T. Huber

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

Transanal minimally invasive surgery (TAMIS) approach for large juxta-anal gastrointestinal stromal tumour

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Surgical therapy of primary intestinal lymphangiectasia in adults

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.

Artificial Versus Video-Based Immersive Virtual Surroundings: Analysis of Performance and User’s Preference:

Physical activity confers a broad spectrum of health benefits. Beyond the obvious role in metabolically driven diseases, the role of physical activity in acute liver injury is poorly explored. To study the role of physical activity in acute liver injury, a novel model of voluntary distance running in mice was developed and mice were subjected to acute liver injury induced by N-galactosamine (GalN) and lipopolysaccharide (LPS). Analyses included histological stains, immunoblotting, qRT-PCR and FACS analysis. Voluntary distance running increased to an average of 10.3 km/day after a learning curve. Running lead to a decrease in the absolute numbers of intrahepatic CD4+ T and B lymphocytes and macrophages after 7 weeks. In parallel, hepatic mRNA expression of inflammatory cytokines including IL-6 and IL-1beta, TGF-beta and monocyte chemoattractant protein-1 (MCP-1/CCL2) were suppressed, while TNF-α was not affected by exercise. Likewise, expression of the macrophage-specific antigen F4/80 was downregulated 1.6-fold from exercise. Notably, acute liver injury from GaIN/LPS was significantly blunted following 7 weeks of voluntary exercise as determined by liver histology, a 84.6% reduction of alanine aminotransferase (P<0.01) and a 54.6% reduction of aspartate aminotransferase (P<0.05) compared with sedentary mice. Additionally, proinflammatory cytokines, activation of caspase 3 and JNK were significantly lower, while antiapoptotic protein A20 increased. Voluntary distance running alters the intrahepatic immune phenotype producing an environment that is less susceptible to acute liver injury.

Structured assessment of laparoscopic camera navigation skills: the SALAS score

Gastrointestinal stromal tumours (GISTs) are rarely found in the rectum. Large rectal GISTs in the narrow pelvis sometimes require extended abdominal surgery to obtain free resection margins, and it is a challenge to preserve sufficient anal sphincter and urogenital function. Here we present a 56-year-old male with a locally advanced juxta-anal non-metastatic GIST of approximately 10 cm in diameter. Therapy with imatinib reduced the tumour size and allowed partial intersphincteric resection (pISR). The patient underwent an electrophysiology-controlled nerve-sparing hybrid of laparoscopic and transanal minimally invasive surgery (TAMIS) in a multimodal setting. The down-to-up approach provided sufficient dissection plane visualisation and allowed the confirmed nerve-sparing. Lateroterminal coloanal anastomosis was performed. Follow-up showed preserved urogenital function and good anorectal function, and the patient remains disease-free under adjuvant chemotherapy as of 12 months after surgery. This report suggests that the TAMIS approach enables extraluminal high-quality oncological and function-preserving excision of high-risk GISTs.