Gordie K. Kaban

Optimizing laparoscopic task efficiency: the role of camera and monitor positions

BackgroundAlterations of video monitor and laparoscopic camera position may create perceptual distortion of the operative field, possibly leading to decreased laparoscopic efficiency. We aimed to determine the influence of monitor/camera position on the laparoscopic performance of surgeons of varying skill levels.MethodsTwelve experienced and 12 novice participants performed a one-handed task with their dominant hand in a modified laparoscopic trainer. Initially, the camera was fixed directly in front of the participant (0°) and the monitor location was varied between three positions, to the left of midline (120°), directly across from the participant (180°), and to the right of the midline (240°). In the second experiment monitor position was constant straight across from the participant (180°) while the camera position was adjusted between the center position (0°), to the left of midline (60°), and to the right of midline (300°). Participants completed five trials in each monitor/camera setting. The significance of the effects of skill level and combinations of camera and monitor angle were evaluated by analysis of variance (ANOVA) for repeated measures using restricted maximum likelihood estimation.ResultsExperienced surgeons completed the task significantly faster at all monitor/camera positions. The best performance in both groups was observed when the monitor and camera were located at 180° and 0°, respectively. Monitor positioning to the right of midline (240°) resulted in significantly worse performance compared to 180° for both experienced and novice surgeons. Compared to 0° (center), camera position to the left or the right resulted in significantly prolonged task times for both groups. Novice subjects also demonstrated a significantly lower ability to adjust to suboptimal camera/monitor positions.ConclusionExperienced subjects demonstrated superior performance under all study conditions. Optimally, the camera should be directly in front and the monitor should be directly across from a surgeon. Alternatively, the monitor/camera could be placed opposite to the surgeon’s non-dominant hand. The suboptimal camera/monitor conditions are especially difficult to overcome for inexperienced subjects. Monitor and camera positioning must be emphasized to ensure optimal laparoscopic performance.

Use of Laparoscopy in Evaluation and Treatment of Penetrating and Blunt Abdominal Injuries

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.

Benefits of laparoscopic adrenalectomy: a 10-year single institution experience.

Introduction We aimed to compare the outcomes of laparoscopic and open adrenalectomies and to assess the impact of the availability of advanced laparoscopy on adrenal surgery at our institution. Materials and Methods A retrospective analysis of data of all patients who underwent adrenalectomy at the University of Massachusetts Medical Center over a 10-year period. Results Sixty-four consecutive patients underwent adrenalectomy during the study periods. There were 19 open (OA) and 45 laparoscopic (LA) adrenalectomies performed. There was no significant difference between the average size of adrenal masses removed for the LA and the OA groups [4.3 vs. 5.5 cm, respectively (P=0.23)]. LA proved superior to OA, resulting in shorter operative times (171 vs. 229 min, P=0.02), less blood loss (96 vs. 371 mL, P<0.01), shorter time to regular diet (1.9 vs. 4.4 d, P<0.001), and shorter hospital stay (2.5 vs. 5.8 d, P=0.02). In addition, the average annual number of adrenalectomies increased significantly since the establishment of our advanced laparoscopic program (10.0 vs. 2.0, P=0.02). Conclusions LA offers superior results when compared to OA in terms of operative time, blood loss, return of bowel function, duration of hospital stay, and functional recovery. The availability of advanced laparoscopy has resulted in a significant increase in the number of adrenalectomies performed at our institution without a shift in surgical indications.

Evaluation of serum cytokine release in response to hand-assisted, laparoscopic, and open surgery in a porcine model.

BACKGROUND Although the immunologic benefits of laparoscopic surgery have been established, effects from hand-assisted (HA) surgery have not been investigated thoroughly. We hypothesized that the HA approach maintains the immunologic advantage of laparoscopic surgery compared with the open (O) approach. METHODS Six O, HA, and laparoscopic (L) transabdominal left nephrectomies were performed on pigs. Blood samples were taken preoperatively, perioperatively, and postoperatively, and serum interleukin-6 and C-reactive protein levels were measured. RESULTS At 24 hours after surgery, interleukin-6 levels were significantly higher in the O group vs the HA and L groups (82.2 vs 37.5 and 29.9 pg/mL, respectively; P < .05). Similar trends were seen at all time periods for both IL-6 and C-reactive protein. No significant differences in postoperative cytokine levels were detected between the HA and L groups. CONCLUSIONS The HA approach mimics the immunologic effects of laparoscopic surgery. These data suggest that the HA technique resulted in a reduced systemic immune activation in the early perioperative period when compared with open surgery. In addition to clinical benefits of minimal access, the HA approach also may afford patients an immunologic advantage over laparotomy.

Hand-Assisted Laparoscopic Surgery

Hand-assisted laparoscopic surgery (HALS) has been sporadically described in the past to assist the surgeon during operations of complexity or when operations require specimen removal. The hand will offer the surgeon an advantage in terms of tactile feedback, exposure, retraction, or orientation so that it will enable him or her to operate with greater safety and efficiency. The fundamental pre-requisite for successful HALS is a reliable hand-assist device. We perform HALS for complex advanced laparoscopic surgery where it may save time, increase accuracy and improve safety. Additionally, this approach is considered for any operation that requires specimen removal, since an enlarged incision may be required. Early introduction of the hand may facilitate dissection and specimen removal.