Impact of laparoscopic cholecystectomy on surgical training.

All cholecystectomies in a single health district were studied during a 5-year period spanning the introduction of laparoscopic cholecystectomy (LC). The number of LCs increased from 2 (1.3%) in year 3 to 86 (56%) in year 5. The number of operative cholangiograms and explorations of the common bile duct performed both fell substantially. The age distribution did not change significantly during the study period, but the percentage of females undergoing cholecystectomy increased. The percentage of trainee operations remained constant in those Firms performing only open cholecystectomy (OC), but fell from 67% to 9% in those adopting LC. An increase in annual cholecystectomy rate was seen with the laparoscopic surgeons, with a corresponding fall for those surgeons performing only OC. There was a threefold increase in the percentage of operations performed privately from years 2 to 5, with 73% being laparoscopic in year 5. The consequences for training of the introduction of LC must be addressed.     

Implications of laparoscopic cholecystectomy for surgical residency training.

BACKGROUND: Widespread adoption of minimal access techniques forced a generation of abdominal surgeons to re-learn many standard abdominal procedures. This threatened to reduce the pool of suitable "training" operations for surgical residents. METHODS: Operator grade, duration of operation, acute/elective operation, conversion rate, complications, and postoperative stay were recorded prospectively on all laparoscopic cholecystectomies (LC) since 1992. This data was evaluated to determine how the introduction of LC affected residents' training. RESULTS: The percentage of LCs performed by residents increased progressively to reach 58%. Operating time was longer for trainee surgeons, particularly for acute cases (145+/-50 minutes vs 111+/-54 minutes, p<0.05); however, conversion rate, incidence of complications, and postoperative stay were no different. CONCLUSIONS: LC can be performed by surgical trainees with similar complication rates and outcomes as those of qualified surgeons. Once institutional experience has accumulated, this procedure can be integrated into residency training.     

Advanced laparoscopic training and outcomes in laparoscopic cholecystectomy

Background

Advanced laparoscopic training is becoming a valuable asset for surgeons as more procedures are carried out in a minimally invasive fashion. The purpose of our study was to determine whether laparoscopic fellowship training affects outcomes in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

Methods

We obtained data from a retrospective review of 110 patients with acute cholecystitis who underwent laparoscopic cholecystectomy on an urgent basis from March 2002 to June 2005. We compared the outcomes of 31 patients whose surgeries were performed by a surgeon with advanced laparoscopic training with those of 79 patients whose surgeries were performed by surgeons without such training.

Results

The 2 groups were similar in terms of demographics and time to surgery. Outcome measures included conversion rates, postoperative length of stay (LOS) and complications. There was a significant difference in conversion rates (3.2 % v. 16.5 %, p = 0.050) and postoperative LOS (1.77 v. 2.82 d, p < 0.006) between the 2 groups, but there was no difference in the rate of postoperative complications. There was no significant difference in conversion rates among the surgeons without advanced training (p = 0.64).

Conclusion

Based on our results, laparoscopic cholecystectomy in acute cholecystitis is associated with improved outcomes when performed by a surgeon with fellowship training in laparoscopic surgery.     

Analysis of a structured training programme in laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy is an established treatment for almost all gallbladder diseases with bile duct injury rates similar to open cholecystectomy. These laparoscopic skills must be passed on to junior surgeons without compromising patient safety. MATERIALS AND METHODS: We analysed our structured training programme over 6years (May 2000 to May 2006) by following three trainee surgeons during their training and beyond. During this period, 1,000 laparoscopic cholecystectomies were carried out with five consultant surgeons supervising and three new trainees who completed their accreditation in laparoscopic cholecystectomy. RESULTS: There were 694 patients operated on by consultant surgeons (Group 1), 202 by trainee surgeons (Group 2) and 104 by newly trained surgeons (Group 3). There were no differences between the groups in terms of age and gender. However, there was a significant difference in gallbladder disease among the three groups; Group 2 had more gallstone pancreatitis patients (P < 0.019). There were no differences among the three groups in conversion rates, bile duct injury rates, general complication rates or length of stay. However, the duration of operation in Group 2 was significantly longer compared to the other two groups (P < 0.0001). CONCLUSION: This programme is effective in training junior surgeons and does not compromise patient safety.     

