Historical Review of Surgical Simulation—A Personal Perspective

Although simulation is relatively new to surgical education, there is a long history in many other disciplines, such as military, aviation, and nuclear power plant operations, among others. In the late 1980s these technologies began to be adapted to the surgical world, along with the new technology of virtual reality. This is a review of the introduction of manikins, computers, and virtual reality into education and training for surgical skills. Two concomitant revolutions occurred: objective assessment of surgical skills and converting training from the apprenticeship model to one of criterion-based training. A personal perspective on these developments adds information not previously published. Opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official, or as reflecting the views of the Departments of the Army, Navy or Air Force, the Defense Advanced Research Projects Agency, or the Department of Defense. This is a declared work of the U. S. Government and as such is not subject to copyright protection in the United States.     

Surgical Pancreatic Sphincteroplasty. Historic or History ? A Review

Background: Minimal invasive techniques represent a constantly expanding field of medicine and numerous well-established operative procedures have gradually been replaced. Likewise, surgical pancreatic sphincteroplasty, which has been the cornerstone in the management of pancreatic flow disorders for decades, has been largely replaced by endoscopy. Endoscopic pancreatic sphincterotomy however, is still not widespread and carries a significant risk of complications. In this study we attempt to review the role of the surgical approach in the modern era. Methods: Pubmed database was searched for reports concerning surgical pancreatic sphincteroplasty alone or in comparison with endoscopy, without other limitations.

Results: Initially, 44 studies were obtained. Finally, 22 full papers were selected, pertaining review articles, case series or clinical studies. Only four of them were recent (after 2002) series of surgical sphincteroplasty, pertaining 561 patients. No randomized-controlled trials or meta-analyses were revealed.

Conclusions: Pancreatic sphincterotomy, either surgical or endoscopic offers good to excellent long-term results in several disorders, like Sphincter Oddi dysfunction, especially when underlying parenchymal disease is limited. Surgical sphincteroplasty is nowadays indicated in most cases of endoscopic failure and in cases that the papilla cannot be approached. Bariatric patients with gastric by-pass and sphincter Oddi dysfunction in particular, have reported to show excellent outcome after surgery. Regardless the method, patient selection is still a very important determinant of success.     

Incisional Hernia Rates After Laparoscopic or Open Abdominal Surgery—A Systematic Review and Meta-Analysis

Background

Incisional hernias are one of the most common long-term complications associated with open abdominal surgery. The aim of this review and meta-analysis was to systematically assess laparoscopic versus open abdominal surgery as a general surgical strategy in all available indications in terms of incisional hernia occurrence.

Methods

A systematic literature search was performed to identify randomized controlled trials comparing incisional hernia rates after laparoscopic versus open abdominal surgery in all indications. Random effects meta-analyses were calculated and presented as risk differences (RD) with their corresponding 95 % confidence intervals (CI).

Results

24 trials (3490 patients) were included. Incisional hernias were significantly reduced in the laparoscopic group (RD ?0.06, 95 % CI [?0.09, ?0.03], p = 0.0002, I ² = 75). The advantage of the laparoscopic procedure persisted in the subgroup of total-laparoscopic interventions (RD ?0.14, 95 % CI [?0.22, ?0.06], p = 0.001, I ² = 87 %), whereas laparoscopically assisted procedures did not show a significant reduction of incisional hernias compared to open surgery (RD ?0.01, 95 % CI [?0.03, 0.01], p = 0.31, I ² = 35 %). Wound infections were significantly reduced in the laparoscopic group (RD ?0.06, 95 % CI [?0.09, ?0.03], p < 0.0001, I ² = 35 %); overall postoperative morbidity was comparable in both groups (RD ?0.06, 95 % CI [?0.13, 0.00], p = 0.06; I ² = 64 %). Open abdominal surgery showed a significantly longer hospital stay compared to laparoscopy (RD ?1.92, 95 % CI [?2.67, ?1.17], p < 0.00001, I ² = 87 %). At short-term follow-up, quality of life was in favor of laparoscopy.

Conclusions

Incisional hernias are less frequent using the total-laparoscopic approach instead of open abdominal surgery. Whenever possible, the less traumatic access should be chosen.

     

Animal Models in Bariatric Surgery—A Review of the Surgical Techniques and Postsurgical Physiology

Bariatric surgery is considered the most effective current treatment for morbid obesity. Since the first publication of an article by Kremen, Linner, and Nelson, many experiments have been performed using animal models. The initial experiments used only malabsorptive procedures like intestinal bypass which have largely been abandoned now. These experimental models have been used to assess feasibility and safety as well as to refine techniques particular to each procedure. We will discuss the surgical techniques and the postsurgical physiology of the four major current bariatric procedures (namely, Roux-en-Y gastric bypass, gastric banding, sleeve gastrectomy, and biliopancreatic diversion). We have also reviewed the anatomy and physiology of animal models. We have reviewed the literature and presented it such that it would be a reference to an investigator interested in animal experiments in bariatric surgery. Experimental animal models are further divided into two categories: large mammals that include dogs, cats, rabbits, and pig and small mammals that include rats and mice.     

