Should simulator-based endovascular training be integrated into general surgery residency programs?

BACKGROUND: The impact of high-fidelity simulators as an adjunct for endovascular training of general surgery residents has not yet been defined. The purpose of this study was to evaluate general surgery resident perspectives on the value of a simulator-based endovascular training program by using various measurement tools. METHODS: General surgery residents in postgraduate years 1 to 5 (n = 50) participated in a focused endovascular training course covering aortoiliac, renal, and carotid artery disease. The components of the course included didactic lecture, self-learning course material and computer training modules, hands-on exposure to endovascular instruments, and endovascular procedure simulation using a mobile SimSuite unit (Medical Simulation Corporation, Denver, CO). Course participants completed pre- and postcourse questionnaires, knowledge-based testing, and endovascular simulator metric testing. RESULTS: Of the 50 general surgery residents who completed the precourse questionnaire and knowledge-based testing, 41 completed the entire program including the postcourse questionnaire and knowledge-based testing, and 33 completed endovascular simulation metric testing. Subjective responses from pre- and postcourse surveys highlighting the residents' perceptions of the potential role of endovascular simulation as part of general surgery residency training showed favorable responses. On completion of the course, mean knowledge-based test scores had statistically significant improvement (pretest, n = 50, 59.5% +/- 12.1% correct and posttest, n = 41, 69.1% +/- 15.4% correct [P = .003]). For metric testing of a simulated endovascular procedure (n = 33), 93.9% completed all of the defined tasks within the allotted time period (mean time, 12.2 +/- 4.36 minutes; range, 4.1-26.6 minutes; 95% confidence interval for mean 10.8-13.6 minutes). CONCLUSIONS: Based on subjective and objective measures, general surgery residents found valuable and benefited in knowledge base from a focused simulator-based endovascular training program. Integrating endovascular simulation into general surgery resident training and its influence on resident interest in vascular specialization as a career choice holds future potential.     

Should all urologists performing vasectomy reversals be able to perform vasoepididymostomies if required?

PURPOSE: While vasectomy reversal is a highly successful procedure 10% to 30% of reversals may fail. Despite the general consensus that an epididymal obstruction may occur following a vasectomy and that some men should undergo vasoepididymostomy (VE) rather than vasovasostomy (VV), the practice of many urologists in our region has been to offer only VV for vasectomy reversal. We examined the potential causes for vasectomy reversal failure in patients who had undergone VV without an attempt at VE. MATERIALS AND METHODS: We conducted a retrospective review of patients who had undergone redo vasectomy reversal from January 1999 to September 2001. A total of 22 patients underwent redo reversal with a minimum followup of 2 years. The medical records of all patients were then reviewed. Patients and partners seen postoperatively in the clinic were questioned regarding any pregnancy or deliveries. RESULTS: We examined 22 patients who had undergone redo vasectomy reversal. Of 22 patients 9 (40.9%) underwent repeat VV, 8 (36.3%) underwent bilateral VE for a presumed unrecognized epididymal obstruction and 5 (22.7%) had a combination of VE and VV. Of the 44 reproductive units studied 23 (52.3%) had a failed vasal anastomosis while 21 (47.7%) had an unrecognized epididymal obstruction. Based on semen analysis patency was observed in 75% of patients who had undergone vasovasostomy as a redo procedure. A patency rate of 60% was found in patients who underwent vasoepididymostomy and vasovasostomy unilaterally, and patency rates for bilateral VE were 63%. CONCLUSIONS: Our study indicates that a large proportion of men (48%) have an epididymal obstruction as the etiology for vasectomy reversal failure. We recommend that all surgeons offering vasectomy reversals be able to offer VE if required based on intraoperative findings to serve the patient adequately as well as his partner and their future fertility.     

Should kidneys from older cadaveric donors be age-matched to the recipient?

