Surgeon's view on the limitations of left-handedness during endoscopic surgery

BACKGROUND: The influence of endoscopic surgery on left-handedness is unclear. The aim of this study was to investigate the role of left-handedness during endoscopic surgery. MATERIALS AND METHODS: A survey distributed during the 15th Congress of the Turkish Society of Surgery, held in 2006, was conducted to 194 participants. The survey was focused on hand preference and endoscopic surgery. Besides demographic data and use of endoscopy, lateral predominance, questions related to surgical performance (open and endoscopic), training support during residency, and operating room experiences during endoscopic surgery were assessed. RESULTS: The laterality preference in performing surgery was left in 9.3% (n = 18). Almost 50% of the left-handed surgeons believed that endoscopic surgery needs to be modified for the left-handed endoscopic surgeon, although 66% reported they had no difficulty while using endoscopic instruments and did not need any modification during surgical endoscopy. Over 86% of all surgeons reported that laterality had no importance for them if they were a patient undergoing endoscopic surgery, while 14% of surgeons refused to be operated on by a left-handed surgeon. CONCLUSION: Endoscopic surgery has impact on laterality-related comfort, and technical modifications are warranted for left-handed surgeons. Further research is needed to address questions related to hand dominance in surgical endoscopic skill performance that allows more comprehensive conclusions.     

Endoscopic Techniques for the Management of Spinal Trauma

Background: In the past few years, endoscopic operations on the spinal column have developed from representing exceptional interventions to becoming standard procedures in spinal surgery. Operating techniques and instruments have been standardized and unified, making it possible now to perform safe endoscopic surgery, as the results of more than 350 operative treatments in a 5-year period show. History: This development was aided by the scarcely satisfactory results of purely dorsal treatment concepts, which intensified the demand for reconstruction of the anterior load-bearing spinal column. It was the high access morbidity of the conventional open procedure which stood in the way of a broader use of open ventral operations in spinal surgery and which limited the indication for open interventions to a few cases showing marked destruction or malformation in the anterior section of the spine. For this constellation, the endoscopic procedures could provide a solution based on the reduced access morbidity typical for endoscopic procedures without the need to accept diminished surgical effectiveness. Indications: The possibilities of endoscopic spinal surgery have been developed continuously during the past few years, so that today nearly all operations in spinal traumatology can be performed endoscopically. Endoscopic splitting of the diaphragm also made it possible to open up the upper sections of the lumbar spine, so that the area between the third thoracic vertebra and the third lumbar vertebra is now accessible to endoscopic surgery. The potential indications include repositioning, the incision and resection of ligaments and intervertebral disks, the removal of fragmented sections of vertebrae including anterior decompression of the spinal canal, the replacement of vertebral bodies with biological or alloplastic materials and, last but not least, the minimally invasive insertion of an implant for ventral stabilization.     

Surgeon-led initiatives cut costs and enhance the quality of endoscopic and laparoscopic procedures.

BACKGROUND: Public perception depicts surgical cost control and quality of care as polar opposites. We describe a program led by practicing surgeons that demonstrates that quality can be maintained, and often improved, while substantial cost reductions are realized. METHODS: A set of evidence-based protocols was developed, revised, and followed for 42 procedures in general, otolaryngologic, urologic, and orthopedic surgery. Each protocol consists of surgeon-initiated guidelines on operative indications, preoperative testing, preadmission planning, length of stay, resource utilization, convalescence, and pharmacy services. Information was collected for 24 months from July 1998 to July 2000 by 62 surgeons in Kentucky and Indiana. Data were obtained for 4302 cases, among them colonoscopy (1145), esophagogastroduodenoscopy (714), laparoscopic cholecystectomy (418), endoscopic retrograde cholangiopancreatography (235), and laparoscopic fundoplication (87). RESULTS: Specific cost reductions occurred in laparoscopic cholecystectomy by limiting the administration of perioperative antibiotics. Sixty-seven percent of patients did not receive antibiotics. Outpatient cholecystectomy was the norm (60%), due primarily to preadmission planning through discussion with the patients and their family. Interestingly, when surgeons were educated on the costs of certain instruments and medications, their practices changed. The avoidance of a particular postoperative antiemetic, which was more than tenfold more expensive than other choices, was rapidly adopted by all surgeons when the costs were discovered. One participating teaching hospital used its own financial data and predicted that if all surgeons at their facility followed the protocols and had similar results, a savings of dollar 1.1 million per quarter would be obtained.     

