James C. Rosser

Surgeon-specific factors in the acquisition of laparoscopic surgical skills

BACKGROUND Training and experience vary widely among surgeons performing laparoscopic surgery (LS). Visual perceptual demands are greater for LS than for traditional surgery, necessitating greater understanding of surgeon variables in skill acquisition and performance. METHODS During an LS skills course incorporating didactic and simulator-based instruction, 94 surgeons completed an experience/demographic questionnaire, a test of course-specific knowledge acquisition, 10 trials of three dexterity drills, 15 suturing trials using course-specific methods, and 3 standardized tests of visual perception. RESULTS Age, years posttraining, and visual perception correlated significantly with time required to complete drills and suturing trials (Pearson correlations ranged from r = 0.21, P <0.05, to r = 0.51, P <0.001) even after statistically controlling for variations in knowledge acquisition, which correlated (r = 0.30, P <0.01) with suturing speed. CONCLUSIONS Surgeon variables play a significant role in speed of acquisition and performance of LS skills. Further studies need to elucidate their role in quality of LS performance.

Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training

BACKGROUND Computer-assisted instruction (CAI) can benefit surgical education by improving efficiency, effectiveness, standardization, and access. This study compares knowledge gains for laparoscopic skill acquisition following a standardized tutorial delivered via CD-ROM versus live instructor. METHODS A standardized tutorial was written and subsequently converted to multimedia CD-ROM format by its author (JR). During a laparoscopic development course, experienced US-trained surgeons (n = 52) participated in the tutorial delivered live by the author. The CD-ROM tutorial replaced the instructor for the following groups: (1) experienced US-trained surgeons (n = 27); (2) US-trained surgical residents (n = 59); and (3) Greek surgeons (n = 63). A 51-item knowledge test was administered before and after tutorial instruction. RESULTS The mean increase in scores between pretest and posttest was significant (P <0.01) and of similar magnitude in each group, with nonsignificant posttest mean differences among US-trained groups. CONCLUSIONS The CD-ROM tutorial effectively transfers cognitive information necessary for skill development. Distance learning modes of this tutorial program may be feasible.

Use of mobile low-bandwith telemedical techniques for extreme telemedicine applications

BACKGROUND Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world. STUDY DESIGN Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine. RESULTS Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps. CONCLUSIONS Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.

MINIMALLY INVASIVE SURGICAL TRAINING SOLUTIONS FOR THE TWENTY-FIRST CENTURY

Despite the tremendous impact of laparoscopic cholecystectomy on the practice of surgery over the past 9 years, minimally invasive surgery faces many challenges that must be addressed. SAGES and the American College of Surgeons already have defined guidelines that, if properly implemented, could eliminate most of these challenges. Medical educators must formulate a detailed program as to how these guidelines can be widely deployed with acceptable effectiveness. The current educational philosophies and techniques will not ensure widespread access to a standardized program that would support the achievement of the goals set forth by major surgical governing bodies. Therefore, new educational strategies and techniques that are assisted with the integration of cost-effective technology are needed. Suggested solutions include the deployment of a standardized, objective-based skill-development program that has a large database to evaluate the progress of participants. Next, the Internet, with its ability to transfer content with the click of a mouse, will play an increasing role in distant education. Video and audio streaming techniques will allow the deployment of content previously shackled to a CD-ROM platform. CD-ROM interactive technology also can help in developing clinical judgment with innovative strategies, such as Objective-Based Clinical Competency Evaluation Scenarios. Telecommunications will fuse the components of a coordinated distant learning strategy. Also, telecommunications will allow the availability of new training capabilities in the form of teleproctoring and telementoring to hospitals, no matter what their size or location. All of these components combined enable the realization of a continuing education program in minimally invasive surgery that is readily available to hospitals worldwide. Last, institutions, resident training programs, and individual surgeons must commit the time to partake in these cutting-edge programs for challenges facing us to be completely eliminated. A high priority must be placed on the resolution of these issues.

The Effect of Video Game "Warm-up" on Performance of Laparoscopic Surgery Tasks

This study suggests that those who “warm-up” with select video games may have improved laparoscopic clinical task performance compared to those not engaged in “warm-up.”

Experience and visual perception in resident acquisition of laparoscopic skills.

