Philippe Grange

Learning basic laparoscopic skills: a randomized controlled study comparing box trainer, virtual reality simulator, and mental training.

OBJECTIVES The objectives of this study were (1) to compare different methods of learning basic laparoscopic skills using box trainer (BT), virtual reality simulator (VRS) and mental training (MT); and (2) to determine the most effective method of learning laparoscopic skills. DESIGN Randomized controlled trial. SETTING Kings College, London. METHODS 41 medical students were included in the study. After randomization, they were divided into 5 groups. Group 1 was the control group without training; group 2 was box trained; group 3 was also box trained with an additional practice session; group 4 was VRS trained; and group 5 was solely mentally trained. The task was to cut out a circle marked on a stretchable material. All groups were assessed after 1 week on both BT and VRS. Four main parameters were assessed, namely time, precision, accuracy, and performance. RESULTS Time: On BT assessment, the box-trained group with additional practice group 3 was the fastest, and the mental-trained group 5 was the slowest. On VRS assessment, the time difference between group 3 and the control group 1 was statistically significant. Precision: On BT assessment, the box-trained groups 2 and 3 scored high, and mental trained were low on precision. On VRS assessment, the VRS-trained group ranked at the top, and the MT group was at the bottom on precision. Accuracy: On BT assessment, the box-trained group 3 was best and the mental-trained group was last. On VRS assessment, the VRS-trained group 4 scored high closely followed by box-trained groups 2 and 3. Performance: On BT assessment, the box-trained group 3 ranked above all the other groups, and the mental-trained group ranked last. On VRS assessment, the VRS group 4 scored best, followed closely by box-trained groups 2 and 3. CONCLUSIONS The skills learned on box training were reproducible on both VRS and BT. However, not all the skills learned on VRS were transferable to BT. Furthermore, VRS was found to be a reliable and the most convenient method of assessment. MT alone cannot replace conventional training.

Using the Mind as a Simulator: A Randomized Controlled Trial of Mental Training

OBJECTIVES Laparoscopic simulators have been introduced as safe and effective methods of developing basic skills. Mental training is a novel training method likened to using the mind as a simulator to mentally rehearse the movements of a task or operation. It is widely used by professional athletes and musicians and has been suggested as a technique that could be used by surgical trainees. The purpose of this study was to assess the use of mental training in developing basic laparoscopic skills in novices. METHODS Sixty-four medical students without laparoscopic experience were randomized into 4 groups. The first 3 groups were trained to cut a circle on a box trainer. Group 1 received no additional training (BT), Group 2 received additional virtual reality training (BT + VRS), and Group 3 received additional mental training (BT + MT). The fourth group was trained on a virtual reality simulator with additional mental training (box-free). The following 4 assessment criterias: time, accuracy, precision and overall performance were measured on both the box-trainer and virtual simulator. RESULTS The mental training group (BT + MT) demonstrated improved laparoscopic skills over both assessments. The improvement in skills in the VRS group (BT + VRS) was limited to VRS assessment and not observed in the box assessment. The fourth group (box-free) had the worst performance on both methods of assessment. CONCLUSION The addition of mental training led to improved laparoscopic skills development. It is a flexible technique and has the potential to challenge VRS as a more cost-effective training method associated with lower capital investment. Given the benefits of mental training with further research, it could be considered for inclusion in training curricula.

Combined Vaginal and Vesicoscopic Collaborative Repair of Complex Vesicovaginal Fistulae

INTRODUCTION This study aimed to describe and demonstrate the feasibility of a minimally invasive surgical technique for the repair of complex vesicovaginal fistulae that may not be amenable to vaginal repair. TECHNICAL CONSIDERATIONS Nine cases of vesicovaginal fistulae, which were repaired laparoscopically at Kings College Hospital, London and Ygia Polyclinic Private Hospital, Limassol between 2011 and 2013, were identified. The repair was carried out by direct placement of the ports into the urinary bladder (vesicoscopy). Preoperative, intraoperative, and postoperative data were collected from a prospective database. All 9 operations were completed without any conversion to open surgery. Four ureteric reimplantations were necessary for ureteric involvement. There were no intraoperative complications but some intraoperative technical difficulties. No early postoperative complications were documented, and the hospital stay varied from 2 to 8 days. The fistula repair success rate was 89% at a median follow-up of 30 months. CONCLUSION This surgical technique is feasible and offers an alternative approach to the classical open or laparoscopic transperitoneal approach. It supplements the vaginal approach for fistulae that are not suitable for pure vaginal approach, allowing close collaboration between the laparoscopic urologist and the vaginal surgeon.