Early experiences of endoscopic procedures in general surgery assisted by a computer-enhanced surgical system

We performed a variety of complete total endoscopic general surgical procedures, including colon resection, distal gastrectomy, and splenectomy, successfully with the assistance of the da Vinci computer-enhanced surgical system. The robotic system allowed us to manipulate the endoscopic instruments as effectively as during open surgery. It enhanced visualization of both the operative field and precision of the necessary techniques, as well as being less stressful for the endoscopic operating team. This technological innovation can therefore help surgeons overcome many of the difficulties associated with the endoscopic approach and thus has the potential to enable more precise, safer, and more minimally invasive surgery in the future.     

乳腺癌腔镜腋窝淋巴结清扫手术方式选择及评价

溶脂法与非溶脂法腔镜腋窝淋巴结清扫在乳腺癌手术中的应用存在争议,也在不断的发展。非溶脂法腔镜腋窝淋巴结清扫在获得与溶脂法同样的腔镜放大视野、精细操作以及微创效果的同时,更符合常规开放手术中腋窝淋巴结处理的手术顺序,不受限于淋巴结大小,完整切除腋窝淋巴脂肪组织,可经乳晕切口顺畅取出手术标本,除了无法应用于内下象限肿瘤的保乳手术外,其避免了溶脂法腔镜腋窝淋巴结清扫的争议点。手术时间的延长及部分乳腺外科医生缺乏腔镜基础训练是限制非溶脂腔镜腋窝淋巴结清扫广泛应用的主要因素,相信随着手术器械的不断进步及外科规培制度的落实,这一技术会有更广阔的应用空间。     

Endoscopic Suturing and Knot Tying: Theory Into Practice

OBJECTIVE: To advance modern surgical techniques of endoscopic knot tying, encompassing a new appreciation of knot-tying theory and the application of second-generation, purpose-designed instruments. SUMMARY BACKGROUND DATA: During open surgery, surgeons automatically create the surgical half-hitch by using either instrument or hand/finger knot-tying methods (figure 4). Each of these methods, which are mirror images of each other, forms the same result, the half-hitch. Two opposing half-hitches are needed to form a square knot. There are many ways for new-generation instruments to create a secure square knot during endoscopic surgery. An overview of the current endoscopic knot-tying methods is presented. METHODS: The author presents a theoretical analysis of square knot-tying techniques as applied during instrument and hand/finger movements. The application of a mirror-image concept was considered in the analysis of these two contrasting methods. RESULTS: There are 12 ways to create a square knot, some of which have previously not been described or needed in open surgery. Some of these methods have particular application in endoscopic surgery. CONCLUSIONS: A new understanding of knot-tying theory has been developed, with innovative methods being defined for tissue approximation during endoscopic surgery. These ergonomic, efficient, and contrasting methods of knot tying are described using second-generation endoscopic instruments. The new techniques have direct and broad application in many fields of minimally invasive surgery.     

Combined procedures in laparoscopic surgery

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30-280 minutes). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1-21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.     

Bariatric and Associated Operations in Private and Academic Practices

Background: The types of bariatric and the associated operations performed by academic and private surgeons were surveyed. Methods: A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery. Results: 46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background. Conclusion: No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.     

Development of tasks and evaluation of a prototype forceps for NOTES

Background and Objectives:

Few standardized testing procedures exist for instruments intended for Natural Orifice Translumenal Endoscopic Surgery. These testing procedures are critical for evaluating surgical skills and surgical instruments to ensure sufficient quality. This need is widely recognized by endoscopic surgeons as a major hurdle for the advancement of Natural Orifice Translumenal Endoscopic Surgery.

Methods:

Beginning with tasks currently used to evaluate laparoscopic surgeons and instruments, new tasks were designed to evaluate endoscopic surgical forceps instruments.

