Open Surgical Simulation—A Review

BackgroundSurgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation.Current State of Open Surgical SimulationOpen surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment.Future of Open Surgical SimulationThe skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient’s safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools.     

人格因素对正颌患者术后满意度的影响

目的：探讨人格因素对正颌患者术后满意度的影响，为临床治疗提供科学的理论依据。方法：采用16PF、EPQ人格问卷和正颌患者术后满意度问卷对30例正颌患者进行调查分析。结果：16PF人格问卷中，稳定性、感情与机警两因子标准得分与满意度总分之间呈正相关(r=0．375～0．462)，敏感性因子标准得分与满意度总分之间呈负相关(r=-0．379)。EPQ人格问卷中，P量表的标准得分与满意度总分之间呈负相关(r=-0．402)。结论：情绪稳定、自控倾向强的正颌患者较情绪不稳定者易于满意手术结果。     

Key Aspects of Health Policy Development to Improve Surgical Services in Uganda

Recently, surgical services have been gaining greater attention as an integral part of public health in low-income countries due to the significant volume and burden of surgical conditions, growing evidence of the cost-effectiveness of surgical intervention, and global disparities in surgical care. Nonetheless, there has been limited discussion of the key aspects of health policy related to surgical services in low-income countries. Uganda, like other low-income sub-Saharan African countries, bears a heavy burden of surgical conditions with low surgical output in health facilities and significant unmet need for surgical care. To address this lack of adequate surgical services in Uganda, a diverse group of local stakeholders met in Kampala, Uganda, in May 2008 to develop a roadmap of key policy actions that would improve surgical services at the national level. The group identified a list of health policy priorities to improve surgical services in Uganda. The priorities were classified into three areas: (1) human resources, (2) health systems, and (3) research and advocacy. This article is a critical discussion of these health policy priorities with references to recent literature. This was the first such multidisciplinary meeting in Uganda with a focus on surgical services and its output may have relevance to health policy development in other low-income countries planning to improve delivery of surgical services.     

艾滋病患者并发外科疾病的诊断和处理

目的 探讨艾滋病(AIDS)患者合并外科疾病手术治疗的安全性。方法 回顾性分析40例AIDS合并外科疾病的临床资料和处理方法。结果 AIDS合并外科疾患患者中l9例经手术治疗后不同程度地好转和治愈。结论 AIDS合并外科疾病时及时的手术治疗对患者是安全和有益的。     

Surgical site marking does not affect sterility

Background: In 2005, surgical site marking became mandatory in Australia, with the introduction of the first Australian guidelines to prevent wrong site surgery. It has been our experience that most surgical site marking occurs with the use of a non‐sterile marking pen, which has been used on multiple patients and there is little information in the published work about the effects of surgical site marking carried out in this fashion. Our aim was to determine whether the sterility of a surgical site was affected by surgical site marking with a non‐sterile surgical marking pen. Methods: Both forearms of 20 volunteers would simulate surgical sites. Surgical site marking was carried out on right forearms with the same non‐sterile surgical marking pen, whereas left forearms were unmarked controls. Microbiology swabs were taken from both forearms before, and after, skin sterilization with 10% povidone–iodine. Routine cultures were carried out on the swabs after sodium thiosulphate was used to deactivate residual iodine. Cultures were assessed for growth after 5 days. Results: One of the 20 marked forearms and 15 of the 20 unmarked forearms had bacterial growth on cultures before skin sterilization (P < 0.1). After sterilization with iodine, no bacterial growth occurred in the cultures of the swabs taken from the marked or control arms. Conclusion: Surgical site marking carried out with a non‐sterile surgical marking pen did not contaminate the surgical site. We recommend the practice of surgical site marking.     