Scarless Single-Port Laparoscopic Pelvic Kidney Nephrectomy

INTRODUCTION We report the first pelvic kidney removal through the umbilicus using a scarless pure single-port technique in a young woman. PATIENTS AND METHODS A 27-year-old woman presented with uro-sepsis and acute renal failure secondary to a dilated, chronically infected, nonfunctioning left-sided pelvic kidney with ureteropelvic obstruction causing an obstruction to the right kidney. The acute episode was managed with bilateral ureteric stents and antibiotics. Definitive treatment involved removal of the diseased pelvic kidney through the umbilicus via a single-port access device (TriPor™; Olympus). A curved tissue grasper and extralong bariatric suction device were used along with standard straight laparoscopic instruments. In addition, a 10-mm flexible-tip video laparoendoscope (HD EndoEYE LTF-VH™; Olympus) and a robotic camera holder (FreeHand™; Prosurgics) were used to reduce external instrument clash. RESULTS The procedure was technically successful leaving the patient with a scarless abdomen. The operative time was 185 minutes, blood loss 100 mL, and length of stay 48 hours. There were no complications. CONCLUSION Scarless transumbilical pelvic nephrectomy is technically feasible. The first reported clinical experience is discussed.

Impact of Laparoscopic Lens Contamination in Operating Theaters: A Study on the Frequency and Duration of Lens Contamination and Commonly Utilized Techniques to Maintain Clear Vision.

Introduction: In laparoscopy, contamination of the distal lens is problematic. Not only a cause of frustration, repeatedly cleaning the laparoscope takes up significant time and disrupts the operative flow. Our study aims to explore and describe quantitatively this particular issue within the operating theaters of a major teaching hospital. Materials and Methods: We recorded data assessing the occurrence of impaired vision on the screen display and quantified the occurrence, duration, and modality of cleaning events. Data were recorded on a time-line sheet and collected for basic quantitative analysis as reported below. A brief interview with the surgeons was carried out at the end of each procedure. Results: A total of 64 hours of laparoscopy covering 25 procedures in 4 surgical disciplines were observed. The study found that 56% of the operation was performed with a clear display, while 37% of the time was spent impaired vision. Seven percent of the operation was spent cleaning the distal lens. The interviews recorded a unison sense of frustration and safety concerns regarding lens contamination. Conclusions: Our observational study demonstrates that one third of the duration of a laparoscopic procedure is performed without perfectly clear display. The suboptimal display during an operation is similar to that of driving with a dirty windshield and having to step out of the car to clean it before continuing with the journey. The disruption to operative flow is transcribed as frustration felt by surgeons when display is compromised and having to clean the lens. However, the economical impact of cleaning the lens during the operation remains to be demonstrated.