Results:

Six tasks have been developed from existing tasks, adapted and modified for use with endoscopic instruments, or newly designed to test additional features of endoscopic forceps. The new tasks include the Fuzzy Ball Task, Cup Drop Task, Ring Around Task, Material Pull Task, Simulated Biopsy Task, and the Force Gauge Task. These tasks were then used to evaluate the performance of a new forceps instrument designed at Pennsylvania State University.

Conclusions:

The need for testing procedures for the advancement of Natural Orifice Translumenal Endoscopic Surgery has been addressed in this work. The developed tasks form a basis for not only testing new forceps instruments, but also for evaluating individual performance of surgical candidates with endoscopic forceps instruments.     

Progress in gastrointestinal tract surgery: the impact of gastrointestinal endoscopy

Background: Gastrointestinal (GI) tract surgeons were challenged with the development of two revolutionary surgical specialities: laparoscopic and endoscopic surgery. Minimal access surgery currently is the surgical speciality with the greatest impact on patient care. Regarding the competitive treatment methods (open, laparoscopic, and intraluminal endoscopic management), each new treatment must be evaluated on the evidence of the patient's benefit, surgical morbidity, short- and long-term outcome, cost effectiveness and maintenance of quality of life. Methods: On the basis of randomized clinical trials, minimal access surgery results in reduced postoperative pain, reduced early postoperative analgetic medication, reduced frequency of systemic inflammatory response syndrome and systemic complications, early restoration of normal bowel function, and minimalization of wounds and skin scars. Among the well-established laparoscopic procedures, laparoscopic cholecystectomy has been convincingly demonstrated as superior to open cholecystectomy on the basis of controlled clinical trials. Superior benefit in favor of laparoscopic hernia repair has been demonstrated only regarding a lower level of pain, a higher level of physical activity, and earlier return to work. However, in terms of operating time and costs, open repair without mesh has benefits. Laparoscopic appendectomy offers benefits in terms of pain reduction, faster postoperative recovery, and lower incidence of wound infections, but has major drawbacks with regard to longer operating time, higher local complication rates, and significantly higher costs for total hospitalization. A cost study group concluded from a randomized clinical trial that only minimal short-term quality-of-life benefits were found for laparoscopically assisted colon resection, as compared with standard open colectomy, for colon cancer. On the basis of controlled clinical trials, there is only a little doubt that the laparoscopic approach is currently the operative treatment of choice for gastroesophageal reflux compliance. Endoscopic intraluminal techniques are increasingly important for minimalization of surgical treatment. For ulcer bleedings, endoscopic treatment is the established first choice. A major old and new challenge for GI tract surgeons is the intraluminal endoscopic approach to lesions. For neoplastic lesion in the esophagus (> 2 cm, mucosa restricted), Barrett's epithelium, early gastric cancer, adenoma of the ampulla of Vater, T1+, TIM lesion of the large bowel, T1 cancer of the rectum, intraluminal endoscopic treatment methods are increasingly replacing open surgical resection or even a laparoscopic technique. The surgeon must be aware that many of the local surgical complications, particularly those of GI tract anastomoses, are managed by endoscopic techniques. Conclusions: The GI tract surgeon must accumulate competent endoscopic experience. His responsibility for GI diseases focuses on surgical treatment using minimal access surgical techniques including surgical endoscopy in preoperative, intraoperative, and postoperative settings. This major assignment is a challenge not only for GI tract surgeons in the near future.     

乳腺癌腔镜腋窝淋巴结清扫手术方式选择及评价

溶脂法与非溶脂法腔镜腋窝淋巴结清扫在乳腺癌手术中的应用存在争议，也在不断的发展。非溶脂法腔镜腋窝淋巴结清扫在获得与溶脂法同样的腔镜放大视野、精细操作以及微创效果的同时，更符合常规开放手术中腋窝淋巴结处理的手术顺序，不受限于淋巴结大小，完整切除腋窝淋巴脂肪组织，可经乳晕切口顺畅取出手术标本，除了无法应用于内下象限肿瘤的保乳手术外，其避免了溶脂法腔镜腋窝淋巴结清扫的争议点。手术时间的延长及部分乳腺外科医生缺乏腔镜基础训练是限制非溶脂腔镜腋窝淋巴结清扫广泛应用的主要因素，相信随着手术器械的不断进步及外科规培制度的落实，这一技术会有更广阔的应用空间。     