腹腔镜培训效果评价方法的研究

目的评价视频评估及现场评估在腹腔镜培训中效果评价的效果及可行性。方法对5名接受腹腔镜模拟器训练的高年资住院医师在体外模型上进行独立的端端吻合,通过视频评估及现场评估以时问评估TestT、视频评估TestR、现场评估TestV三种不同的评价方法对受训者腹腔镜技能进行成绩评分。结果5名考生均顺利完成考核操作。在TestT中,Dr．4用时最短,而Dr．5在TestV和TestR中得分最高。结论TestR能够全面评估受试者的技能水平,但其较费时、耗人力,适用于受试者不多的技能评估。     

Role of the teaching hospital in the development of a laparoscopic cholecystectomy program.

Laparoscopic cholecystectomy was introduced at McGill University-affiliated hospitals in a planned manner to evaluate the safety and results of this new procedure while training attending and resident surgeons. Laparoscopy was performed with the intent of carrying out cholecystectomy in 500 consecutive patients (70% female, 30% male), whose age averaged 48 years (range from 7 to 93 years). Thirty-seven percent had undergone intra-abdominal surgery previously, and 9.1% had had acute cholecystitis. There were two common-bile-duct injuries and one major small-bowel injury. The procedure had to be converted to open cholecystectomy in 25 (5%) patients. There were no deaths. The mean duration of surgery was 88 minutes. Fifty-five percent of patients were discharged home in 24 hours or less after surgery, and 75% were back to normal activity within 1 week of discharge. Fourteen attending staff and 8 senior residents achieved competence to carry out laparoscopic cholecystectomy independently.     

A new training device for laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy provides a new approach for gallbladder removal with which most general surgeons are not familiar. Requisites for the safe performance of this procedure are good hand-eye coordination, depth perception, and team cooperation. To aid with problems in depth perception and in the opposing movements caused by the lever principle, a training model was designed in which surgeons may execute a variety of exercises to enhance their motor skills and learn to work cooperatively with two other surgeons before operating on an experimental animal.     

单切口腹腔镜胆囊切除术与腹腔镜胆囊切除术的病例对照研究

目的回顾性分析单切口腹腔镜胆囊切除术（SILC）与传统腹腔镜胆囊切除术（LC）的优劣性。方法19例SILC及46例LC患者的临床资料,比较两者的手术时间、术中出血量、术后并发症、中转率、术后疼痛、住院时间、切口长度的差异。结果SILC手术耗时（49．00±8．34）min长于LC（P=0．000）。术中出血量差异无统计学意义。两组均无中转、术后无并发症;SILC与Lc术后患者第一天疼痛评分、术后第三天疼痛评分、总疼痛天数差异均无统计学意义。两者住院时间差异无统计学意义。SILC切口长度（22．5±3．5）mm短于LC切口长度（P=0．000）。结论SILC总切口长度短于LC总切口长度,切口效果更美观。SILC能安全地用于单纯胆囊结石、胆囊息肉。同时对于没有严重合并症和腹部手术史的胆囊疾病患者SILC也是一种理想的手术选择。     

Development of a valid, cost-effective laparoscopic training program

BACKGROUND: Practical programs for training and evaluating surgeons in laparoscopy are needed to keep pace with demand for minimally invasive surgery. METHODS: At the University of Kentucky five inexpensive simulations have been developed to train and assess surgical residents. Residents are videotaped performing laparoscopic procedures on models. Five surgeons assess the taped performances on 4 global skills. RESULTS: Creating mechanical models reduces training costs. Trainees agreed procedures were well represented by the simulations. Blinded assessment of performances showed high interrater agreement and correlated with the trainees' level of experience. Nonclinician evaluations on checklists correlated with evaluations by surgeons. CONCLUSIONS: Inexpensive simulations of laparoscopic appendectomy, cholecystectomy, inguinal herniorrhaphy, bowel enterotomy, and splenectomy enable surgical residents to practice laparoscopic skills safely. Obtaining masked, objective, and independent evaluations of basic skills in laparoscopic surgery can assist in reliable assessment of surgical trainees. The simulations described can anchor an innovative educational program during residency for training and assessment.     

A modular laparoscopic training program for pediatric surgeons.

OBJECTIVES: A structured endoscopic training program for pediatric surgeons has not yet been established. This study was conducted to develop a modular training program (MTP) for pediatric surgeons and to evaluate its effectiveness for surgeons with and without previous experience in laparoscopic surgery. METHODS: Nine pediatric surgeons participated in the study. They were divided into 2 groups: group A (n=4), surgeons who had experienced more than 10 cases of laparoscopic surgery prior to MTP; group B (n=5), those who had experienced fewer than 10 cases. They participated in a standardized MTP workshop, which consisted of 2 "see-through" and 3 "laparoscopic" tasks. Each participant's psychomotor skills were evaluated objectively before and after MTP with a computer-generated virtual simulator and were evaluated for precision, efficiency, and speed. RESULTS: In participants, speed was significantly enhanced after MTP. In group A, no differences were observed after MTP, whereas significant improvements were noted in efficiency and speed after MTP in group B. Before MTP, efficiency was significantly higher in group A than in group B; however, no difference remained between the 2 groups after MTP. CONCLUSIONS: MTP is effective for nonlaparoscopic pediatric surgeons to become familiar with basic endoscopic skills.     

