Laparoscopic adjustable gastric banding: is there a learning curve?

Background: To be certified for laparoscopic placement of adjustable gastric banding, surgeons must have advanced laparoscopic experience. Despite previous exposure to other kinds of laparoscopy, there may a learning curve specific to Lap-Band placement. Methods: Sixty consecutive patients were prospectively separated into two groups: the first 30 patients operated on (group 1) and the second 30 patients operated on (group 2). Results: Both groups were similar statistically in regard to gender, age, and body mass index. Operative time for group 1 was 79 ± 31.1 min. There were 11 (37%) complications in 10 patients. Operative time for group 2 was 59 ± 19.9 min. There were two complications (7%). All operations were completed laparoscopically. Operative time was significantly lower in group 2 (t-test; p = 004). Complications were also significantly lower (chi-square; p = 0.005). The number of reoperations was also reduced and approached statistical significance (chi-square; p = 0.054). Readmissions, although reduced, were not statistically significant. There were no deaths in either group. Conclusions: Despite a surgeons history of advanced laparoscopic experience, there is a definite learning curve associated with the laparoscopically placed adjustable gastric band.     

Laparoscopic right donor nephrectomy: is there a right way?

BACKGROUND AND PURPOSE: There is a continuing reluctance among transplant surgeons to procure a right-kidney allograft laparoscopically. We describe our experience with right laparoscopic donor nephrectomy (RLDN) by three techniques. PATIENTS AND METHODS: We retrospectively analyzed all seven RLDNs performed at our center from January 2002 to June 2005. The technique used in a particular case depended on the anatomy of the renal vasculature and included transperitoneal (N = 1), retroperitoneoscopic (N = 4), and retroperitoneoscopy-assisted approaches without the use of hand port or other assist devices (N = 2). No stapling or manual-assist devices were used in the last four cases for division of the renal vessels. RESULTS: The mean blood loss, operating time, hospital stay, and serum creatinine concentration on day 7 were 94.3 +/- 46.9 mL (SD), 212.8 +/- 66 minutes, 4.9 +/- 1.9 days, and 1.1 +/- 0.2 mg/dL, respectively. The overall warm ischemia time was 217 +/- 116 seconds. Our preferred technique currently is to go for a total retroperitoneoscopic approach to the right kidney initially. If the renal vein appears short, we make a small subcostal incision to retrieve the kidney openly at this stage (retroperitoneoscopy-assisted approach) with minimal risks to the donor and recipient. CONCLUSIONS: Retroperitoneoscopic RLDN performed without hand-assist or stapling devices is safe and cost-effective and yields kidneys with excellent function. Rather than have a fixed approach to RLDN, we suggest a choice depending on the length of the renal vessels observed during surgery.     

Robot-assisted total mesorectal excision: is there a learning curve?

Background

Laparoscopic total mesorectal excision (TME) is associated with a steep learning curve, but the learning curve for robotic TME is unknown. This study aimed to evaluate the learning curve for robotic TME.

Methods

Between November 2004 and April 2009, 80 patients underwent robotic TME performed by a single surgeon. The operative experience was divided into two groups: group 1 (the first 40 cases) and group 2 (the subsequent 40 cases). Patient demographics, operative characteristics, and morbidities were compared.

Results

The two patient populations selected did not differ statistically in age, body mass index (BMI), preoperative risk assessment, stage, preoperative chemoradiotherapy, or tumor location. The mean operative times in group 1 (310?min) and group 2 (297?min) were similar (p?=?0.55), and the mean robotic TME time did not differ between the two groups (60 vs. 64?min; p?=?0.65). In addition, the operative times did not improve during the course of the study. There were no differences in EBL, margin status, or number of lymph nodes harvested. Furthermore, there were no differences in conversion rate, time to resumption of diet, length of hospital stay, or postoperative complications.

Conclusion

Robot-assisted TME may attenuate the learning curve for laparoscopic rectal cancer resection. Further studies are necessary to establish the role of robotic surgery in minimally invasive rectal operations.     

Laparoscopic colectomy in the elderly: is there a benefit?

The role of laparoscopic surgery has gained widespread acceptance as a feasible and safe option in the management of many benign colorectal diseases. Short-term benefits such as earlier return of bowel function, less postoperative pain, and shorter length of hospital stay have been demonstrated for laparoscopic-assisted colectomy (LAC). This has been accomplished with no significant difference in morbidity and mortality when compared with open colorectal surgery. The role of laparoscopy for malignant disease remains unclear as we await the results of the COST trial. To date there is little literature regarding the impact of LAC in the elderly population (ie, patients over the age of 70 years) as the vast majority of studies regarding laparoscopic colectomy have evaluated younger patients (less than 65 years). It is unknown if elderly patients garner the same benefits from LAC that younger patients have been shown to receive. As a result, there has been reluctance to offer laparoscopy to elderly patients. This is a review of the literature examining the positives and negatives of LAC in patients >70 years of age.     

Is there a learning curve in foot and ankle surgery?

BackgroundPrevious studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome.Methods150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups.ResultsFunctional improvement was greater, approaching significance, in the second group (p = 0.0605). There was no difference for forefoot cases (p = 0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p = 0.0333).ConclusionsA learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.     

Is there a role for partial nephrectomy in patients with metastatic renal cell carcinoma?

