepatic duct

A 73-year-old lady presented with colicky central abdominal, anorexia, nausea and rigors. Physical examination revealed that she was afebrile, but had right upper quadrant tenderness, mildly deranged liver function and a white cell count of 25 ¥ 10/L and a C reactive protein of 586 units. Abdominal ultrasound and computerised topography scanning findings were consistent with acute cholecystitis, (a large, thick walled gall bladder with pericholecystic fluid). She was initially treated with intravenous antibiotics and surgery was planned for the following morning. Laparoscopy revealed a gangrenous gall bladder with colon and omentum adherent to it. At laparotomy, an empyema was encountered and retrograde cholecystectomy was performed. An aberrant 4-mm diameter duct was found passing from the lateral aspect of the gall bladder fossa of the liver to the body of the gall bladder. This was divided, cholecystectomy was completed and cholangiography was performed via both the cystic and aberrant ducts (Figs 1,2). The cholangiogram revealed an aberrant duct passing from the cannulation site to join the right posterior segmental duct. As the aberrant duct was not draining a discrete segment of the liver it was able to be ligated. The cystic duct was also ligated. Post-operatively, the patient made an uneventful recovery with no bile leak.

Intrapancreatic Accessory Spleen Masquerading as a Pancreatic Neuroendocrine Tumor

A 74-year-old male presented to his GP with a 5-week history of diarrhea. Subsequent CT of the abdomen and pelvis revealed a 27-mm lesion in the tail of the pancreas as well as a 27-mm exophytic lesion associated with the lesser curve of the stomach (Image 1). He was otherwise healthy with no significant co-morbidities. A diagnosis of synchronous gastric GISTand functional pancreatic neuroendocrine tumor (NET) was made. He had unremarkable blood tests including a normal chromogranin A, full blood count, and liver function tests. He was also investigated with anMRI, a DOTATATEPETscan, and an EUS to further characterize the lesions. His MRI pancreas scan was identified as a well-circumscribed lesion in the distal pancreas suspicious for a pancreatic NET with no evidence of vascular invasion of local invasion into adjacent structures. DOTATATE PET revealed an intensely DOTATATE avid lesion arising from the tail of the pancreas suggestive of a welldifferentiated NET. The lesion in the stomach was not DOTATATE avid (Image 2). There was no radiological evidence of metastatic disease. An endoscopy did not show any mucosal abnormalities in the stomach and on EUS; there was a 21-mm wellcircumscribed homogenous lesion associated with the lesser curve. This was biopsied and confirmed a GIST. The lesion in the tail of the pancreas was a 22-mmwell-circumscribed mass without evidence of vascular invasion. This lesion was not biopsied. He subsequently underwent a synchronous laparoscopic distal pancreatectomy, splenectomy, and wedge resection of the gastric tumor. Final histology revealed a 35mm low-grade GISTwith the pancreatic lesion being a 25-mm spenunculus (Image 3). He had an uneventful recovery. Accessory splenic tissue or spenunculus is a relatively common phenomenon with the incidence of splenuculus being reported in 10–30% of post-mortem specimens. They can be located anywhere along the splenic vessels, gastrosplenic ligament, splenorenal ligament, wall of the stomach or bowel, and omentum. Splenuculus within the pancreatic parenchyma is an uncommon location but well described in literature.