F. W. Jansen

The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery

Background: The pneumoperitoneum is the crucial element in laparoscopic surgery. Different clinical problems are associated with this procedure, which has led to various modifications of the technique. The aim of this guideline is to define the scientifically proven standards of the pneumoperitoneum. Methods: Based on systematic literature searches (Medline, Embase, and Cochrane), an expert panel consensually formulated clinical recommendations, which were graded according to the strength of available literature evidence. Recommendations: Preoperatively, all patients should be assessed for the presence of cardiac, pulmonary, hepatic, renal, or vascular comorbidity. Presupposing appropriate perioperative measures and surgical technique, there is no reason to contraindicate pneumoperitoneum in patients with peritonitis or intraabdominal malignancy. During laparoscopy, monitoring of end tidal CO2 concentration is mandatory. The available data on closed- (Veress needle) and open-access techniques do not allow us to principally favor the use of either technique. Using 2 to 5-mm instead of 5 to 10-mm trocars improves cosmetic result and postoperative pain marginally. It is recommended to use the lowest intraabdominal pressure allowing adequate exposure of the operative field, rather than using a routine pressure. In patients with limited cardiac, pulmonary, or renal function, abdominal wall lifting combined with low-pressure pneumoperitoneum might be an alternative. Abdominal wall lifting devices have no clinically relevant advantages compared to low-pressure (5–7 mmHg) pneumoperitoneum. In patients with cardiopulmonary diseases, intra- and postoperative arterial blood gas monitoring is recommended. The clinical benefits of warmed, humidified insufflation gas are minor and contradictory. Intraoperative sequential intermittent pneumatic compression of the lower extremities is recommended for all prolonged laparoscopic procedures. For the prevention of postoperative pain a wide range of treatment options exists. Although all these options seem to reduce pain, the data currently do not justify a general recommendation.

Options on fibroid morcellation: a literature review

In laparoscopy, specimens have to be removed from the abdominal cavity. If the trocar opening or the vaginal outlet is insufficient to pass the specimen, the specimen needs to be reduced. The power morcellator is an instrument with a fast rotating cylindrical knife which aims to divide the tissue into smaller pieces or fragments. The Food and Drug Administration (FDA) issued a press release in April 2014 that discouraged the use of these power morcellators. This article has the objective to review the literature related to complications by power morcellation of uterine fibroids in laparoscopy and offer recommendations to laparoscopic surgeons in gynaecology. This project was initiated by the executive board of the European Society of Gynaecological Endoscopy. A steering committee on fibroid morcellation was installed and experienced ESGE members requested to chair an action group to address distinct clinical questions. Clinical questions were formulated with regards to the sarcoma risk in presumed uterine fibroids, diagnosis of sarcoma, complications of morcellation and future research. A literature review on the different subjects was conducted, systematic if appropriate and feasible. It was concluded that the true prevalence of uterine sarcoma in presumed fibroids is not known given the wide range of prevalences (0.45–0.014xa0%) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics such as ‘lacunes’ suggesting necrosis and increased central vascularisation of the tumour are associated with a higher risk of uterine sarcoma, although the risks remain low. There is not enough evidence to estimate this risk in individual patients. Complications of morcellation are rare. Reported are direct morcellation injuries to vessels and bowel, the development of so-called parasitic fibroids requiring reintervention and the spread of sarcoma cells in the abdominal cavity, which may possibly or even likely upstaging the disease. Momentarily in-bag morcellation is investigated as it may possibly prevent morcellation complications. Because of lack of evidence, this literature review cannot give strong recommendations but offers only options which are condensed in a flow chart. Prospective data collection may clarify the issue on sarcoma risk in presumed fibroids and technology to extract tissue laparoscopically from the abdominal cavity should be perfected.

Laparoscopic skills simulator: construct validity and establishment of performance standards for residency training

Our aim was to test our laparoscopic simulator for construct validity and for establishing performance standards. The skills of laparoscopic novices (nu2009=u200918) and advanced gynaecologists (experts, nu2009=u20095) were tested on our inanimate simulator by their performance of five tasks. The sum score was the sum of scores of all five tasks. We calculated the scores by adding completion time and penalty points. After baseline evaluation, the novices were assigned to five weekly training sessions (nu2009=u20098, training group) or no training (nu2009=u200910, control group). Both groups were retested. The experts were tested once, and their performance was compared with the baseline scores of all novices to establish construct validity. The training group improved significantly in all tasks. The final scores of the trained group were significantly better than those of the control group. The training group reached a plateau within seven trials, except for intra-corporeal knot tying. During final testing, the trained group reached the experts’ level of skills on the simulator. We concluded that our simulation model has construct validity. Novices can reach the experts’ basic laparoscopic skills level on the simulator after a short and intense simulator training course. Experts’ basic skills level on the simulator is an achievable performance standard during residency training.