ObjectivesThe incidence of metastatic disease in patients with renal cell carcinoma (RCC) correlates with tumor size. We sought to determine the incidence of metastatic disease by tumor size, and the utilization and impact of nephron-sparing surgery on survival in those with metastatic disease.Materials and methodsUtilizing the Surveillance, Epidemiology, and End Results (SEER) database, we identified 56,011 patients between 1988 and 2005 diagnosed with RCC. Patients were initially separated into two groups—those with and without metastatic disease—and stratified by tumor size. Cox proportional hazard modeling and Kaplan-Meier analyses were then utilized to evaluate the role of gender, age, grade, histology, tumor size, and type of surgery (radical vs. partial nephrectomy) on overall- and cancer-specific survival in patients with metastatic disease.ResultsEight thousand four hundred ninety-eight patients (15%) had metastatic disease. Four percent of patients with tumors less than 2 cm and 5% of patients with tumors between 2 and 3 cm presented with metastatic disease. Two thousand nine hundred fifty patients (35%) with metastatic disease underwent surgery (radical or partial nephrectomy). Seventy patients (2% of those undergoing surgery) had a partial nephrectomy. Those who underwent partial nephrectomy were 0.49 times less likely to die of RCC than those who underwent radical nephrectomy (95% CI 0.35–0.69, P < 0.001).ConclusionsAlbeit small, the risk of metastases in patients with small kidney tumors is distinct and should be considered in management discussions. Partial nephrectomy, when able to be done, should be utilized in the setting of metastatic disease.     

Is there a "learning curve" for muscle perforator flaps?

Although soft tissue free flaps have been in the mainstream for over 40 years, muscle perforator flaps per se are a relatively recent addition to the armamentarium of the reconstructive microvascular surgeon. Even though actually only a fasciocutaneous flap subtype, a distinctively different approach is necessary for their safe and reliable use, which has deterred many from adopting this valuable asset for fear of not being able to master an implied "learning curve." Whether this is a justifiable excuse led to our examination of our original microsurgical experience from 1982-1986, which in retrospect had its own learning curve. All 30 soft tissue flaps during that initiation period were muscle free flaps, which not only had a now unacceptable 37% major complication rate but also a complete failure rate of 26% due specifically to our technical inadequacies with the requisite microanastomoses. When compared with our first 30 muscle perforator flaps, there was a similar incidence of major complications (30%), although the eventual transferred flap success rate was 97%. This confirmed the existence of a learning curve in our preliminary experience with muscle perforator flaps that was consistent with any surgical innovation. However, our microsurgical prowess by this time had facilitated the acquisition of the skills to comfortably harvest a muscle perforator flap with a very acceptable success rate that minimized the steepness of our particular learning curve. Just what will be the configuration of the unavoidable muscle perforator flap learning curve specific for each individual will depend on their own capabilities, the relative technical difficulty of a given flap, and the level of competency expected.     

Perforated appendicitis in children: is there a best treatment?

Purpose

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors’ hospital.

Methods

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

Results

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

Conclusions

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm³. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.     

Cytoreductive nephrectomy: is it a realistic option in patients with renal cancer?

OBJECTIVE: To evaluate the role of cytoreductive nephrectomy (CRN) in improving survival in patients with renal cell cancer. PATIENTS AND METHODS: The case-notes of 268 consecutive patients who presented to our specialized renal cancer clinic between 1998 and 2001 were reviewed. All patients with metastatic disease were assessed for CRN. If their primary tumour was considered operable, they were assessed further using the European Cooperative Oncology Group performance score; only patients with a performance score of 0 or 1 were considered for surgery. RESULTS: In all, 168 patients underwent nephrectomy with curative intent for M0 disease and 11 were treated conservatively. Ninety-four patients with M+ disease (mean age 65 years, range 38-80) were considered for CRN. Thirty-eight patients had an inoperable primary. Of the remaining 56 patients, 20 had a performance status of 0 or 1 and were offered CRN. CONCLUSION: Metastatic disease at presentation occurred in 34% of all patients referred; 40% patients had an inoperable primary and 38% had a performance score of > or =2. With an active policy of considering all patients for CRN, only 7% of those with renal cancer were suitable for this procedure. CRN is unlikely to have a significant effect on overall survival within a population of patients with renal cancer.     

Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?

PURPOSE OF REVIEW: Laparoscopic radical nephrectomy has been developed and applied for patients with renal cell carcinoma since 1992. The number of patients undergoing laparoscopic radical nephrectomy has increased explosively worldwide in recent years, and laparoscopy is now extended to patients with advanced disease. It is very important to clarify the present status of laparoscopic radical nephrectomy among the treatment modalities for patients with renal cell carcinoma. RECENT FINDINGS: Laparoscopic radical nephrectomy has a minimally invasive nature as well as comparable long-term cancer control in patients with pT1-3a renal cell carcinoma to open surgery. It is technically applicable for N1-2 disease and T3b disease if the tumor thrombus is within the renal vein. Also, it is feasible as a cytoreductive surgery for patients with M1 disease. SUMMARY: Laparoscopic radical nephrectomy is a standard treatment modality for T1-3a renal cell carcinoma patients. It is also available for treating patients with N1-2 disease, and for patients with M1 disease as a cytoreductive surgery.