Persistent shortage of kidneys for transplantation has forced most transplant centers to include procurement and use of kidneys from older donors. It is not clear whether the optimal use of these kidneys involve age-matching to the recipient. The aim of this study was to evaluate the clinical outcome of older cadaveric kidneys (>60 years), transplanted to young recipients (<50 years) and older recipients (>60 years). From 1989 through 2002, 252 first kidney grafts were procured from donors above the age of 60; 149 of the recipients to these grafts were above 60 years and 45 recipients were below 50. Minimum follow-up time was 12 months. Variables for waiting time to transplantation, DR mismatches, PRA, dialysis prior to transplantation, episodes of acute rejection, number of steroid-resistant rejections, creatinine levels, cold ischemia time, and causes of graft loss did not differ between the two groups. There was no significant difference in graft survival for young and older recipients receiving kidney from donors above 60 years of age. Graft survival at 1 year for young recipients was 90% and for older recipients 93% (NS). Five-year graft survival was 72% and 79%, respectively (NS). However, there was a significant positive effect on long-term graft survival if the donor kidney was less than 50 years. From our data, there is no evidence that age-matching of older donors has any beneficial effect on graft survival in kidney transplantation.     

A single training center’s experience with 200 consecutive cases of diverticulitis: Can all patients be approached laparoscopically?

Background  This study aimed to evaluate the outcomes for consecutive patients with diverticular disease who underwent elective laparoscopic sigmoid colectomy. Methods  Data for this patient population were collected by chart review and analyzed retrospectively. Results  Between December 2001 and March 2007, 200 consecutive patients (93 men and 107 women) with an average age of 55 years were identified. All cases were managed by one of two colorectal surgeons. Of the 200 patients, 158 had recurrent diverticulitis, 20 had fistulas, 12 had abscesses, 8 had strictures, 1 had a mass, and 1 had a bleed. The mean operative time was 159 min, and the conversion rate was 8%. A total of 30 early postoperative complications occurred for 26 patients including wound infection (n = 9), ileus (n = 8), Clostridium difficile colitis (n = 3), urinary retention (n = 3), pelvic abscess (n = 2), deep vein thrombosis and pulmonary embolism (n = 1), pneumonia (n = 1) urinary tract infection (n = 1), anastomotic leak (n = 1), and small bowel obstruction (n = 1). Late complications experienced by 11 patients included Clostridium difficile colitis (n = 3), incisional hernia (n = 3), wound infection (n = 3), wound hematoma (n = 1), and intraabdominal hemorrhage (n = 1). Conclusions  The authors believe it is feasible to offer elective laparoscopic sigmoid colectomy to all patients with symptomatic diverticular disease despite preoperative risk factors.     

Microsurgical training with chicken wings: Could it be an option to increase experience for vascularized bone flaps?

ObjectiveTo our knowledge, a vascularized bone flap training model has not been described in the literature. In this study, we hypothesized that chicken wing radius bone can be used as a cheap, realistic and easily accessible vascularized pedicled bone flap training model.MethodsA final total of 10 specimens were included in the study. All procedures were planned and conducted by the same surgeon. In all 10 specimens, the length of the radius bone and the length of the vascularized bone flap were measured with a standard ruler. The external diameters of the ulnar artery and the radial artery forming the flap pedicle were measured.ResultsFlap harvesting time (40.4 ± 7.98′) was measured as the time between proper positioning of the chicken wing and the complete separation of the flap from the wing. Mean radius bone length was 6.09 ± 0.72 cm, bone flap length (3.92 ± 0.36 cm) was measured as the distance between two osteotomies in the maximum length of bone (proximal and distal) according to the preparation of the radial artery pedicle. Mean radial artery pedicle external diameter was 0.51 ± 0.05 mm, while mean ulnar artery pedicle external diameter was 0.6 ± 0.04 mm. On average, 4.3 ± 0.82 perforators of the radial artery (to the other regions of the flap) were ligated.ConclusionWe think that this model can be a pioneer in defining the bone flap model in living animals in future studies. Since this inanimate animal model is a cost-effective and easily accessible technique, it offers the opportunity to be applied easily and repeatedly, even in the comfort of surgeons’ homes.