M. Paschold

Preconditioning in laparoscopic surgery—results of a virtual reality pilot study

BackgroundThis prospective study investigated the effect of preconditioning in laparoscopic cholecystectomy (LC) and appendectomy (LA) based on pre- and postoperative virtual reality laparoscopy (VRL) performances, with specific regard to the impact of different motor skills, types of surgery and levels of experience.Study designForty laparoscopic procedures (28 LC and 12 LA) were performed by 13 residents in the operating room. Participants completed a defined set of tasks on the VRL simulator directly prior to and after the operation: one preparational task (PT), a virtual procedural task with emphasis on fine preparation (VPT) and a navigational manoeuvre for instrument coordination (ICT). VRL performances were evaluated based on the assessed items of the simulator.ResultsOverall analysis of the surgeons’ performance demonstrated better postoperative results for PT and VPT in 28 and 26 cases (p = 0.001 and p = 0.034), respectively. No significant difference was found for ICT (p = 0.638). Less-experienced residents had better postoperative results for PT and VPT (p = 0.009 and p = 0.041), whereas more-experienced surgeons had better postoperative results for PT only (p = 0.030). LC resulted in better postoperative performance for PT (p = 0.007). LA improved performance for PT and VPT (p = 0.034 and p = 0.006, respectively). Comparisons of surgeon’s experience demonstrated a significant advantage for more-experienced surgeons in ICT (p = 0.033), while type of surgery showed an advantage for LA in VPT (p = 0.022).ConclusionThere is a preconditioning effect in laparoscopic surgery. The differing results related to LC and LA and the experience levels of surgeons suggest that differentiated warm-up strategies are required.

Virtuelle 3-D-Laparoskopie-Simulation in der chirurgischen Aus- und Weiterbildung – Ergebnisse einer Pilotstudie

BACKGROUND The use of three-dimensional imaging in laparoscopy is a growing issue and has led to 3D systems in laparoscopic simulation. Studies on box trainers have shown differing results concerning the benefit of 3D imaging. There are currently no studies analysing 3D imaging in virtual reality laparoscopy (VRL). MATERIALS AND METHODS Five surgical fellows, 10 surgical residents and 29 undergraduate medical students performed abstract and procedural tasks on a VRL simulator using conventional 2D and 3D imaging in a randomised order. RESULTS No significant differences between the two imaging systems were shown for students or medical professionals. Participants who preferred three-dimensional imaging showed significantly better results in 2D as wells as in 3D imaging. DISCUSSION First results on three-dimensional imaging on box trainers showed different results. Some studies resulted in an advantage of 3D imaging for laparoscopic novices. This study did not confirm the superiority of 3D imaging over conventional 2D imaging in a VRL simulator. CONCLUSION In the present study on 3D imaging on a VRL simulator there was no significant advantage for 3D imaging compared to conventional 2D imaging.

Appendectomy in surgical residency. What has changed over the past 10 years

BACKGROUND Surgical residents need to train laparoscopic skills for minimally invasive procedures at an early stage. The aim of this study was the investigation and assessment of appendectomy carried out at a university medical center over the previous decade regarding the frequency of operations by residents in training and the type of surgical technique used (laparoscopic vs. open). METHODS A retrospective analysis of appendectomies carried out from 2005 to 2014 at the clinic for general, visceral and transplant surgery was performed. Operators were stratified into two groups (group 1: residents and group 2: fellows/attending surgeons). Surgery was classified as laparoscopic or open appendectomy. RESULTS Out of 1,587 appendectomies analyzed 946 were performed laparoscopically (59.6 %). The percentage of laparoscopic appendectomies increased significantly over the decade analyzed (p < 0.001) and reached 94.4 % in 2014. From 2005 until 2007 the rate of appendectomies by residents was 17.9 % (77 out of 430). Laparoscopic appendectomy was performed in 5.8 % and was only performed by fellows or attending surgeons. From 2008 to 2014 the rate of surgeries by residents significantly increased (p < 0.001) and accounted for 57.6 % (range 19.4-66.9 %). CONCLUSION Regardless of the surgical technique used, appendectomy is still a primary training operation for surgical residents. An early and focused training of minimally invasive visceral surgery in the new regulations for continuing medical education starts with laparoscopic appendectomy.ZusammenfassungHintergrundWeiterbildungsassistenten müssen frühzeitig Fertigkeiten für minimal-invasive Operationsverfahren erwerben. Ziel der Arbeit war es, die Operationshäufigkeit durch Weiterbildungsassistenten sowie die Operationstechnik (laparoskopisch vs. konventionell) bei indizierter Appendektomie an einer Universitätsklinik über eine Dekade zu analysieren und hinsichtlich der Weiterbildungsbedürfnisse zu bewerten.MethodenAlle an der Klinik für Allgemein-, Viszeral- und Transplantationschirurgie der Universitätsmedizin Mainz im Zeitraum von 2005 bis 2014 durchgeführten Appendektomien wurden retrospektiv ausgewertet. Die Operateure wurden zwei Gruppen zugeordnet (Weiterbildungsassistenten, Fach- und Oberärzte). Bei den Operationen wurde zwischen laparoskopischer und offener Appendektomie unterschieden.ErgebnisseVon 1587 analysierten Operationen erfolgten 946 laparoskopisch (59,6 %). Der Anteil laparoskopischer Appendektomien hat über den analysierten 10-Jahres-Zeitraum signifikant zugenommen (p < 0,001) und betrug 2014 94,4 %. In den Jahren 2005 bis 2007 wurden 17,9 % (77/430) der Appendektomien von Weiterbildungsassistenten offen durchgeführt. Eine laparoskopische Appendektomie erfolgte in 5,8 % der Fälle nur durch Fach- oder Oberärzte. Von 2008 bis 2014 nahm die Rate der im Rahmen der Weiterbildung assistierten Operationen signifikant zu (p < 0,001) und betrug 57,6 % (Streubreite:19,4–66,9 %).SchlussfolgerungDie Appendektomie hat sich unabhängig vom operativen Zugang als Weiterbildungseingriff bestätigt. Eine frühzeitige und verstärkte Abbildung der laparoskopischen Viszeralchirurgie in der neuen Weiterbildungsordnung wird nicht zuletzt durch die laparoskopische Appendektomie katalysiert.SummaryBackgroundSurgical residents need to train laparoscopic skills for minimally invasive procedures at an early stage. The aim of this study was the investigation and assessment of appendectomy carried out at a university medical center over the previous decade regarding the frequency of operations by residents in training and the type of surgical technique used (laparoscopic vs. open).MethodsA retrospective analysis of appendectomies carried out from 2005 to 2014 at the clinic for general, visceral and transplant surgery was performed. Operators were stratified into two groups (group 1: residents and group 2: fellows/attending surgeons). Surgery was classified as laparoscopic or open appendectomy.ResultsOut of 1,587 appendectomies analyzed 946 were performed laparoscopically (59.6 %). The percentage of laparoscopic appendectomies increased significantly over the decade analyzed (p < 0.001) and reached 94.4 % in 2014. From 2005 until 2007 the rate of appendectomies by residents was 17.9 % (77 out of 430). Laparoscopic appendectomy was performed in 5.8 % and was only performed by fellows or attending surgeons. From 2008 to 2014 the rate of surgeries by residents significantly increased (p < 0.001) and accounted for 57.6 % (range 19.4–66.9 %).ConclusionRegardless of the surgical technique used, appendectomy is still a primary training operation for surgical residents. An early and focused training of minimally invasive visceral surgery in the new regulations for continuing medical education starts with laparoscopic appendectomy.