腹腔镜肾盂成形术的多模培训模式

目的：介绍一项腹腔镜肾盂成形术（Laparoscopic Pyeloplasty,LP）的多模培训模式,并评价其安全性、可行性和有效性。方法：该多模培训模式包括模拟器、动物模型和手术室培训三部分,5位具有不同开放肾盂成形术和腹腔镜经验的学员参加了这项培训,我们对5个学员参加培训过程中的相关数据和学员独立完成手术的5组LP患者的围手术期数据进行了评价。结果：5位学员均成功地完成了整个培训,并成功地独立完成了5例LP。所有患者手术均未转开放手术,均未输血,无患者死亡。模拟器培训和动物模型培圳所需的时间,学员1（3周,7天）比学员5（4周,8天）少,学员4（2周,6天）比学员2（3周,8天）和学员5（4周,8天）少。在手术室培训中,各学员训练每个手术步骤所需的手术例数相当。5位学员独立完成手术的5组患者手术时间、估计失血量、术后住院时间和围手术期并发症的差异均无统计学意义（P〉0．05）。结论：该项多模培训模式是安全、可行和有效的,并适合于没有开放肾盂成形术和腹腔镜经验的学员进行LP培训。     

Outpatient laparoscopic cholecystectomy: a reality.

BACKGROUND: The author reports on his personal experience with outpatient laparoscopic cholecystectomy (LC), focusing on the main guidelines for preoperative and postoperative care and operating technique. METHODS: From January 1, 2000 to December 31, 2000, 71 laparoscopic cholecystectomies were performed on outpatients. The patients remained in the outpatient surgery center for 36 hours. In 4 cases, the operation was converted into laparotomy. Twenty patients remained in the hospital and were discharged 5 to 7 days later. Twelve were rehospitalized due to pathologies that could not be treated at home. RESULTS: In all 71 cases, a complete remission of the symptoms occurred, and none of the patients died either during the operation or during the postoperative period. Eighty percent of patients were treated in outpatient surgery centers. CONCLUSIONS: With clear guidelines, LC is a major surgical operation that can be performed in outpatient surgery centers without death or other major complications and with very good remission of symptoms.     

Electrosurgical laparoscopic cholecystectomy.

Though laparoscopic cholecystectomy has become widespread, questions remain as to its success rate, its role in acute cholecystitis, the role of cholangiography, and whether laser use is necessary. To attempt to answer these questions, the first 100 patients undergoing laparoscopic cholecystectomy at Emory University using electrosurgical diathermy were reviewed. Patients underwent cholecystectomy for biliary colic (87), gallstone pancreatitis (1), and acute cholecystitis (12). The average length of hospital stay was 29 hours (range: 12 hours to 5 days). Laparoscopic cholecystectomy was not possible in 7 patients because of gangrenous cholecystitis (2), adhesions from previous surgery (2), equipment failure (2), and choledochoduodenal fistula found at surgery (1). Two patients developed bile leaks from accessory bile ducts that healed spontaneously. There were no other complications. The average time required to complete the laparoscopic cholecystectomy was 115 minutes (range: 45 to 238 minutes) and was not significantly different in those patients undergoing intraoperative cholangiography (117 minutes) versus those without (109 minutes). Common duct stones were uncommon in this series. Thirty-three patients underwent intraoperative cholangiogram. One patient was found to have a common duct stone, which was pushed into the duodenum using a Fogarty catheter (American Edwards Laboratories; Anasco, Puerto Rico) inserted through the cystic duct at the time of laparoscopic cholecystectomy. Twelve patients with acute cholecystitis underwent an attempt at laparoscopic cholecystectomy that was successful in nine. These procedures were difficult and lengthy (mean of 143 minutes). Causes for failure were gangrenous cholecystitis (2) and equipment failure (1). In conclusion, laparoscopic cholecystectomy can be performed with a high success rate (93%) and low morbidity (2%). No complications seemed attributable to electrosurgical dissection.     

Simulated laparoscopic cholecystectomy.

A new simulator specifically designed for practising techniques in laparoscopic cholecystectomy is described. The simulator is inexpensive and utilises pig gallbladders. It allows a surgeon to practice without the need for assistance.