Assess the role of experience and visual perception (VP) in resident acquisition of laparoscopic surgical skills (LSS).Thrity-nine residents (20 PGY-1s tested just before starting residency; 19 PGY 3+) completed an LSS course, including examination of course-specific knowledge before and after didactic tutorials, 10 trials of 3 dexterity drills and suturing, and 3 standardized VP tests.Mean speed increased significantly (p < 0.001) across trials for all dexterity drills and suturing. Senior residents performed suturing trials 1 to 4 significantly faster (p < 0.05) than did PGY 1s (M +/- SD averaged across trials 1 to 4: 166.5 +/- 59.9 vs 252.3 +/- 108.2 seconds, p < 0.01). Group differences on later trials were progressively smaller and nonsignificant, as were all group differences on dexterity drills. Significant correlations between VP and speed on drills ranged from (r = -0.41, p < 0.01) to (r = -0.71, p < 0.001). Visual perception did not correlate significantly with suturing speed; neither pretest nor posttest scores correlated significantly with drill or suturing speeds.Residents at all levels can significantly increase LSS performance speed to comparable levels during a brief intensive skills course. Proficiency in specific aspects of VP is directly associated with performance speed on dexterity drills, shown in previous studies to be fundamental in the development of intracorporeal suturing skill. (Curr Surg 57:368-372. Copyright 2000 by the Association of Program Directors in Surgery.)

A traumatic abdominal wall hernia repair: a laparoscopic approach.

Traumatic abdominal wall hernia following blunt trauma, although rare, can be successfully managed with a laparoscopic approach.

Laparoscopic Repair of a Ruptured Diaphragm: Avoiding a Trauma Laparotomy

Background: A traumatic diaphragm rupture presents a unique obstacle to a minimally invasive surgical approach; most repairs are performed during an emergency laparotomy. Diaphragm injuries are diagnosed in the acute phase of blunt-force trauma in only 10% of cases, and a high index of suspicion must be maintained to avoid strangulation of the abdominal organs that have herniated into the thoracic cavity. A laparoscopic evaluation and repair of an acute blunt-force rupture of the diaphragm can be diagnostic and curative, mimicking the outcome of an open procedure. Case Description: A 23-year-old woman had a left-side blunt-force rupture of the diaphragm sustained in a high-impact motor vehicle collision. The focused assessment with sonography for trauma (FAST) was negative. The survey chest radiograph identified only streaky opacities that were read as atelectasis. Computed tomography of the abdomen revealed the presence of a congenital abnormality versus a ruptured diaphragm. A diagnostic trauma laparoscopy was performed to evaluate for the possibility of a left-side rupture, and at that point, the spleen and the stomach were found to be located in the left chest, herniating through a rupture in the left diaphragm. A grade I splenic laceration was present. The abdominal structures were reduced and the traumatic rupture was successfully repaired laparoscopically. Discussion: Traumatic rupture of the left diaphragm can occur as an occult injury after blunt-force trauma to the torso. The liver lends protection to the diaphragm and a right-side rupture is far less common than one on the left side. The initial diagnostic plain chest x-ray may not reveal the tear in the diaphragm and the herniation of abdominal viscera into the thoracic cavity. Laparoscopy has been used to evaluate the possibility of a rent in the diaphragm when the patient is hemodynamically stable and the diagnosis is uncertain. Although initial laparoscopic or thorascopic evaluation of a potential rupture of the diaphragm is the standard of care in the trauma literature, laparoscopic repair is not widely accepted. However, laparoscopic evaluation of acute torso trauma with reduction of abdominal viscera and subsequent laparoscopic repair of the diaphragm can be successful.

Laparoscopic Placement of Feeding Tubes

Under normal circumstances, oral intake of carbohydrates, proteins, and fats is sufficient to meet daily caloric requirements. Upper gastrointestinal cancer, mental obtundation or retardation, multiple trauma, and sepsis are special conditions that make it impossible to obtain an adequate amount of nutrients by mouth. Short-term parenteral nutrition is necessary in instances such as enterocutaneous fistulas and short bowel syndrome; however, patients with functional gastrointestinal tracts should be fed enterally. Enterai feeding locally stimulates enterocyte growth and enhances intestinal immune function. Most enterai formulas provide glutamine, which is the principle enterocyte nutrient. Standard total parenteral nutrition (TPN) solutions do not contain glutamine as it is unstable in solution. Even with optimal parenteral nutrition, enterocyte atrophy is well documented. Animal studies demonstrate impaired mucosal immunity when TPN is compared with enterai feeding.1 The combination of mucosal atrophy and decreased local immunity may predispose for bacterial translocation and sepsis. In a study of trauma patients, septic complications were decreased when enterai nutrition was compared with parenteral nutrition.2

Technique of Laparoscopic Nissen Fundoplication

This Nissen fundoplication technique has been successfully employed in more than 350 patients. It was designed with the knowledge that there are many technical variations in a laparoscopic Nissen fundoplication. The following specifics, however, were designed to provide maximum exposure and technical ease for the surgeon. It must be emphasized that this procedure can be done equally well whether the surgeon is right handed or left handed. This surgery however, can only be initiated if the surgeon is facile with the simultaneous use of both hands.