Mentorship in urological laparoscopic surgery: lessons learned

OBJECTIVE

To review the results of our experience with a mentorship programme in laparoscopic nephrectomy, set up in 1999 by the British Association of Urological Surgeons Section of Endourology.

METHODS

Mentors were contacted in 2007 to submit data on the number of visits and the outcome, which included whether a urologist was able to establish an independent laparoscopic practice and sustain it.

RESULTS

Four urologists acting as mentors reported a total of 164 procedures carried out in the training of 39 urologists during 148 visits. There were no conversions to open surgery and only one major complication. Overall, 29 of 39 mentored consultants were able to establish an independent laparoscopic practice and 23 continue to do so. The number of visits was associated with initial success, although this was not statistically significant. Working in a large department was associated with being able to sustain a laparoscopic practice. More experienced consultants were less likely to have initial success, but were more likely to sustain a successful practice.

CONCLUSIONS

Mentorship for laparoscopic nephrectomy has been carried out safely thus far. Sustaining a laparoscopic practice requires a critical volume of cases. Future efforts should be focused on trainees rather than consultants.     

Perioperative analgesia in pulmonary surgery

AIM: In pulmonary surgery many studies have shown how pain associated with residual doses of anaesthetic drugs can cause a decrease in pulmonary volumes and depression of the cough reflex. Both these phenomena are responsible for a rising incidence of postoperative mortality and morbidity. The most widely used postoperative analgesic techniques are continuous systemic analgesia and epidural analgesia. The aim of this study is to verify the advantages and the disadvantages of both analgesic techniques. METHODS: Fifty patients, undergoing pulmonary surgery, were recruited and divided, after randomization into 2 groups. Patients included in A group received an epidural administration of naropina 0.2%+fentanyl 4 microg/mL by elastomeric pump (rate 5 ml/h). Patients included in B group received an ev continuous infusion of tramadol 600 mg+ketorolac trometamina 120 mg+ranitidina 200 mg+ondansetron 16 mg by elastomeric pump (rate 5 ml/h for 48 hours). RESULTS: Both groups showed good analgesic effects. Pain rest relief was between 3 and 1.7 points in group B and between 2.5 and 0.4 points in group A. Incident pain was 4.8 at awakening time and it decreased to 4 after 48 hours in group B while in group A it was from 3.2 to 1.8 in the same period of B group. CONCLUSIONS: Our data show that both analgesic techniques are able to guarantee a good rest pain relief after thoracotomy. Epidural analgesia showed more efficacy as far as incident pain relief but it was more difficult to realise and it showed less acceptance by patients.     

Modulation of renal cell injury by heat shock proteins: lessons learned from the immature kidney

The mechanisms that underlie tolerance to injury in immature animals and tissues have been a subject of interest since 1670. Observations in neonatal units that premature infants are less prone to develop acute renal failure than adults in critical care units have prompted a series of investigations. Although initially attributed to metabolic adaptation such as increased glycolytic capacity and preservation of high energy phosphate, more recent studies have indicated a prominent role for the heat shock response. Observed modulations of injury by heat shock proteins in the immature kidney have significant implications for advancement of our understanding of renal cell injury in both adults and children.     

Evolution of vascular surgery and vascular surgery training: lessons learned

Over the last decade, surgery as a discipline, and vascular surgery in particular, has been faced with a rapid growth in the scope of knowledge and array of techniques to be mastered by the graduating resident and the constraints of work hour limitations. In response, the U.S. vascular surgery community significantly altered its surgical training curriculum. This article will discuss the factors that prompted these changes, the challenges that continue to face vascular surgery education and the expectations for the future. We will also comment on the relevance of this experience to other surgical specialties.     

How to successfully implement a robotic pediatric surgery program: lessons learned after 96 procedures

Background

Both our teams were the first to implement pediatric robotic surgery in France. The aim of this study was to define the key points we brought to light so other pediatric teams that want to set up a robotic surgery program will benefit.

Methods

We reviewed the medical records of all children who underwent robotic surgery between Nov 2007 and June 2011 in both departments, including patient data, installation and changes, operative time, hospital stay, intraoperative complications, and postoperative outcome. The department’s internal organization, the organization within the hospital complex, and cost were evaluated.

