Philip Omotosho

Effectiveness of Laparoscopic Computer Simulator Versus Usage of Box Trainer for Endoscopic Surgery Training of Novices

OBJECTIVE Teaching of laparoscopic skills is a challenge in surgical training programs. Because of the highly technical nature and the steep learning curve, students and residents must learn laparoscopic skills before performing them in the operating room. To improve efficiency of learning and patient safety, research in simulation is essential. Two types of simulators currently in use include virtual reality and box trainers. Our study examined which simulator technique was most effective in teaching novice trainees laparoscopic techniques. DESIGN This is a prospective, randomized, blinded, controlled trial that enrolled fourth-year medical students and surgical interns to participate in a supervised 6-month laparoscopic training program with either computer simulators or box trainers. Subjects were randomized and trained on appropriate laparoscopic camera skills, instrument handling, object positioning, dissection, ligation, suturing, and knot tying. Students within one group were not allowed to practice, learn or train on the opposing trainers. At time points 0, 2, and 6 months all subjects completed a series of laparoscopic exercises in a live porcine model, which were captured on DVD and scored by blinded expert investigators. RESULTS Scores improved overall from the pretest to subsequent tests after training with no difference between the virtual reality and box simulator groups. In the medical students specifically, there was overall improvement, and improvement in the needle-transfer and knot-tying skills specifically, with no difference between the box simulator and virtual reality groups. For the interns, both groups showed significant overall improvement with no difference between the virtual reality and box simulator groups or on individual skills. CONCLUSIONS We conclude that laparoscopic simulator training improves surgical skills in novice trainees. We found both the box trainers and the virtual reality simulators are equally effective means of teaching laparoscopic skills to novice learners.

Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature

BACKGROUND Gastric bypass is a proven treatment option for weight loss and the reduction of medical co-morbid conditions in the obese population. Severe refractory and/or recurrent hypoglycemia can occur, especially in postoperative patients who do not comply with the guidelines for oral glucose consumption. In a very small number of patients, the cause is not dietary indiscretions but, instead, factitious insulin administration or nesidioblastosis. The optimal evaluation and management for these diagnoses is not completely lucid yet important for bariatric surgeons and physicians alike to be familiar. Our objectives were to review the appropriate evaluation and treatment options for etiologies of hypoglycemia after gastric bypass and to create an algorithm that biochemically assesses the etiology of hypoglycemia. The setting was a university hospital in the United States. METHODS We present the cases of 3 patients who developed symptomatic hypoglycemia from distinct etiologies after laparoscopic Roux-en-Y gastric bypass. We also reviewed the current data regarding diagnosis and treatment. RESULTS Each patients evaluation and management is elaborated in detail. We propose a novel algorithm for the biochemical evaluation of hypoglycemia after gastric bypass according to our experience and the review of the literature. CONCLUSION Most cases of symptomatic hypoglycemia that develop in gastric bypass patients are associated with dietary indiscretions. However, a small subset of patients can develop refractory, recurrent, hyperinsulinemic hypoglycemia from factitious insulin administration or nesidioblastosis.

Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater.

Objective: The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). Background: The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. Methods: Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. Results: After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. Conclusions: In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.

In Vivo Assessment of an Absorbable and Nonabsorbable Knotless Barbed Suture for Laparoscopic Single-Layer Enterotomy Closure: A Clinical and Biomechanical Comparison Against Nonbarbed Suture

BACKGROUND Laparoscopic intracorporeal suturing and knot tying is a complex skill that requires repeated deliberate practice to master. A novel self-anchoring barbed suture material that does not require knot tying can eliminate knot failure and reduce operating time. The goal of this study was to compare the in vivo efficacy of two novel knotless barbed sutures (absorbable and nonabsorbable) for use with the Endo Stitch™ device (Covidien), against conventional suture (Endo Stitch device with Polysorb™ suture; Covidien) for laparoscopic closure of viscerotomies in canine stomach, jejunum, and colon. METHODS Following Institutional Animal Care and Use Committee approval, 24 dogs underwent laparoscopic creation of 25-mm viscerotomies, three each in the stomach, jejunum, and colon. All viscerotomies were closed with the Endo Stitch device using the absorbable or nonabsorbable barbed suture or conventional suture. Closure time for each viscerotomy was recorded. Animals were survived for 3, 10, or 21 days, at which point the viscerotomies were burst-pressure tested. RESULTS The closure leak rate in this study with 216 total viscerotomy closures was 0%. There was no statistically significant difference in mean burst pressure between viscerotomies closed with barbed suture versus control suture at any of the survival intervals. Barbed suture with the Endo Stitch device was associated with statistically significantly faster closure times than the control suture with the Endo Stitch device (P<.05), resulting in a reduction in closure time between 35% and 42%. CONCLUSION This study reports the first use of barbed suture for the Endo Stitch device in laparoscopic gastrointestinal closure. The barbed suture for the Endo Stitch device is effective for laparoscopic single-layer gastrointestinal closure and is associated with a significantly reduced closure time.

Predictors of weight regain in patients who underwent Roux-en-Y gastric bypass surgery

BACKGROUND Roux-en-Y gastric bypass (RYGB) is a highly effective treatment for obesity and results in long-term weight loss and resolution of co-morbidities. However, weight regain may occur as soon as 1-2 years after surgery. OBJECTIVES This retrospective study aimed to investigate the prevalence of weight regain and possible preoperative predictors of this phenomenon after RYGB. SETTING An academic medical center in the United States. METHODS A total of 1426 obese patients (15.8% male) who underwent RYGB during January 2000 to 2012 and had at least a 2-year follow-up were reviewed. We included only patients who were initially successful, having achieved at least 50% excess weight loss at 1 year postoperatively. Patients were then categorized into either the weight regain group (WR) or sustained weight loss (SWL) group based upon whether they gained≥15% of their 1-year postoperative weight. RESULTS Weight regain was observed in 244 patients (17.1%). Preoperative body mass index was similar between groups. Body mass index was significantly higher and percent excess weight loss was significantly lower in the WR group (P<.001). Average weight regain was 19.5±9.3 kg and-.8±8.5 in the WR and SWL groups, respectively (P<.001). Time elapsed since RYGB was significantly longer in the WR group (WR 6.0±2.4 years versus SWL 3.3±1.8 years; P<.001; range 2-12 yr). Patients in the WR group were significantly younger (WR 42.3±9.8 yr versus SWL 45.7±10.8 years; P<.001), had fewer co-morbidities, and were less likely to have type 2 diabetes with insulin dependence preoperatively. Univariate analysis found that older age, male gender, having hypertension, dyslipidemia, and insulin-treated type 2 diabetes were all factors associated with sustained weight loss. Moreover, a longer duration after RYGB was associated with weight regain. Multivariate analysis revealed that younger age was a significant predictor of weight regain even after adjusting for time since RYGB. CONCLUSION The present study confirmed that a longer interval after RYGB was associated with weight regain. Younger age was a significant predictor of weight regain even after adjusting for time since RYGB. The findings of this study underscore the complexity of the mechanisms underlying weight loss and regain after RYGB. Future prospective studies are needed to further explore the prevalence, predictors, and mechanisms of weight regain after RYGB.

Robotic assisted laparoscopic radical cystectomy with stentless intracorporeal modified Ves.Pa neobladder: early experience

AbstractThis study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.