Clavicle Malunions: Surgical Treatment and Outcome—a Literature Review

Background

Successful treatment of clavicle malunion represents a major challenge for orthopedic surgeons.

Questions/Purposes

The aim of this study was to provide an overview of surgical options for the treatment of clavicle malunions regarding their technical details and clinical results.

Methods

A comprehensive search of the literature was performed to retrieve articles and conference abstracts regarding the surgical treatment of clavicle malunions. A total of 1873 records were identified and 29 studies were included in the present review, with a total of 103 patients.

Results

The majority of the patients (77/103) were treated with an osteotomy and subsequent open reduction internal fixation (ORIF). The next most frequent management choice was debridement, excision, or removal of excess callus or bone (n = 19), but other techniques like resection of the clavicle (n = 5) or nerve exploration and decompression (n = 2) were also reported. The preferred method of fixation was plate fixation (n = 53) followed by pin fixation (n = 6). The complication rate was low, reported in less than 6% of patients.

Conclusion

All of the currently reported surgical techniques to manage symptomatic clavicle malunion have resulted in good clinical outcomes with a low complication rate. Considering biomechanical aspects, correction osteotomy followed by plate fixation seems to be the preferred method. Further studies are needed to compare the various surgical techniques and their specific outcomes in a prospective manner. Nevertheless, this review article can be used as an overview to help choose an optimal operative treatment for patients presenting with a clavicle malunion.

     

Surgical Education,Simulation, and Simulators—Updating the Concept of Validity

Purpose of Review

Competency-based medical education (CBME) is rooted in the use of iterative assessments. We must ensure that the assessments used in CBME are valid, to make acceptable and accurate decisions regarding the competency of a trainee. Until recently, much of the educational and assessment literature in urology have used a now-outdated method of determining validity, based on theory and recommendations from over 50 years ago. We describe a contemporary approach to gathering construct validity evidence for the assessment of urologic trainees, for use in both clinical and simulation environments.

Recent Findings

Five sources of evidence make up Messick’s contemporary framework of validity: test content, response process, internal structure, relationship to other variables, and consequences. These are all components of construct validation and concern the accuracy, quality, reproducibility, generalizability, and wider impact of the scores generated by an assessment, respectively.

Summary

When deciding the competency of a trainee, program directors and educators must have a clear understanding of how the validity is established and is determined in each assessment context. The contextual specificity of validity means that stakeholders must be prepared to defend the outcome of an assessment, particularly when making high-stake or summative decisions.

     

Is Video-Based Education an Effective Method in Surgical Education? A Systematic Review

Objective

Visual signs draw more attention during the learning process. Video is one of the most effective tool including a lot of visual cues. This systematic review set out to explore the influence of video in surgical education. We reviewed the current evidence for the video-based surgical education methods, discuss the advantages and disadvantages on the teaching of technical and nontechnical surgical skills.

Does Surgical Timing Influence Functional Recovery After Lumbar Discectomy? A Systematic Review

Background

The impact of the duration of preoperative symptoms on outcomes after lumbar discectomy has not been sufficiently answered in a single study but is a potentially important clinical variable.

Questions/purposes

A systematic review was performed to answer two questions: (1) Does symptomatic duration before surgery influence functional recovery after lumbar discectomy? (2) What is the time point for intervention beyond which the extent of postoperative recovery might be compromised?

Methods

The systematic review began with a query of PubMed using a structured algorithm comprised of medical subject heading terms. This was supplemented by a keyword search in PubMed along with queries of Embase, Scopus, and Web of Science and searches of reference lists as well as the tables of contents of relevant journals. Eligible studies were those that evaluated aspects of recovery after elective discectomy and stratified duration of symptoms before surgery. Included papers were abstracted by two authors and determinations regarding the period of symptom duration and its impact on outcome were recorded. Eleven studies met all inclusion criteria. No prospectively randomized trials addressed our study questions.

Results

Nine of 11 studies, four of which were prospective, maintained that longer symptom duration adversely impacted postsurgical recovery. There were substantial differences among the critical periods of symptom duration reported by individual studies, which ranged from 2 to 12 months. A preponderance of studies (five of nine) reported that surgical interventions could be performed at periods of 6 months or greater without impacting recovery.

Conclusions

Longer symptom duration had an adverse impact on results in most studies after lumbar discectomy. A possible point beyond which outcomes may be compromised is 6 months after symptom onset. Limitations in the literature surveyed, however, prevent firm conclusions.     

Popliteal Venous Aneurysm—A Systematic Review

Background Popliteal vein aneurysm is a rare but potentially problematic disease with a risk of pulmonary embolism. Method A systematic literature search was performed. Results A total of 105 popliteal vein aneurysms were identified, with a slight female and left-sided preponderance. Dominating symptoms are caused by pulmonary embolism, followed by local symptoms with a palpable mass. In four patients arterial symptoms were reported. The most frequently used diagnostic test was phlebography, increasingly replaced by duplex ultrasonography in recent years. Because pulmonary embolism is a potential, it motivates surgical removal. In most cases excision and lateral suture is possible. Four fatal cases were reported. Unfortunately follow-up time and results are poorly documented. Conclusion Popliteal venous aneurysm is rare but should be considered as a local source of pulmonary embolism when no other explanation is found.