Results

A total of 96 procedures were evaluated. There were 38 girls and 56 boys with average age at surgery of 7.6 years (range, 0.7–18 years) and average weight of 26 kg (range, 6–77 kg). Thirty-six patients had general surgery, 57 patients urologic surgery, and 1 thoracic surgery. Overall average operative time was 189 min (range, 70–550 min), and average hospital stay was 6.4 days (range, 2–24 days). The procedures of 3 patients were converted. Median follow-up was 18 months (range, 0.5–43 months). Robotic surgical procedure had an extra cost of €1934 compared to conventional open surgery.

Conclusions

Our experience was similar to the findings described in the literature for feasibility, security, and patient outcomes; we had an overall operative success rate of 97 %. Three main actors are concerned in the implementation of a robotic pediatric surgery program: surgeons and anesthetists, nurses, and the administration. The surgeon is at the starting point with motivation for minimally invasive surgery without laparoscopic constraints. We found that it was possible to implement a long-lasting robotic surgery program with comparable quality of care.     

Fetal endoscopic surgery: lessons learned and trends reviewed

Purpose: Fetal surgery is performed increasingly with minimal access approaches. The authors report their experience with fetal endoscopic procedures (fetendo) with emphasis on changing techniques and outcome trends. Methods: All fetal endoscopic cases performed at a single institution from January 1996 to August 2001 were reviewed (n = 66). Cases were examined with respect to year performed, type of operation, operative data, and outcome. Results: Twin-twin transfusion syndrome (26 cases) and congenital diaphragmatic hernia (35 cases) were the most common diseases treated. From 1996 to 2001, there was a decrease in average operating time (256 to 127 minutes [P = .0006]), number of ports utilized (3.8 to one [P = .00001]), pump volume (28.7 to 2.7 L [P = .00001]), and estimated blood loss (408 to 29 mL [P = .008]). In addition, port size changed from 10 mm to 5 mm. Chorioamniotic separation (31 of 66), premature rupture of membranes (32 of 66), chorioamnionitis (12 of 66), and fetal death (10 of 66) continued to be significant complications. Conclusions: Fetal endoscopic surgery over the last 6 years has evolved toward shorter operating time, the use of smaller and fewer ports, decreased pump fluid exchange, and decreased blood loss, with the types of cases centered on twin-twin transfusion syndrome and congenital diaphragmatic hernia.     

骨科手术围手术期多模式镇痛的疗效评价

目的 评价围手术期多模式镇痛在骨科手术的疗效.方法 将110例于我科实施骨科手术的患者随机分为两组:试验组在围手术期多模式使用镇痛药物,对照组术后常规使用镇痛药物.记录术后镇痛药物的使用量及整个围手术期镇痛药物的使用量.于术后不同时间段采用视觉模拟评分法(VAS)评估患者疼痛程度.结果 术后24 h、术后48 h试验组...     

小儿外科围手术期输血

随着小儿外科手术方法的改进及各种微创技术的应用,在小儿外科临床上,需要输血的病种及输血量逐渐减少,但仍有一些小儿外科疾患需要不同量的围手术期输血.众所周知,输血可导致各种并发症和不良反应,减少围手术期输血是现代小儿外科的一个目标.本文就小儿外科围手术期输血几个有关问题进行探讨.     

Development of quality indicators: lessons learned in bariatric surgery

Quality indicators will likely be used in comprehensive surgical quality assessment and improvement programs. Quality indicators are the actions equated with good quality of care. As a case example, bariatric surgery quality indicators were developed using evidence in the literature combined with formal expert opinion validation. Qualitative analysis was performed to identify the critical thematic issues surrounding development of these surgical quality indicators. Researchers identified five major thematic categories during the development process. These included feasibility in medical records (availability, ease of abstraction, and cost), the number of indicators developed (optimal number), the lack of evidence in the literature (weight on expert opinion), structural versus process indicators, and linkage to outcomes (need to demonstrate that adherence to indicators is associated with better outcomes). This project, using bariatric surgery as an example, uncovered important issues that need to be addressed when developing quality assessment and quality improvement programs for evaluating surgical quality. As quality indicators will likely be developed and used increasingly, future projects in this regard will benefit from these lessons.     