A surgical skills elective can improve student confidence prior to internship

BACKGROUND: A focused surgical resident readiness curriculum for senior medical students can improve confidence in surgical skills compared to current surgical interns. MATERIALS AND METHODS: A 3-week surgical skills lab elective enrolled senior medical students applying to surgical residency programs, with the purpose of improving surgical skills and easing anxiety prior to surgical internship. Students were surveyed before and after the elective regarding their confidence in performing 21 skills covered by the curriculum. A similar confidence survey was administered to the incoming surgical intern class. Interns were also surveyed regarding prior skills lab instruction during medical school. Statistical analyses included Student's paired t-test and two-way analysis of variance. RESULTS: Six medical students and 23 interns were surveyed. All medical students significantly improved their confidence by the end of the resident readiness curriculum (P = 0.0004). Although students initially had lower confidence than surgical interns in performing surgical skills and in their knowledge of anatomy prior to the course, their confidence after the course was significantly higher than that of the incoming surgical interns (P = 0.035). Surgical interns with prior skills lab experience in their medical school reported higher confidence than those who did not have a skills lab experience (P = 0.019). Among all subgroups, medical students with skills lab experience had the highest confidence score, followed by interns with previous skills lab experience, then by interns with no previous skills lab experience, and last, by medical student with no skills lab experience. CONCLUSION: Surgical interns often feel unprepared to perform skills necessary for residency. A focused skills lab elective during medical school can bridge the gap and improve confidence prior to internship.     

Einrichtung eines chirurgischen Trainingslabors an einer Ausbildungsklinik

The improvement of surgical skills of trainees in Germany often occurs solely in the operating room. In recent years, several countries have established surgical skills labs as an essential part of surgical education, with the goal of improving and refining surgical skills before clinical application. Several years ago, training units were established by the industry wherein the curricula focused on products of the respective company. Selected training courses are still offered in a few clinics. Presently, laboratories which train the surgical skills of novices in an individually adapted form are lacking. A surgical skills lab with a comprehensive curriculum of training courses was introduced at the University Hospital of Marburg in 2005. The present article describes the development and introduction of such facilities. The authors are convinced that surgical skills labs will become increasingly important in German surgical education for improving patient safety in the operating room.     

The current and future role of surgical physician assistants. Report of a national survey of surgical chairmen in large U.S. hospitals

The chairman of departments of surgery in general hospitals with more than 400 beds were surveyed to assess their current and projected use of surgical physician assistants. Of the 552 institutions represented in our survey, surgical physician assistants were working in one-third, providing preoperative, intraoperative, and postoperative care. Two-thirds of the chairmen felt that the introduction of physician assistants had improved surgical patient care in their institutions. In institutions with surgical housestaff, almost half the chairmen felt that surgical physician assistants had improved the quality of residency training. During the next five years an increase of 87% in the number of surgical physician assistants is projected by respondents. We conclude that appropriately trained and supervised surgical physician assistants will play an increasingly important role in improving the care of surgical patients and, by functioning as junior housestaff, make it possible to reduce the number of surgeons being trained.     

重视外科手术适应证的选择与把控

现代外科学技术发展迅速,外科手术方式及治疗理念与日俱新,极大地提高了手术安全性及患者治疗效果。但是,无论外科技术发展到何种程度,正确、合理地选择与把控手术适应证始终是外科学的基本问题,也是外科医师职业生涯中的基本素养。外科医师应当严格把控外科手术适应证,提高理论知识和技术水平,避免不良因素干扰手术决策;敢于实施符合指征...     

Computer assisted analysis of neuroradiological data in planning neurosurgical procedures

A surgical graphic console is presented. It allows the display of multimodal images (CT, MR and digital angiography), and the identification of tridimensional outlines of structures of surgical relevance, within a surgical reference system, together with the trajectory of surgical approach.     

Should a positive surgical margin following radical prostatectomy be pathological stage T2 or T3? Results from the SEARCH database

PURPOSE: The finding of a positive surgical margin associated with extracapsular extension at radical prostatectomy is a poor prognostic factor. However, whether a positive surgical margin with no documented extracapsular extension portends a similarly poor prognosis is unclear. We examined the significance of the pathological features of positive surgical margin and extracapsular extension for predicting biochemical failure following radical prostatectomy. MATERIALS AND METHODS: We examined data on 1,621 men from the SEARCH Database of patients treated with radical prostatectomy without lymph node metastasis. Patients were separated into 5 groups based on the pathological findings of positive surgical margin, extracapsular extension, and/or seminal vesicle invasion. Preoperative clinical variables were compared across the groups and the groups were compared for time to biochemical recurrence using Cox proportional hazards analysis. RESULTS: Men with seminal vesicle invasion had the highest prostate specific antigen (PSA) recurrence rates, while men with a negative surgical margin and no extracapsular extension had the lowest PSA recurrence rates. There were no differences in PSA failure rates between men with a positive surgical margin and no extracapsular extension versus men with a negative surgical margin and extracapsular extension versus men with extracapsular extension and a positive surgical margin. In this subset of patients with a positive surgical margin and/or extracapsular extension but no seminal vesicle invasion only serum PSA was a significant independent predictor of biochemical recurrence. CONCLUSIONS: Men with a positive surgical margin but no extracapsular extension had PSA recurrence rates similar to those in men with extracapsular extension with or without positive margins. Men with extracapsular extension had similar biochemical recurrence rates whether the surgical margin was positive or negative. If confirmed at other institutions, consideration should be given to modifying the current TNM staging system to reflect these findings.     

