SE16VIRTUAL REALITY LAPAROSCOPIC TRAINING IN AUSTRALIA

Opinions on the role of virtual reality simulation in surgical training are diverse and usually not evidence‐based. Several adequately powered, randomised and blinded studies have demonstrated an improvement in the operative performance of those who have undergone virtual reality training. Nonetheless there remains reluctance by the medical profession to incorporate simulation into training. This seems to be based on three misconceptions.

• 1 Simulators are expensive
• 2 It is difficult to incorporate them into an already overcrowded curriculum
• 3 The transfer of skill to the real world has not been demonstrated to reduce risk or improve patient outcomes.

We report on our attempts to assess the feasibility of establishing virtual training for local trainees and to assess its outcome on operative performance. 16 Basic surgical trainees were randomised into control and training groups. All underwent baseline testing of their psychomotor ability before the training group were allowed 24 hour access to a LapSim virtual reality simulator. It was not possible to complete this study and we will discuss the reasons for this which we believe has important implications for the future use of simulation in surgical training. 16 final year medical students were also recruited, and similarly randomised and assessed before being allowed access to the simulator. After four weeks of training, we were able to demonstrate a significant improvement in their simulated laparoscopic surgical skills when compared with the skills of local specialists. Using an animal model, we were able to demonstrate the effect of this on their operative performance.     

HAND ASSISTED LAPAROSCOPIC NEPHRECTOMY: COMPARISON TO STANDARD LAPAROSCOPIC NEPHRECTOMY

Purpose

We report our initial experience with hand assisted laparoscopic nephrectomy, and compare it to our results of standard laparoscopic nephrectomy.

Materials and Methods

The results of 21 hand assisted and standard laparoscopic nephrectomies (15 simple and 4 radical nephrectomies, and 2 nephroureterectomies) were reviewed. Hand assisted laparoscopic nephrectomy was performed with a hand placed intra-abdominally using the Pneumo Sleeve,^* in addition to standard laparoscopic instruments manipulated through laparoscopic ports. Standard laparoscopic nephrectomy was performed using laparoscopic instruments alone. Perioperative data were recorded and questionnaires, including visual analog pain scales, were administered prospectively to 17 of 21 cases.

Results

The average operative time for 13 hand assisted laparoscopic nephrectomies was 240 minutes, which was significantly less than the 325-minute average for 8 standard laparoscopic nephrectomies (p = 0.04). Major complications tended to be more frequent in the standard group (38 versus 8%, p = 0.10). Hospital stay, return to normal activity and corrected 2-week abdominal/flank pain score in the hand assisted group (3.1 days, 14 days and 0.8, respectively) were not significantly different from the standard group (3.0 days, 10 days and 0.2, respectively).

Conclusions

Compared to standard laparoscopic techniques, hand assistance appears to facilitate the operative speed and safety of laparoscopic nephrectomy without sacrificing the benefits of minimally invasive surgery. Hand assistance may make laparoscopic nephrectomy more appealing to urologists without advanced laparoscopic experience, may facilitate the laparoscopic management of demanding pathological conditions and is particularly useful when intact specimens are required. Hand assistance, by improving manipulative ability and tactile sense, is helpful for select cases of laparoscopic nephrectomy.     

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES AFTER CONCENTRATED TRAINING IN UROLOGICAL LAPAROSCOPY

PURPOSE: To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS: Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS: During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS: The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.     

LEARNING CURVE AND CONVERSION TO OPEN SURGERY IN CASES OF LAPAROSCOPIC ADRENALECTOMY AND NEPHRECTOMY

Purpose

We examine how the level of experience acquired by the laparoscopist affects the outcome of laparoscopic adrenalectomy and nephrectomy, and what is necessary to avoid complications in these surgeries.

Materials and Methods

We retrospectively evaluated the experience levels of 8 urological laparoscopists between 1991 and 1995. In addition, other cases that were converted to open surgery were collected from the institutes with which the 8 laparoscopists were affiliated.

Results

The rates of conversion to open surgery were 6.4% in 204 cases of adrenalectomy and 14.3% in 63 of nephrectomy. Conversion rates were related to blood loss volume but not operative time. The major causes of conversion were bleeding in 45% of cases and adhesion in 34%. There were no mortalities. Mean operative time decreased significantly, reaching that of open surgery as the number of procedures increased up to 20 adrenalectomies and 10 nephrectomies. The volume of blood lost remained low from the early experience. Blood transfusion rates were 4.4% for adrenalectomy and 11.1% for nephrectomy.