Highly immersive virtual reality laparoscopy simulation: development and future aspects

PurposeVirtual reality (VR) applications with head-mounted displays (HMDs) have had an impact on information and multimedia technologies. The current work aimed to describe the process of developing a highly immersive VR simulation for laparoscopic surgery.MethodsWe combined a VR laparoscopy simulator (LapSim) and a VR-HMD to create a user-friendly VR simulation scenario. Continuous clinical feedback was an essential aspect of the development process. We created an artificial VR (AVR) scenario by integrating the simulator video output with VR game components of figures and equipment in an operating room. We also created a highly immersive VR surrounding (IVR) by integrating the simulator video output with a

Surgical therapy of primary intestinal lymphangiectasia in adults

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Structured assessment of laparoscopic camera navigation skills: the SALAS score

360∘ video of a standard laparoscopy scenario in the department’s operating room.ResultsClinical feedback led to optimization of the visualization, synchronization, and resolution of the virtual operating rooms (in both the IVR and the AVR). Preliminary testing results revealed that individuals experienced a high degree of exhilaration and presence, with rare events of motion sickness. The technical performance showed no significant difference compared to that achieved with the standard LapSim.ConclusionOur results provided a proof of concept for the technical feasibility of an custom highly immersive VR-HMD setup. Future technical research is needed to improve the visualization, immersion, and capability of interacting within the virtual scenario.

Management of bleeding complications in virtual reality laparoscopy

BACKGROUND Laparoscopic assistance is often entrusted to a less experienced resident, medical student, or operating room nurse. Data regarding laparoscopic training for operating room nurses are not available. OBJECTIVES The aim of the study was to analyse the initial performance level and learning curves of operating room nurses in basic laparoscopic surgery compared with medical students and surgical residents to determine their ability to assist with this type of procedure. DESIGN The study was designed to compare the initial virtual reality performance level and learning curves of user groups to analyse competence in laparoscopic assistance. PARTICIPANTS The study subjects were operating room nurses, medical students, and first year residents. METHODS Participants performed three validated tasks (camera navigation, peg transfer, fine dissection) on a virtual reality laparoscopic simulator three times in 3 consecutive days. Laparoscopic experts were enrolled as a control group. Participants filled out questionnaires before and after the course. RESULTS Nurses and students were comparable in their initial performance (p>0.05). Residents performed better in camera navigation than students and nurses and reached the expert level for this task. Residents, students, and nurses had comparable bimanual skills throughout the study; while, experts performed significantly better in bimanual manoeuvres at all times (p<0.05). CONCLUSION The included user groups had comparable skills for bimanual tasks. Residents with limited experience reached the expert level in camera navigation. With training, nurses, students, and first year residents are equally capable of assisting in basic laparoscopic procedures.

Virtual reality laparoscopy: which potential trainee starts with a higher proficiency level?

Primary intestinal lymphangiectasia (PIL) is a rare disorder, especially in adults. It causes a local disruption of chylus transport and is part of the exudative gastroenteropathies. Conservative therapy includes dietary measures or somatostatin medication. Taking the differential diagnosis of PIL into consideration is a major challenge, since patients suffering from PIL may present with diarrhoea and lymphedema or chylous ascites. This can be explained by the chronic lymphedema of the bowel leading to dilation of the vessels (intraluminal loss) and sometimes even to a rupture (peritoneal loss). Push–pull enteroscopy and capsule endoscopy are the proper interventional diagnostic tools to discover PIL. Exploratory laparoscopy may be useful in unclear cases. Surgical resection of the altered intestine has been described with positive results. Exploratory laparoscopy may even be a diagnostic tool in unclear cases. Resection of the altered intestine is a treatment option in symptomatic and treatment-refractory cases.