When can I be proficient in laparoscopic surgery? A systematic review of the evidence

Purpose: The aim of this study was to quantify the learning curve in laparoscopic surgery. Methods: A systematic review of the evidence using a defined search strategy (PubMed, Medline, OVID, Embase, ERIC, Cochrane databases) was performed. Studies without statistical evaluation of the learning curve and opinion articles were excluded. The authors analysed 7 common laparoscopic procedures: cholecystectomy, fundoplication, colectomy, herniorrhaphy, splenectomy, appendicectomy, and pyloromyotomy. The [ldquo ]initial[rdquo ] and [ldquo ]late[rdquo ] stages of experience were compared with regards to the following outcome measures: operating time, conversion rate, complication rate, and length of stay in hospital. Results: A total of 3,641 articles were reviewed, of which, 37 (25,777 patients) fulfilled the entry criteria (5 in children). In all articles, the definition of proficiency was subjective, and the number of operations required to reach it was highly variable. There were improvements in all 4 outcome measures for cholecystectomy, fundoplication, colectomy, herniorrhaphy, and splenectomy between the [ldquo ]initial[rdquo ] and [ldquo ]late[rdquo ] experience. No data were available for the learning curves in appendicectomy or pyloromyotomy. Conclusions: The number of procedures required to reach proficiency in laparoscopic surgery has not been defined clearly. These findings are important for training, ethical and medico-legal issues. J Pediatr Surg 38:720-724. [copy ] 2003 Elsevier Inc. All rights reserved.     

Does the evidence support the use of spinal and epidural anesthesia for surgery?

When spinal and epidural anesthesia were introduced into clinical practice, their primary use was as an alternative to general anesthesia. Later, largely as a result of the realization that opioids could be safely and effectively used to produce selective spinal analgesia, spinal and epidural (neuraxial) analgesia began to be used specifically for the treatment of perioperative pain. We present a systematic review of the literature on neuraxial anesthesia and analgesia, new meta-analyses that illustrate the powerful effect of improvements in perioperative safety in general on the ability of neuraxial techniques to make a difference, and a consideration of why a literature analysis does not provide clear answers.     

What are the results of laparoscopic re-operative rectal surgery?

IntroductionReoperative rectal surgery is challenging, performed selectively by experienced colorectal surgeons. The minimally invasive approach has not been well defined. This study reviewed the results of laparoscopy in this challenging setting.MethodsRetrospective analysis of patients who underwent trans-abdominal re-operative rectal surgery from 2010 to 2019 was performed.ResultsSeventy-eight patients [35 females (45%); BMI 25kg/m2) were included. Reasons for reoperation were recurrent cancer in 18 (43%) patients and anastomotic failure in 57 (73%). Twenty-two (28%) had laparoscopic surgery and 4 had attempted laparoscopy converted to laparotomy. A higher success rate was noted for laparoscopy with prior laparoscopic surgery. Benefits of laparoscopy included significant reduction in length of stay (6.7 vs 9.7 days, p = 0.012) and abdominal superficial surgical site infection (0% vs 25%, p < 0.001) and higher rate of achieving bowel continuity compared to laparotomy (77% vs 50%, p = 0.021)ConclusionsReoperative laparoscopic rectal surgery is safe and feasible in the context of a high-volume laparoscopic surgeon with substantial experience in redo proctectomies. It offers clear benefits including decreased surgical site infection rates and length of stay.     

Is laparoscopic surgery the technique of choice in nephrectomy?

Laparoscopic is performed in adults for the treatment of benign renal diseases. It is widely accepted that laparoscopic surgery has more advantages than open surgery in many procedures such as nephrectomy, but there is no further experience in this technique. In pediatric urology laparoscopy has become an accepted approach for varicocele, non palpable testis, bladder augmentation, adrenalectomy and urinary diversion. We report our experience with 25 laparoscopic nephrectomies in children.     

The carbon footprint of laparoscopic surgery: should we offset?