Conclusions

Operative time of these procedures decreased significantly with surgeon experience and reached that of open surgery. Cases in which adhesion is anticipated should be restricted to avoid conversion. These laparoscopic procedures are acceptable as a standard operative techniques for adrenal and renal diseases.     

LAPAROSCOPIC NEPHRECTOMY USING A RETROPERITONEAL APPROACH: COMPARISON WITH A TRANSABDOMINAL APPROACH

To evaluate the efficacy of the retroperitoneal approach in laparoscopic nephrectomy, our procedures involving laparoscopic nephrectomy using a retroperitoneal approach are described and the clinical results of six patients treated in this way are compared with those of 32 transabdominally nephrectomized patients. Of the six retroperitoneally nephrectomized patients, six kidneys were successfully removed without severe complication, and 28 kidneys were successfully removed in the 32 intraabdominally approached group. Three of the 28 patients had complications requiring open laparotomy. The operating time was 2.7 hours in the 6 retroperitoneal patients and 4.4 hours in the 28 transabdominal patients. Estimated blood loss was 92 ml in the retroperitoneal group and 450 ml in the transabdominal group. The mean postoperative hospital stay was 8 days and 9 days, respectively. These results indicate that the retroperitoneal approach might be preferable in laparoscopic nephrectomy.     

LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: THE PRELIMINARY EXPERIENCE

Background : Recent improvements in video technology and surgical instrumentation have resulted in the application of minimally invasive techniques to many surgical procedures including splenectomy and adrenalectomy. ^{1 , 2} Nephrectomy requires a long flank incision with division of abdominal musculature and possible subcostal nerve damage. Severe postoperative pain and a prolonged recuperative period may result, and the cosmetic outcome may not be satisfactory. A new surgical approach utilizing laparoscopic dissection and delivery of the kidney through a small incision was performed to circumvent these problems. The aim of this paper is to describe the technique of laparoscopic live donor nephrectomy (LLDN) and present the preliminary outcome. Methods : Over the 12-month period between May 1997 and April 1998, 16 donors underwent donor nephrectomy by a laparoscopic approach. The procedure was assessed with regard to its safety, feasibility and advantages over the open method. Results : All the nephrectomies were completed without conversion to an open procedure. The average postoperative pain score on a visual analogue scale of 1–10 was 2 in LLDN. The donors required 36 mg morphine on average over 36 h postoperatively. Postoperative stay averaged 3 days. One donor developed an infective complication along the wound drain tract which settled with adequate drainage and antibiotics. All the removed donor kidneys were transplanted with immediate good function. There were no surgical complications or graft losses. The recipients’ serum creatinine was in the range of 96–181 mmol/L 3 months after transplantation. Conclusions : Significant potential advantages of LLDN include less postoperative pain, shorter hospitalization and decreased recuperative time. This preliminary experience indicates LLDN to be effective in terms of safety and feasibility.     

LAPAROSCOPIC RADICAL NEPHRECTOMY: CANCER CONTROL FOR RENAL CELL CARCINOMA

PURPOSE: We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma. MATERIALS AND METHODS: Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status. RESULTS: In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate. CONCLUSIONS: Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.     

HELICAL COMPUTERIZED TOMOGRAPHY ARTERIOGRAPHY FOR EVALUATION OF LIVE RENAL DONORS UNDERGOING LAPAROSCOPIC NEPHRECTOMY

PURPOSE: Traditionally, live renal donors are evaluated with excretory urography and renal arteriography. Helical computerized tomography (CT) arteriography offers a less invasive alternative for demonstrating necessary anatomical information before laparoscopic allograft harvest. We evaluate the accuracy of helical CT arteriography in depicting renal vascular anatomy with an emphasis on the detection of arterial and venous anomalies. MATERIALS AND METHODS: Imaging studies were done on 175 patients according to a standard CT arteriography protocol with early arterial phase scanning (14 to 20-second delay), and 1 mm. axial and 3-dimensional maximum intensity projection reconstructions. Renal vascular anatomy was mapped with attention to aberrant arterial and venous anatomy. Intraoperative findings were correlated at laparoscopic donor nephrectomy. RESULTS: There was overall agreement between CT arteriography and laparoscopic findings in 163 cases (93%). Supernumerary renal arteries were identified in 40 cases (23%). Sensitivity, specificity and accuracy of CT arteriography for arterial anatomy were 91, 98 and 96%, respectively. Cases with less than 2 mm. accessory arteries or early branching single vessels simulating dual arteries were misdiagnosed. Venous anomalies occurred in 11 patients (6.3%). Sensitivity, specificity and accuracy of CT arteriography for venous anatomy were 65, 100, and 97%, respectively. Misdiagnoses included early venous bifurcations and supernumerary tributary veins, which were poorly opacified. CONCLUSIONS: Helical CT is highly accurate and specific for the demonstration of renal arterial anatomy. Poor opacification resulted in a lower sensitivity for venous anatomy. Overall, helical CT provides essential anatomical information, and is an alternative to standard urography and arteriography.     