Resection of rectal cancer: A historical review

Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques and adjuvant therapy. By applying advanced surgical principles, surgeons can now excise most rectal cancers completely, often preserving the anal sphincter and leaving the patient with relatively normal bowel and pelvic function. Historically, the earliest surgical approaches to rectal cancer were via the perineum. As surgical techniques and general anesthesia improved, other approaches such as a posterior approach were undertaken to improve access to the whole rectum. Consequently, abdominoperineal resection became the standard treatment until anterior resection was introduced for proximal rectal cancers. The most important surgical breakthrough in recent years has been the advent of total mesorectal excision (TME). The emphasis in rectal cancer surgery is on preservation of function, with dissection being done in appropriate anatomical planes. Thus, mobilization of the rectum has a long history, and is seen in modern procedures including TME and intersphincter resection. This article reviews the progression of the surgical management of rectal cancer with reference to historical perspectives. We discuss the major surgical considerations for mobilization of the rectum in several surgical procedures, from conventional operations to modern standardized TME.     

A New Methodology for Laboratory Evaluation of Neurosurgical Approaches Based on the Volume and Shape of the Surgical Space with a Mathematical Model to Quantify the Surgical Maneuverability in Laboratory Settings

We conducted this study to validate the volume/shape of the surgical exposure and to introduce a mathematical model to quantify the maneuverability in a surgical space. We executed the pterional and lateral supraorbital approach four times in fresh cadavers in skull base laboratory. The surgical volumes were filled with a computed tomography (CT)-imageable mixture; CT scans were obtained to evaluate the volume and shape of the surgical space. The volume of the surgical space was 23.60 and 32.90 mL for the lateral supraorbital and pterional approach, respectively, (p < 0.05). The three-dimensional shape of the lateral supraorbital approach was cylindrical and that of the pterional approach pyramidal. The volume of the surgical approach can be used to define, together with other variables, the maneuverability (maneuvering in a surgical volume) by using the following formula where M, A, V, and L represent the maneuverability, the degree of the surgical freedom, the volume of the surgical exposure, and the surgical depth, respectively. Volume and shape of the surgical exposure are two objective parameters that can be used to define and contrast different microsurgical approaches in a laboratory setting. The volume of the surgical exposure may be integrated into a mathematical formula defining maneuverability.     

Association of tumor size and surgical approach with oncological outcomes and overall survival in patients with adrenocortical carcinoma

ObjectivesTo investigate the association of surgical approach with outcomes in patients with adrenocortical carcinomas smaller and larger than 6 cm in size.MethodsWe reviewed the national cancer database for patients undergoing minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) from 2010 to 2017. To adjust for differences between patients undergoing MIA and OA, we performed propensity score matching within each size strata of ≤6 cm, 6.1 to 10 cm, and 10.1 to 20 cm. We fit generalized estmiating equations with a logit link function to assess for the association of surgical approach with positive surgical margins and a Cox proportional hazards model to assess for the association of surgical approach with overall survival.ResultsWe identified 364 patients that underwent MIA (182) and OA (182) in the matched cohort.  We noted 21% and 18% of patients undergoing MIA and OA had a positive surgical margin, respectively. We did not identify a significant association between surgical approach and positive surgical margins in the cohort as a whole or within each of strata. Furthermore, we did not appreciate a significant association between surgical approach and overall survival in the cohort as a whole or within each size strata.ConclusionIn the National Cancer Database, patients undergoing MIA had similar positive surgical margins and overall survival compared with OA for masses ≤6 cm, 6.1 to 10cm, and >10 cm in size. Patients undergoing MIA should be carefully selected with surgical oncologic integrity being the primary determinants of surgical approach.     