NANOTECHNOLOGY IN THE MANAGEMENT OF PROSTATE CANCER

© 2 0 0 8 T H E A U T H O R S J O U R N A L C O M P I L A T I O N

Hormone therapy: a revolution in understanding prostate cancer

Until the middle of the 20th century, little knowledge of the behaviour of prostate cancer existed and awareness of its exquisite sensitivity to hormones had not been realised. The conventional understanding was that prostate cancer was an autonomous, self-perpetuating, and fatal malignant disease, the progression of which could not be changed by external manipulation. In 1941, Charles Brenton Huggins, a Canadian-born American surgeon, revolutionised our understanding of prostate cancer and irrevocably changed the approach of physicians in managing and researching the treatment of neoplastic disease in general. His pioneering work heralded the era of rational drug therapy for all cancers and earned Huggins the Nobel Prize in Physiology and Medicine in 1966. Charles Huggins graduated from Harvard Medical School (Boston, MA, USA) in 1924. In 1927, he was appointed to the surgical faculty at the University of Chicago (Chicago, IL, USA) where he became Professor of Surgery in 1936. Subsequently, in 1966, he became the second surgeon to win a Nobel Prize in Medicine, with a comment from the Nobel Committee proclaiming Huggins’ work had “already given many years of an active and useful life to patients with advanced cancer over the entire civilized world—patients who would have been lost to other forms of therapy”. Many have suggested that his ground-breaking discoveries, fi rst published in 1941, should have been acknowledged by the committee at a much earlier date. In the original study by Huggins and Hodges (his student), eight patients with metastatic disease to bone were selected from an initial group of 47 patients with prostate cancer. All eight patients underwent bilateral orchidectomy; however, before this procedure, fi ve were started on daily injections of stilboestrol or oestradiol benzoate, and three were injected with daily testosterone propionate. Serum acid-phosphatase concentrations decreased in patients who received oestrogen injection before the procedure and increased in those who received testosterone propionate. From these fi ndings, Huggins and Hodges concluded that prostate cancer was receptive to androgenic activity in the body and that metastatic prostate cancer was inhibited by eliminating circulating androgens—either by surgical orchidectomy or by administration of oestrogens. Moreover, they also showed that prostate cancer was activated by androgen injections. These fi ndings have provided the scientifi c basis for the contemporary treatment of prostate cancer. For nearly 30 years after this seminal report by Huggins and Hodges, patients with advanced prostatic carcinoma were managed either by surgical orchidectomy or oestrogens, until it was shown that treatment with oestrogens resulted in substantial thromboembolic and cardiovascular complications. This fi nding stimulated further research into alternative hormonal treatments, which culminated in the development of various antiandrogens (eg, cyproterone acetate and fl utamide) and most notably synthetic luteinising-hormonereleasing-hormone (LHRH) agonists in the 1970s. The therapeutic eff ectiveness of LHRH in achieving medical castration has yet to be surpassed. Although these hormonal treatments were originally used to manage patients with metastatic disease, androgen ablation therapy is now used in a neoadjuvant or adjuvant setting in combination with surgery or radiation in patients with locally advanced disease only or in those with biochemical relapse after radical treatment for localised disease. The epic work by Huggins and Hodges will remain a cornerstone in the annals of medical literature because it initiated the use of endocrine therapy in the management of disseminated prostate cancer and showed that the course of neoplastic disease could be changed by rational external intervention. One can state with certainty that there are few articles in science, which have had, or will have, such a lasting impact.

Das GeSRU Endo-Training – Strategien zur Optimierung der endourologischen Ausbildung

Die Diskussion uber die Ausbil- dungssituation des urologischen Nachwuchses ist aktueller denn je. Vor dem Hintergrund wachsender Anforderungen an diemedizinische Versorgung durch den demogra- phischen Wandel und (trotz) des allgegenwartigen Druckes zum wirtschaftlichen Arbeiten ist eine qualifizierte urologische Ausbil- dungdringendnotwendig.Um diese sicherzustellen, sind neue, nach- haltige Konzepte gefragt. Das in diesem Jahr erstmals durchgefuhr- te GeSRU Endo-Trainingsoll hierzu einenBeitrag leisten.

Expanding role of nanotechnology in the management of colorectal cancer

Surgery, chemotherapy and radiot herapy are the standard treatment parameters available but treatment modalities are still substandard. Recurrence rates after surgical intervention can be as high as 29% [2] and chemotherapy and radiotherapy efficacy has not dramatically improved over the last 5 years, often giving rise to nonspecific distribution of the anti-tumor agents, with poor delivery at inadequate concentrations in the former and collateral damage in the latter. Another obstacle is the development of multi drug resistance, which can result in relapse and failure of tumor mass reduction. There is, therefore, an unmet clinical requirement for image-based detection and targeted treatment delivery systems, and efforts are constantly being made to develop technology that would improve sensitivity and specificity in the diagnosis and treatment of colorectal cancer. Nanotechnology appears to be a savior on the horizon in developing such multitasked systems, particularly at an atomic or molecular level. Recently, great strides have been made in the development and advancement of nano technology, with the USA investing approximately US

Impact of nanotechnology in breast cancer

1.4 billion into this technology in 2008 [102]. Its application in the medical field is rapidly increasing, particularly in the diagnosis and treatment of various cancers.