The "cost" of operative training for surgical residents

HYPOTHESIS: There is an increase in the amount of time required to perform an operation when the procedure involves training a surgical resident. This increased time does not translate into a financial burden for the hospital. DESIGN: Retrospective review of prospectively collected data. During the study period, surgeons and residents were blinded to the study's intent. We compared the operative times of academic surgeons performing 4 common surgical procedures before and after the introduction of a postgraduate year 3 resident into a community teaching hospital. Between January 1, 2001, and June 30, 2002, 4 academic surgeons performed operations without a resident in a community hospital that was recently integrated into a tertiary medical center system. During that period, surgeons operated alone (hernia surgery) or assisted one another (laparoscopic cholecystectomy, colectomy, and carotid endarterectomy). From July 1, 2002, through March 31, 2003, these same 4 surgeons were assisted by a postgraduate year 3 resident on similar procedures. SETTING: Community hospital recently integrated into a tertiary medical center system. PARTICIPANTS: Four experienced academic surgeons operating in the community setting and patients undergoing 1 of 4 surgical procedures (inguinal hernia repair, laparoscopic cholecystectomy, partial colectomy, or carotid endarterectomy) from January 1, 2001, through March 31, 2003. INTERVENTION: The introduction of a postgraduate year 3 surgical resident rotation into a community hospital in which the same academic surgeons had been performing operations without a resident for 18 months. MAIN OUTCOME MEASURES: Mean operating time with and without a postgraduate year 3 resident participating in 4 common surgical procedures.Result For the 4 procedures studied, there was a significant increase in the operative time required to complete such procedures. CONCLUSIONS: There is an increased time cost associated with the operative training of surgical residents. This "cost" primarily impacts the attending surgeon.     

Real-time Internet connections: implications for surgical decision making in laparoscopy

OBJECTIVE: To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. SUMMARY BACKGROUND DATA: Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. METHODS: Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. RESULTS: The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.     

Training, credentialing, and evaluation in laparoscopic surgery.

Laparoscopic cholecystectomy has become the procedure of choice for the treatment of gallbladder disease. Many general surgeons have incorporated laparoscopic cholecystectomy into their clinical practices, usually after completing a postgraduate didactic and laboratory animal training course. This additional formal training is both appropriate and necessary because laparoscopic surgery involves techniques different from those of traditional celiotomy, and most surgeons who completed their residencies prior to 1992 have had no laparoscopic training. Because additional formal training for practicing surgeons is necessary at this time, it is appropriate for hospitals to mandate separate granting of operative privileges for laparoscopic surgical procedures. In the near future, when graduates of general surgery residency programs have had training in laparoscopic surgery, separate privileges will no longer be necessary, and laparoscopic procedures should be included in the standard privilege category of biliary tract surgery. Once privileges in laparoscopic surgery are granted, laparoscopic operations, like all surgical procedures, should be monitored by peer review to ensure that they continue to be performed safely and appropriately. Only those laparoscopic procedures that are similar to open operations and have been shown by pilot studies to be safe (e.g., cholecystectomy) should be included currently in a surgeon's laparoscopic privileges. Laparoscopic procedures that are very different from proven open procedures and are investigational (e.g., inguinal herniorrhaphy) should be permitted by the hospital only as part of an experimental protocol monitored by an institutional review board. Only after their safety and efficacy have been established should they become part of standard privilege categories.     

Surgery in space: the future of robotic telesurgery

Background  

The origins of telemedicine date back to the early 1970s, and combined with the concept of minimally invasive surgery, the idea of surgical robotics was born in the late 1980s based on the principle of providing active telepresence to surgeons. Many research projects were initiated, creating a set of instruments for endoscopic telesurgery, while visionary surgeons built networks for telesurgical patient care, demonstrated transcontinental surgery, and performed procedures in weightlessness. Long-distance telesurgery became the testbed for new medical support concepts of space missions.     

Towards scarless surgery: an endoscopic ultrasound navigation system for transgastric access procedures.