WHITE BOX: LOW COST BOX FOR LAPAROSCOPIC TRAINING

Background:

Laparoscopic surgery is a reality in almost all surgical centers. Although with initial greater technical difficulty for surgeons, the rapid return to activities, less postoperative pain and higher quality aesthetic stimulates surgeons to evolve technically in this area. However, unlike open surgery where learning opportunities are more accessible, the laparoscopic training represents a challenge in surgeon formation.

Aim:

To present a low cost model for laparoscopic training box.

Methods:

This model is based in easily accessible materials; the equipment can be easily found based on chrome mini jet and passes rubber thread and a webcam attached to an aluminum handle.

Results:

It can be finalized in two days costing R$ 280,00 (US$ 90).

Conclusion:

It is possible to stimulate a larger number of surgeons to have self training in laparoscopy at low cost seeking to improve their surgical skills outside the operating room.     

LAPAROSCOPIC BILATERAL HAND ASSISTED NEPHRECTOMY FOR AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: INITIAL EXPERIENCE

PURPOSE: The laparoscopic technique for bilateral nephrectomy in patients with autosomal dominant polycystic kidney disease is technically difficult. The procedure may be more acceptable if alterations to the technique made it safer and easier to perform. We describe our initial experience with, and the feasibility and potential benefits of hand assisted laparoscopic nephrectomy for approaching these large kidneys in patients with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: This approach was successfully applied in 3 patients with end stage renal disease due to autosomal dominant polycystic kidney disease. After obtaining transumbilical pneumoperitoneum ports were placed in the umbilicus (12 mm.), sub-xiphoid in the midline (12 mm.) and subcostal in the midclavicular line on each side (12 mm.). The table was tilted 40 degrees away from the planned side of initial nephrectomy with the patient in the half lateral position. A 7 cm. midline incision was made that incorporated the umbilical port and a commercially available hand assistance device was positioned. One surgeon hand was inserted into the abdomen to serve as a retractor/blunt dissector, while the other operated the electrosurgical instruments. The right hand was inserted for left nephrectomy and the left hand was inserted for right nephrectomy. The laparoscope was passed via the sub-xiphoid port and the instruments were placed through the ipsilateral subcostal laparoscopic port. Nephrectomy was completed and the specimen was removed through the hand port incision by draining the cysts as they were exposed to view via the midline incision. When dissection was difficult, an additional port was placed in the anterior axillary line at the umbilical level. Some cysts were ruptured or aspirated to decrease overall kidney size and make extraction possible via the 6 to 7 cm. midline incision. RESULTS: All procedures were successfully completed. Mean operative time for bilateral hand assisted laparoscopic nephrectomy was 5.5 hours (range 4.5 to 6.6). Estimated blood loss was 200 cc or less. Patients resumed oral intake on postoperative day 1. The mean amount of parenteral analgesics required postoperatively was decreased. Mean hospital stay was 4.3 days but it was 3 days when considering nephrectomy only. Patients returned to normal activity after an average of 2 weeks. There was sustained resolution of preoperative discomfort based on pain analog scales. At 1 month or less all patients recorded absent pain. They uniformly noticed improved preoperative pulmonary and gastrointestinal symptoms CONCLUSIONS: Hand assisted laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease makes bilateral nephrectomy a reasonable option. The bilateral procedure may be performed as rapidly as laparoscopic only, unilateral nephrectomy in these cases. The advantages of the hand assisted approach include using tactile sensation to facilitate dissection, rapid blunt finger dissection, hand retraction and the application of immediate tamponade when needed. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay and rapid convalescence in this group of patients at high risk.     

