L. S. Feldman

Evaluating laparoscopic skills

Background: The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) was developed to assess laparoscopic skills and to score them objectively. This system has been described previously. The purpose of the current study was to determine a pass/fail threshold. Methods: In this study. 165 individuals were tested and grouped according to their clinical competency in laparoscopic surgery. The noncompetent group consisted of medical students and surgical residents in their first 2 years of training (n = 83). The competent group consisted of chief general surgical residents in their last year of training, laparoscopy fellows. and practicing laparoscopic surgeons (n = 82). The Mann-Whitney U test was used to evaluate differences in task performance between the two groups. Results: There was a significant difference in total scores and individual MISTELS task scores between the noncompetent and competent laparoscopic surgeons (189 vs 372.5; p < 0.0001). By setting specific pass/fail total score thresholds (cutoff scores), competent surgeons can be discriminated from noncompetent surgeons. Conclusion: An objective pass/fail evaluation can be given to individuals tested with the MISTELS system.

Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach

BackgroundThe most appropriate approach to the repair of large paraesophageal hernias remains controversial. Despite early results of excellent outcomes after laparoscopic repair, recent reports of high recurrence require that this approach be reevaluated.MethodsFor this study, 60 primary paraesophageal hernias consecutively repaired at one institution from 1990 to 2002 were reviewed. These 25 open transabdominal and 35 laparoscopic repairs were compared for operative, short-, and long-term outcomes on the basis of quality-of -life questionnaires and radiographs.ResultsNo difference in patient characteristics was detected. Laparoscopic repair resulted in lower blood loss, fewer intraoperative complications, and a shorter length of hospital stay. No difference in general or disease-specific quality-of-life was documented. Radiographic follow-up was available for 78% open and 91% laparoscopic repairs, showing anatomic recurrence rates of 44% and 23%, respectively (p = 0.11).ConclusionsLaparoscopic repair should remain in the forefront for the management of paraesophageal hernias. However, there is considerable room for improvement in reducing the incidence of recurrence.

Characterizing the learning curve for a basic laparoscopic drill

Background:The psychomotor challenges inherent in laparoscopic surgery are evident by the steep procedural “learning curves” documented throughout the literature. Few methods have been described to evaluate learning curves. The cumulative summation (CUSUM) method is a criterion-based evaluation of the learning process. The purpose of this study is to describe the CUSUM learning curves for a simple task for individuals and for a group of novice laparoscopists.Methods:Sixteen medical students undertook four weekly sessions of 10 laparoscopic pegboard transfers in the MISTELS system. Their performance was scored and recorded for each trial. CUSUM learning curves were constructed based on the goal of achieving mean scores for senior, intermediate, or junior laparoscopists ≥95% of the time.Results:Based on senior criteria, one student achieved the goal by the 40th peg transfer trial. Based on intermediate criteria, three students achieved the goal by their 40th trial (trials 21 and 36), and for junior criteria, 10 students achieved the acceptable success rate by their 40th trial (range, 26–40).Conclusion:CUSUM analysis suggests criterion-based practice is useful for novice laparoscopists. It allows educators to track the progress of an individual toward target criteria for each MISTELS task, to more logically allocate time for training and set attainable goals, to objectively evaluate trainee acquisition of basic laparoscopic skills, and to identify trainees who need remediation.

Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia.

BackgroundThe purpose of this study is to assess how subjective evaluation (heartburn, dysphagia, quality of life, and satisfaction) correlates with objective data after Heller myotomy and Dor fundoplication for achalasia.MethodsA total of 53 consecutive patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication were studied prospectively. Subjective evaluation was done preop and postop using the Gastroesophageal Reflux Disease Health-Related Quality of Life instrument (GERD-HRQL; 0 = best, 45 = worse), 4-point dysphagia and heartburn scales (0 = best, 3 = worst), patient satisfaction scale (0 = very satisfied, 5 = incapacitated), and the SF-12 general health-related quality-of-life score. At 3 months postop, patients were asked to undergo objective evaluation with 24-h pH testing, manometry, and endoscopy. Data are expressed as median (interquartile range) and analyzed by Wilcoxon signed rank test or Mann–Whitney U test.ResultsForty-nine patients were more than 3 months postsurgery. Comparing preop to postop, improvements were found in dysphagia [3 (2–3) to 0 (0–1)], heartburn [1 (0–2) to 0 (0–1)], GERD-HRQL [13.5 (6.3–22.5) to 2 (0–5)], satisfaction [3 (3–4) to 1 (0–1)], and SF-12 mental component summary [46 (37–56) to 58 (50–59)] and physical component summary [46 (36–53) to 55 (48–56)] scores (p < 0.0001 for all). Thirty-eight patients (78%) agreed to undergo objective testing, and complete data were available for 32 (65%). Four of 32 patients (12.5%) had evidence of reflux based on 24-h pH testing. Of nine patients with GERD-HRQL >5, only two had positive pH test (22%). Of 23 patients with GERD-HRQL <5, two had positive pH test (7%). Of four tested patients with moderate to severe heartburn, two had an abnormal pH test. There was no significant relationship between GERD-HRQL score and pH test results. Lower esophageal sphincter pressure (LESP) decreased from 24 (16–35) to 13 mmHg (11–17) (p < 0.001). There was no relationship between dysphagia score and postop absolute LESP or a decrease in LESP after operation.ConclusionsLaparoscopic Heller myotomy and Dor fundoplication is an effective treatment for achalasia. Subjective evaluation can document patient satisfaction and health-related quality of life but does not accurately reflect postop reflux. Twenty-four-hour pH study is required to accurately assess reflux disease.