Patient-controlled analgesia in pediatric surgery

Patient-controlled analgesia (PCA) with a microprocessor-operated infusion syringe was first suggested for human use in 1965. Clinical studies from the United States and Europe have shown this form of analgesia to be well accepted by adults, but the use of this technology for children has not been studied. We evaluated PCA in 15 consecutive pediatric surgical patients between the ages of 11 and 18 years undergoing major thoracic or abdominal surgery. The patients and their parents were instructed in the use of the equipment prior to surgery and PCA was initiated after the patients left the recovery room. The mean duration of PCA was 2.6 days. No serious mechanical difficulties with the infusion apparatus were encountered. The acceptance of PCA was excellent with only two patients preferring some other method of analgesia. Pain relief was assessed twice daily by a registered nurse using a verbal-visual pain scale. On a 1 to 10 scale average pain relief was 7.2. Eight of the patients had had a previous operation, and seven of these reported that PCA was a better method of achieving pain control. A comparison of the 15 study patients with 15 previous patients with similar procedures indicated that PCA patients used less analgesia in the postoperative period, although they tended to use more in the first 24 hours. PCA is found to be a safe and effective means of analgesia in pediatric patients. Adequate pain relief was achieved with less analgesia and with less nursing attention. This technology is recommended for postoperative pediatric patients.     

儿童围手术期外科处理

儿童外科治疗中的主要手段是手术,围绕手术的处理包括合理选择手术时机、严格掌握手术适应证和熟练的外科手术操作技术外,其中小儿麻醉与围手术期监护也甚为重要.围手术期外科处理还包括手术前准备与术后监护、并发症处理等.下面谈谈相关的几个问题.     

Hepatobiliary surgery: lessons learned from live donor hepatectomy

The liver is unique in the rapid tissue regeneration occurs after resection or injury, and affords the surgeon the opportunity to safely remove up to 60% to 70% of the liver volume for treatment of cancer or for use as a live donor graft for transplantation. The complex development of the liver and biliary system in utero results in multiple and complicated anatomic variations. The hepatobiliary surgeon of today must be able to integrate a broadening array of radiologic and liver resection techniques that may improve patient safety and surgical outcome. Equally important is the ability to quickly recognize postoperative complications so that prompt intervention can be instituted. Successful outcome requires a balance between sound judgement, technical acumen, and attention to detail. Herein, we provide lessons learned from live donor liver transplantation that are directly applicable to any patient undergoing major hepatic resection.     

Disaster response in a pediatric field hospital: lessons learned in Haiti

Purpose

This study outlines the evolution of a pediatric field hospital after the January 2010 Haiti earthquake.

Methods

Project Medishare set up a field hospital in Port-au-Prince 48 hours after the event. Our institution staffed the pediatric component for 45 days, with sequential deployment of 9 volunteer medical teams. Evolving facility and manpower requirements and changing patient demographics over time were evaluated.

Results

Delegations consisted of surgeons, pediatricians, nurses, operating room (OR) personnel, physical therapists, pharmacists, and support staff. Primary goals involved creation of a child-specific ward, pediatric OR, and a wound care center. Major inpatient demographic changes occurred as time from the disaster elapsed. Initial census showed that 93% of the patients were surgical admissions with 40% undergoing operations, mostly fracture and wound care, over the first week. Eight weeks later, medical illnesses accounted for 70% of inpatients, whereas OR volume dropped by more than 50%. A second trend involved increasing acuity of care. Initially, children were admitted for serious or limb-threatening, but usually not life-threatening, injuries. Within 2 months, one third of the patients were housed in the developing NICU/PICU; and only 12% were admitted for injuries related to the earthquake. This change in patient needs led to alterations in facility requirements and in staffing and leadership needs.

Conclusion

A disaster involving significant casualties in a populated area demands the rapid development of a field facility with pediatric personnel. Requirements for equipment, manpower, medical records, and systems addressing volunteer stress and ethical dilemmas can be anticipated.     

儿童外科围手术期的液体治疗

围手术期液体治疗首先必须考虑液体量和组成必须适应患儿当前的状况、手术的类型和手术后所期待患儿出现的状态.目的是提供维持机体所需的液体、纠正液体的不足、提供满足合适组织灌注的液体量.     

围手术期个体化多模式镇痛的临床应用

目的评价围手术期个体化多模式镇痛的疗效。方法将470例于我科实施手术的患者以严重疼痛、重度疼痛、中度疼痛及轻度疼痛划分为A、B、C、D四组,各组在围手术期使用不同的镇痛模式,于术后不同时间段（2h、24h、48h、4d、8d、12d）采用视觉模拟评分法（VAS）评估患者疼痛程度。结果各组VAS评分低,疼痛程度弱。结论围手术期采用个体化多模式镇痛能有效地减轻术后疼痛,有利于功能的康复。