BILATERAL NEPHRECTOMY DELAYS GASTRIC EMPTYING OF A LIQUID MEAL IN AWAKE RATS

Aims: This study evaluates the effect of bilateral nephrectomy on the gastric emptying of a liquid meal. Methods: Male rats were submitted under anesthesia to cervical vessels cannulation and bilateral lumbar incision, followed or not by nephrectomy. Next day, they were gavage fed (1.5 mL) with phenol red (0.5 gmL^?1) in 5% glucose solution and sacrificed 0, 10, 20, 30 or 45 min later. A blood sample was obtained for biochemical analysis while gastric dye retention was determined by spectrophotometry. Data (mean ± SEM) were compared by ANOVA and Student–Newman–Keuls tests. Results: Gastric emptying values from nephrectomy group at 10, 20, 30 and 45 min were lower (P<0.05) than those of sham-operated animals (22.0 ± 4.0 vs. 38.9 ± 6.1%, 34.1 ± 1.4 vs. 66.9 ± 1.3%, 45.5 ± 6.1 vs. 64.9 ± 5.4% and 59.7 ± 2.4 vs. 81.5 ± 4.0%, respectively). Mean arterial pressure, blood volume, serum osmolarity, urea, creatinine and potassium values were higher (P < 0.05) in nephrectomy group than in sham-operated animals (143.3 ± 2.7 vs. 100.5 ± 4.1 mmHg, 15.7 ± 0.9 vs. 8.9 ± 1.1 mL 100 g^?1, 344.0 ± 10.8 vs. 299.4 ± 1.3 mOsm KgH₂O^?1, 344.0 ± 33.7 vs. 47.0 ± 2.8 mg dL^?1, 3.6 ± 0.3 vs. 1.1 ± 0.1 mg dL^?1, 6.4 ± 0.7 vs. 3.7 ± 0.2 mEq L^?1, respectively). The plasmatic Na⁺ values did not change (139.3 ± 2.0 in sham-operation vs. 123.0 ± 7.5 mEq L^?1 in nephrectomy). Conclusion: Acute loss of kidney function markedly delays the gastric emptying rates, which could be involved in gastrointestinal dysmotility complaints seen after renal failure.     

IN VITRO INHIBITION OF TUMOUR GROWTH IN A HELIUM-RICH ENVIRONMENT: IMPLICATIONS FOR LAPAROSCOPIC SURGERY

Background : The recent results of several experimental studies have suggested that tumour implantation after laparoscopic surgery for intra-abdominal malignancy may be partly related to the chemical composition of the insufflation gas used during surgery. These studies have demonstrated that the use of helium as a laparoscopic insufflation agent for cancer surgery results in less tumour implantation and growth at port sites. To further investigate these findings, the present study was performed to compare the growth of cultured tumour cells after exposure to simulated laparoscopic environments, rich in helium, carbon dioxide (CO₂), or air. Methods : A rat mammary adenocarcinoma cell suspension was exposed to a simulated laparoscopic environment for 40 min in one of the following groups: (i) control (atmospheric air, equivalent to a ‘gasless’ laparoscopic environment); (ii) a CO₂-rich environment; and (iii) a helium-rich environment. Cells were then cultured for 18 h and optical density readings were used to assess the number of viable tumour cells at the end of this period. The experiment was performed twice using an identical protocol to ensure consistency in the results. In a further study, pH was continuously measured using an antimony probe during a 40 min insufflation period and for 10 min after insufflation. Results : Cell growth was significantly lower after incubation in the helium-rich environment compared to both the CO₂ and control groups (P < 0.001). There was a significant decrease in pH in the CO₂ group which was not observed during exposure to either air or helium. Conclusions : The inhibition of tumour growth in a helium-rich environment demonstrated by this study, and the reduced incidence of port–site metastases seen in other experimental studies, suggests that the clinical use of helium as an insufflation gas may have important advantages over CO₂.     

腹腔镜超声检查在胆囊切除胆道探查术中的应用

目的：探讨腹腔镜超声检查在胆囊切除胆道探查术中的应用价值。方法：腹腔镜下对126例腹腔镜胆囊切除胆道探查术患者常规行腹腔镜超声检查,并选择其中30例行术中胆管造影。与腹腔镜超声检查行对比研究。结果：腹腔镜超声检查平均时间17min,对胆道系统和血管系统扫描结果显示：胆囊和门静脉100％显像,肝胆管,胆总管97％显像,胆总管未端85％显像,腹腔镜超声检查和术中胆管造影对比结果显未腹腔镜超声检查的胆总管检查成功率及胆管结石的敏感性,特异性及总诊断成功率均优于术中胆管造(影（分别为97％,82％,97％,98％和80％,75％,95％,95％）。结论：腹腔镜超声检查的应用有助于判断胆道系统的解剖结构,防止发生胆管损伤,有助于发现或排除肝内外胆管结石,为胆管造影及胆道探查术提供重要指标。降低了胆道残石和阴性胆道探查术的发生率。