Optimization of cardiac preload during laparoscopic donor nephrectomy: A preliminary study of central venous pressure versus esophageal doppler monitoring

Background: While the popularity of laparoscopic donor nephrectomy (LDN) has increased, concern persists about the potential deleterious effects of pneumoperitoneum on renal function. Thus, preload optimization with vigorous intravenous hydration has been recommended. The purpose of this study was to compare central venous pressure (CVP) monitoring with a noninvasive measure of cardiac preload (esophageal Doppler) during LDN. Methods: Thirteen patients were studied. Following induction of general anesthesia, a Doppler probe was inserted in the lower third of the esophagus to measure flow time corrected for heart rate (FTc), which is an index of preload. In 10 patients, a catheter was placed in the right internal jugular vein and CVP measured. CVP and FTc were measured at baseline in the supine and right lateral decubitus positions, then 15 and 60 min after the establishment of CO2 pneumoperitoneum (12–15 mmHg). IV fluids were increased if the FTc fell below 300 msec. Results are expressed as means (±SD). Data were analyzed using repeated measures ANOVA. Results: Lateral positioning and pneumoperitoneum significantly increased CVP from baseline (p < 0.01), while the FTc did not change (p = 0.57). After 60 min of pneumoperitoneum, the FTc was <300 msec in only one patient. Conclusion: CVP is not an accurate guide for administration of IV fluids during LDN. Esophageal Doppler monitoring can be used to noninvasively follow changes in preload during LDN and is worthy of further study.

Does aggressive hydration reverse the effects of pneumoperitoneum on renal perfusion

BackgroundAlthough pneumoperitoneum (PP) decreases renal blood flow, it remains unclear whether this impacts renal function. Our aim was to characterize the effects of PP on renal perfusion and function using two fluid strategies for intravenous fluid administration.MethodsTwelve 30-kg pigs were randomized into two groups: maintenance (3 cc/kg/h of normal saline (NS)) and bolus (15 cc/kg/h + 20 cc/kg NaCl bolus prior to induction of PP). Pigs were studied in a blinded fashion for 30 min prior, 60 min during, and 30 min after release of 15 mmHg CO2 PP. Cardiac output (CO) and stroke volume (SV) were measured using an esophageal Doppler probe, renal cortical perfusion (RCP) was measured with a laser Doppler probe on the right kidney, and renal function was measured using the fractional excretion of sodium (FeNa) and urine output. Statistical analysis was performed with area-under-the-curve (AUC) analysis and analysis of varianceResultsAUC analysis revealed moderate effect size for CO (0.416) and small effect size for SV (0.366) and RCP (0.363), with decreases seen in the control group but not the bolus group. During PP, urine output increased in the bolus group (p = 0.04) but not in the control group; there was no difference in FeNa in either group.ConclusionAggressive fluid hydration during CO2 PP of 15 mmHg preserves CO, SV, and RCP while increasing urine output. No effect on renal function as measured by FeNa was observed in either group.

Does a special interest in laparoscopy affect the treatment of acute cholecystitis

Background: We tested the hypothesis that the treatment of patients with acute cholecystitis (AC) would be improved under the care of laparoscopic specialists. Methods: The records of patients undergoing cholecystectomy for AC from 1 January 1996 to 31 December 1998 were reviewed retrospectively. Of 170 patients, 48 were cared for by three laparoscopic specialists (LS group), whereas 122 were treated by nine general surgeons who perform only laparoscopic cholecystectomy (LC) (GS group). The rates of successful LC, complications, and length of hospital stay were compared. Multivariate analysis was used to control for baseline differences. Results: The patients in the GS group were older (median age, 63 vs 53 years; p = 0.01). In all, 31 LS patients (65%), as compared with 44 GS patients (36%), had successful laparoscopic treatment (p = 0.001). The operating time was the same (median, 70 min). The proportion of patients with postoperative complications was similar in the two groups (37% in the GS vs 3l% in the LS group; p = 0.6). The median postoperative hospital stay (3 vs 5 days; p <0.01) was shorter in the LS group. On logistic regression analysis, significant predictors of a successful laparoscopic operation included LS group (p <0.01) and age (p = 0). Predictors of prolonged length of hospital stay were age (p <0.01) and comorbidity score (p <0.01), with LS group status not a significant factor (p = 0.21). Conclusions: Patients with AC are more likely to undergo successful LC if cared for by a surgeon with an interest in laparoscopy. However, length of hospital stay is influenced more by patient factors in a multivariate model.