OBJECTIVE: Scarless surgery is an innovative and promising technique that may herald a new era in surgical procedures. We have created a navigation system, named IRGUS, for endoscopic and transgastric access interventions and have validated it in in vivo pilot studies. Our hypothesis is that endoscopic ultrasound procedures will be performed more easily and efficiently if the operator is provided with approximately registered 3D and 2D processed CT images in real time that correspond to the probe position and ultrasound image. MATERIALS AND METHODS: The system provides augmented visual feedback and additional contextual information to assist the operator. It establishes correspondence between the real-time endoscopic ultrasound image and a preoperative CT volume registered using electromagnetic tracking of the endoscopic ultrasound probe position. Based on this positional information, the CT volume is reformatted in approximately the same coordinate frame as the ultrasound image and displayed to the operator. RESULTS: The system reduces the mental burden of probe navigation and enhances the operator's ability to interpret the ultrasound image. Using an initial rigid body registration, we measured the mis-registration error between the ultrasound image and the reformatted CT plane to be less than 5 mm, which is sufficient to enable the performance of novice users of endoscopic systems to approach that of expert users. CONCLUSIONS: Our analysis shows that real-time display of data using rigid registration is sufficiently accurate to assist surgeons in performing endoscopic abdominal procedures. By using preoperative data to provide context and support for image interpretation and real-time imaging for targeting, it appears probable that both preoperative and intraoperative data may be used to improve operator performance.     

Telerobotic gastrointestinal surgery: phase 2--safety and efficacy

Background The Federal Drug Administration (FDA) approved the da Vinci surgical system for all abdominal operations in July 2000. In the past 6 years, virtually all gastrointestinal operations have been accomplished using telerobotic techniques. The purpose of this review is to summarize the short-term outcomes achieved with telerobotic gastrointestinal operations. Methods All case series of telerobotic gastrointestinal operations identified by PubMed searches are included in this review. Results Case series document the safety and efficacy of telerobotic cholecystectomy, fundoplication, Heller myotomy, gastric bypass, colectomy, gastrectomy, and pancreatectomy. The procedures were accomplished with low rates of conversion to laparoscopic operations, mortality, and morbidity. When comparison groups were available, the analysis shows that telerobotic operations required more time than the laparoscopic operations, although for telerobotic cholecystectomy and telerobotic fundoplication, this difference disappeared in 10 to 20 operations. Specific patient advantages were not identified for telerobotic operations compared with laparoscopic operations, except for a decreased esophageal perforation rate during telerobotic Heller myotomy. Surgeons benefited from the three-dimensional imaging, the handlike motions of the robotic instruments, and an ergonomically comfortable position. Conclusion All telerobotic gastrointestinal operations are feasible and can be performed with safety and efficacy. It is difficult to demonstrate patient-specific advantages of telerobotic surgery over laparoscopic operations. Nonetheless, telerobotic surgical systems offer distinct advantages to surgeons and may facilitate an increase in the number of surgeons performing advanced laparoscopic gastrointestinal operations. In addition, telerobotics offer a digital information platform that enables surgical simulation and augmented-reality surgery.     

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.     

Improving the quality of life after gastrectomy is the next issue after saving the lives of patients with gastric cancer

Gastrectomy saves the lives of many patients with gastric cancer. However, this surgical treatment is associated with clinical problems called postgastrectomy syndrome (PGS) which affect the quality of life (QOL) of such patients. For surgeons, improving the QOL after gastrectomy is an important goal after performing curative surgery. In the clinical setting, various surgical procedures such as limited resection, function-preserving procedures, and reconstruction using gastric substitutes have been advocated to reduce the severity of PGS. However, the actual conditions and pathophysiology of PGS have not been fully investigated. Various clinical studies and basic research have partially clarified the features and pathophysiology of PGS, although the strategies developed to treat PGS have been limited. The development of standardized, reliable instruments for understanding PGS and performing large-scale collaborative studies are required to improve the diagnosis and treatment of PGS. In Japan, such a project called the PGSAS has recently been completed. The results are being analyzed and will be reported in the near future.     

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

Background

NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.

Methods

Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.

Results

At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.

Conclusion

As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods—combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.