Tumor-associated eosinophilic infiltrate of cervical cancer is indicative for a less effective immune response

The local inflammatory tumor infiltrate related to cervical carcinoma has been shown to consist mainly of T lymphocytes and macrophages. In 5% to 40% of the cases, eosinophilic granulocytes from a major part of the tumor-infiltrating cells. The presence of a high percentage of eosinophilic granulocytes in the infiltrate might reflect a less effective antitumor response, resulting in a worse overall survival. In the present study, histological slides from 83 patients who had been treated for cervical squamous carcinoma were reviewed. Special emphasis was put on the presence of eosinophils in the tumor infiltrate and correlated with clinical outcome as a parameter of the strength of the host-antitumor response. Multivariate analysis showed that the presence of a large amount of eosinophils among the infiltrate was an independent parameter, predicting a worse overall survival in patients with tumor-negative lymph nodes and tumor-negative resection margins (n = 61). The presence of eosinophilic granulocytes might represent a less appropriate immune response based on a disturbed equilibrium between Th-1- and Th-2-mediated immune response.

Medical liability insurance claims on entry-related complications in laparoscopy.

BackgroundInstallation of the pneumoperitoneum is an essential part of laparoscopic surgery. Creation can be performed by either the open or a closed technique. The aim of this study was to assess the number of and contributing factors to entry-related complications in medical liability insurance claims in the Netherlands.MethodsA retrospective chart review was performed, including all malpractice claims filed at MediRisk, which is presently the largest medical liability mutual insurance company for institutions, mainly hospitals, in healthcare in the Netherlands.ResultsFrom January 1993 to December 2005, 41 claims were identified as entry-related complications which comprised 18% of all laparoscopy-related complications leading to claims. Most were young (median age = 35 years) female patients who had routine, nonadvanced, laparoscopic procedures planned as short-stay or day-care procedures. The claims were equally divided between general surgery (n = 20) and gynecology (n = 21). A total of 51 structures were injured. There were 18 vascular structure injuries, 30 bowel injuries, and three other injuries. An open entry technique was used in only two (5%) patients. Vascular injury was exclusively associated with closed entry. In only 19 (46%) patients the entry-related complication was diagnosed peroperatively, consisting of 70% of the vascular and 25% of the bowel injuries. Twenty-six patients (64%) were admitted to the intensive care unit for a median of five days. There was no mortality. Besides conversion, the majority of the patients filed a claim to compensate for a longer hospital stay and related costs. A payment was made in 17 (57%) of the 30 settled claims.ConclusionsMedical liability claims concerning laparoscopic entry-related complications comprised a fifth of all laparoscopy-related claims. Claims concerning entry-related complications occurred in young patients who had routine, nonadvanced procedures. In the investigated cases most claims involved the closed-entry technique.

Vaginal cuff dehiscence in laparoscopic hysterectomy: influence of various suturing methods of the vaginal vault

Vaginal cuff dehiscence (VCD) is a severe adverse event and occurs more frequently after total laparoscopic hysterectomy (TLH) compared with abdominal and vaginal hysterectomy. The aim of this study is to compare the incidence of VCD after various suturing methods to close the vaginal vault. We conducted a retrospective cohort study. Patients who underwent TLH between January 2004 and May 2011 were enrolled. We compared the incidence of VCD after closure with transvaginal interrupted sutures versus laparoscopic interrupted sutures versus a laparoscopic single-layer running suture. The latter was either bidirectional barbed or a running vicryl suture with clips placed at each end commonly used in transanal endoscopic microsurgery. Three hundred thirty-one TLHs were included. In 75 (22.7xa0%), the vaginal vault was closed by transvaginal approach; in 90 (27.2xa0%), by laparoscopic interrupted sutures; and in 166 (50.2xa0%), by a laparoscopic running suture. Eight VCDs occurred: one (1.3xa0%) after transvaginal interrupted closure, three (3.3xa0%) after laparoscopic interrupted suturing and four (2.4xa0%) after a laparoscopic running suture was used (pu2009=u2009.707). With regard to the incidence of VCD, based on our data, neither a superiority of single-layer laparoscopic closure of the vaginal cuff with an unknotted running suture nor of the transvaginal and the laparoscopic interrupted suturing techniques could be demonstrated. We hypothesise that besides the suturing technique, other causes, such as the type and amount of coagulation used for colpotomy, may play a role in the increased risk of VCD after TLH.

Visual force feedback improves knot-tying security.