The aim of this study was to estimate the effect that the expansion of laparoscopic surgery has had on global warming. Laparoscopic procedures performed in a hospital over a 10-year period were analysed. The number of CO₂ cylinders (size C) used over a 2.5-year period and the “carbon footprint” of each cylinder was calculated. There was a fourfold increase of in the number of laparoscopic procedures performed over the past 10 years (n = 174–688). Median operative time for the laparoscopic procedures performed over the past 2.5-years (n = 1629) was 1.01 h (range 0.3–4.45 h) with 415 cylinders used in this period giving an operative time per cylinder of 3.96 h. Each cylinder produces only 0.0009 of tonnes of CO₂. Despite increasing frequency of the laparoscopic approach in general surgery, its impact on global warming is negligible.     

Does laparoscopic surgery decrease the risk of atrial fibrillation after foregut surgery?

Background  Atrial fibrillation, which occurs in 12% of all major foregut surgeries, can prolong hospital stay and increase morbidity. Minimally invasive techniques in foregut surgery have been suggested to cause less tissue trauma. We examined the factors associated with new-onset atrial fibrillation after foregut surgery at our institution. Methods  We retrospectively examined the records of 154 adult patients who underwent major foregut surgery which included esophagectomy, partial or total gastrectomy, redo Heller myotomy, redo or transthoracic fundoplications. Univariate and multivariate logistic regression analysis with standard modeling techniques were performed to determine risk factors for new-onset atrial fibrillation. Results  Of the 154 patients, 14 patients developed new-onset atrial fibrillation with a higher mean age of 67.1 years (±8.8 years) versus 56.4 years (±14.1 years) (p = 0.006). Laparoscopic (p = 0.004) and nonthoracic surgeries (p = 0.01) were associated with lower risk of atrial fibrillation. Patients with atrial fibrillation had received more fluid (6.5 ± 2.8 liters versus 5.3 ± 2.0 liters) and had longer operations (370 ± 103 min versus 362 ± 142 min), none of which were statistically significant. The average intensive care length of stay of patients was longer: 7.5 ± 6.8 days versus 4.0 ± 7.1 days (p = 0.004). Multivariate analysis revealed an association of atrial fibrillation with age (OR 1.08, 95% CI 1.02–1.14, p = 0.01), and laparoscopic surgery (OR 0.09, 95% CI 0.01–0.95, p = 0.04) after adjusting for surgery type. Conclusions  Laparoscopic surgery is associated with lower risk of atrial fibrillation in foregut surgery. Development of atrial fibrillation is associated with increased length of intensive care stay. We recommend a prospective trial to confirm our findings.     

Could we measure the efficiency of prostate cancer treatment? A critical appraisal of economic evaluation studies

The objective of this paper is to introduce the methodology of economic analysis in health care, and its application to the measurement of the efficiency analysis of prostate cancer treatment. We presented the methodology of economic analysis. To review its application in prostate cancer treatment, we performed a bibliographic search in the main biomedical databases (February 1988-January 2001) to identify economic evaluation studies that compared both costs and effects of prostate cancer treatments. The lack of economic studies for localized prostate cancer and the diversity of treatments for advanced prostate cancer make it difficult to make comparisons across studies and to make therapeutic recommendations.Prostate Cancer and Prostatic Diseases (2001) 4, 217-220.     

Does the evidence support the existence of lumbar spine coupled motion? A critical review of the literature

STUDY DESIGN: Literature review. OBJECTIVES: To synthesize the current literature addressing coupled motion between side bending and rotation in the lumbar spine to determine if a consistent pattern exists across articles. BACKGROUND: [corrected] Low back pain is one of the most common conditions seen in outpatient physical therapy clinics. This condition is often treated with manual therapy techniques. Many approaches to manual therapy incorporate the concept of coupled motion. METHODS AND MEASURES: Using OVID databases, we reviewed and categorized articles published between 1982 and 2006 that addressed coupled motion between side bending and rotation in the lumbar spine. We identified 24 articles in which 32 analyses addressed our clinical question. RESULTS Seventeen of the 24 articles identified concluded that some form of coupled motion exists; however, there was little agreement across articles as to the specific characteristics of coupled motion. CONCLUSIONS: The inconsistency in reported patterns of coupled motion suggests that physical therapists should use caution when applying concepts of coupled motion to the evaluation and treatment of patients with low back pain.