重症急性胰腺炎外科手术干预时机的探讨

目的 探讨重症急性胰腺炎(SAP)外科手术干预的时机.方法 回顾我院1998年3月～2007年12月收治的157例SAP病例,按胰腺坏死面积及是否感染分级,分别分析外科干预及保守治疗对治愈率的影响.结果 本资料显示:总手术治愈率为80.4%,总非手术治愈率为87.1%,差异无统计学意义.30%的坏死面积者,非手术疗法效佳;50%的坏死面积者,手术疗法效佳;而在30%～50%之间者,手术及非手术疗法疗效无明显差异.胰腺坏死未合并感染组,非手术疗法效佳;町疑感染组及胰腺坏死合并感染组,手术疗法效佳.结论 外科干预在治疗SAP中占有重要地位,应结合胰腺坏死面积及是否感染等具体情况选择外科手术干预的时机.     

Management of rectal prolapse: the role of laparoscopic approaches

Rectal prolapse is a lifestyle-altering disability which has been treated with over 100 surgical options. The specific goals of surgical management of full thickness rectal prolapse are to minimize the operative risk in this typically elderly population, eradicate the external prolapse of the rectum, improve continence, improve bowel function, and reduce the risk of recurrence. The theoretical advantages of a laparoscopic approach are to couple reductions in surgical morbidity and good post-operative outcome. Studies which compare the same laparoscopic and open surgical approach for rectal prolapse have demonstrated that laparoscopy confers benefits related to postoperative pain, length of hospital stay, and return of bowel function. Virtually every type of open transabdominal surgical approach to rectal prolapse has been laparoscopically accomplished. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis, with or without rectopexy. The growing body of literature supports the concept that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with full thickness rectal prolapse.     

足踝Ⅰ类切口手术部位感染的临床分析

目的 探讨并分析足踝Ⅰ类切口手术部位感染的发病率、临床特征、相关因素及病原菌种类,为预防足踝Ⅰ类切口手术部位感染提供依据.方法 回顾性调查西南医科大学附属医院2011年6月-2015年6月行足踝Ⅰ类切口手术的患者,收集分析发生手术部位感染患者的临床资料,对手术部位感染的发病率、临床特征、相关因素及病原菌种类等情况进行研究.结果 761例足踝Ⅰ类切口手术患者中,发生手术部位感染的患者42例,感染发病率为5.5％.不同年龄、不同性别、麻醉方式、是否吸烟、是否酗酒、是否合并风湿性疾病或痛风、切口数量,以及是否为开放伤转归后的Ⅰ类切口等方面,手术部位感染的发病率差异无统计学意义(P＞0.05).糖尿病伴周围神经病变的患者手术部位感染发病率明显高于非糖尿病患者(P＜0.05).手术时间＞3h的患者相较于手术时间≤lh的患者,手术部位感染的发病率明显增高(P＜0.05).术中植入内固定的患者相较于外固定组和无植入组手术部位感染发病率明显增高(P＜0.05).结论 足踝Ⅰ类切口手术部位感染发病率较高,与足部独特的解剖结构密切相关.糖尿病伴周围神经病变,手术时间长,术中植入内固定等可能是其高危因素.     

周围静脉畸形281例手术治疗分析

目的：分析周围静脉畸形的手术治疗经验。方法：1996年12月至2004年4月共手术治疗周围静脉畸形28l例。根据临床观察及磁共振(MRI)检查结果分为局限性非浸润型、局限性浸润型、弥漫性非浸润型及弥漫性浸润型等4型，按不同分类，采用不同的手术方式，如病变切除术、病变手术翻瓣联合Nd：YAG激光治疗术及病变手术切除联合Nd：YAG激光治疗术。结果：经随访3月～7．5年，局限性非浸润型总有效率为98．1％。复发率为1．9％。并发症发生率为1．9％，而弥漫性浸润型总有效率为85．2％，复发率为14．9％，并发症发生率为21．0％。结论：静脉畸形的治疗仍是临床难题之一，根据病变分类采用不同的手术方式是必要的，对于弥漫性病变，手术联合Nd：YAG激光治疗术是一种安全、有效、并发症少的新术式。