BACKGROUNDnResidents in surgical specialties suture multiple wounds in their daily routine and are expected to be able to perform simple sutures without supervision of experienced surgeons. To learn basic suture skills such as needle insertion and knot tying, applying an appropriate magnitude of force in the desired direction is essential. To investigate if training with real-time visual force feedback improves the suture skills of novices, a study was conducted using a training platform that measures all forces exerted on a skin pad, i.e., the ForceTRAP.nnnMETHODnTwo groups of novices were trained on this training platform during a suture task. One group (nov-c) received no visual force feedback during training, whereas the test group (nov-t) trained with visual feedback. The posttest and follow-up test were performed without visual force feedback.nnnRESULTSnA significant difference in reaction force, (nov-c: mean 2.47N standard deviation [SD] ± 0.62, nov-t: mean 1.79N SD ± 0.37), suture strength (nov-c: median 25N interquartile range (IQR) 15, nov-t: median 50N interquartile range 25), and task time (nov-c: mean 109s SD ± 22, nov-t: mean 134s SD ± 31) was found between the control and training group of the posttest.nnnCONCLUSIONnParticipants that are trained with visual force feedback produce the most secure knots in the posttest and their suturing results in lower applied forces. Therefore, the results of this study indicate that visual force feedback supports students while learning to insert the needle smoothly, to effectively align the suture threads and to balance the force between instruments during knot tying. However, for long-term learning effects, probably more than 1 training session is required.

Prevalence of Musculoskeletal Disorders Among Surgeons Performing Minimally Invasive Surgery: A Systematic Review

Objective: The aim of this study was to review musculoskeletal disorder (MSD) prevalence among surgeons performing minimally invasive surgery. Background: Advancements in laparoscopic surgery have primarily focused on enhancing patient benefits. However, compared with open surgery, laparoscopic surgery imposes greater ergonomic constraints on surgeons. Recent reports indicate a 73% to 88% prevalence of physical complaints among laparoscopic surgeons, which is greater than in the general working population, supporting the need to address the surgeons’ physical health. Methods: To summarize the prevalence of MSDs among surgeons performing laparoscopic surgery, we performed a systematic review of studies addressing physical ergonomics as a determinant, and reporting MSD prevalence. On April 15 2016, we searched Pubmed, EMBASE, the Cochrane Library, Web of Science, CINAHL, and PsychINFO. Meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method. Results: We identified 35 articles, including 7112 respondents. The weighted average prevalence of complaints was 74% [95% confidence interval (95% CI) 65–83]. We found high inconsistency across study results (I2 = 98.3%) and the overall response rate was low. If all nonresponders were without complaints, the prevalence would be 22% (95% CI 16–30). Conclusions: From the available literature, we found a 74% prevalence of physical complaints among laparoscopic surgeons. However, the low response rates and the high inconsistency across studies leave some uncertainty, suggesting an actual prevalence of between 22% and 74%. Fatigue and MSDs impact psychomotor performance; therefore, these results warrant further investigation. Continuous changes are enacted to increase patient safety and surgical care quality, and should also include efforts to improve surgeons’ well-being.

Laparoscopic entry techniques: a protocol for daily gynaecological practice in The Netherlands

This Dutch model protocol aims to formulate recommendations on insertion of laparoscopic instruments in order to reduce entry-related complications. It was written on behalf of the Dutch Society of Gynaecological Endoscopy and Minimal Invasive Surgery and serves as guidance to safe entry in laparoscopy for the Dutch gynaecologist in daily practice. It was translated and made suitable for publication in English. Despite the variety of methods described for creating pneumoperitoneum, no one single method can claim to be fundamentally superior to another. The practising laparoscopist should be familiar with at least more than one entry technique.

Laparoscopic management of adnexal masses with the open entry technique in second-trimester pregnancy

Background and ObjectivesTo describe laparoscopic management of adnexal mass during pregnancy between January 1994 and November 2003 and give an overview of existing literature on this subject (1992–2003).DesignObservational (descriptive) study with prospectively collected database supplemented by retrospective chart review.SettingTertiary-care referral centre.SubjectsEleven consecutive pregnant patients with an adnexal mass.InterventionsTen patients had laparoscopy with the open entry technique and one with the closed entry technique.Main outcome measuresBlood loss, operating time, number of conversions to laparotomy, complications and pregnancy outcome.ResultsThe incidence of laparoscopic management of adnexal pathology during pregnancy in our institution was 1:1,206 pregnancies (0.1%). One patient was suspected to have an ovarian malignancy, which appeared to be a large malignant tumour originating from the intestine. Ovarian malignancy was not found. In seven cases, surgery was postponed until the 16th week of gestation; however, four patients required surgery earlier in pregnancy due to suspicion of ovarian malignancy (n=1) or adnexal torsion (n=3). No entry-related or intra-operative complications occurred. Two procedures were converted to laparotomy but were not due to laparoscopic complications. One intra-uterine foetal death occurred at 24 weeks of gestation (12 weeks after adnexal detorsion). No postoperative maternal complications occurred, and nine healthy infants were born. One patient continues to have an uncomplicated pregnancy.ConclusionsAdnexal masses requiring surgical intervention can be explored laparoscopically. We advise the open entry technique in order to avoid entry-related complications, e.g. to the pregnant woman’s uterus and the adnexal mass.