What is the definition of “conversion” in laparoscopic colorectal surgery?

Background

A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery.

Methods

Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s).

Results

325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5–12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case.

Conclusions

It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.     

Beta-blockers in vascular surgery patients: is the debate still going on?

Patients undergoing vascular surgery are under increased risk for perioperative myocardial ischemia and cardiovascular complications, and optimal medical treatment is therefore imperative for these patients. Beta-blockade has been introduced as a cornerstone of optimal management, and standardized preoperative initiation has been recommended in the past. However, recent pooled data have questioned prior recommendations and have led to revision of international guidelines. This review aims to highlight the debate on perioperative beta-blockade for vascular surgery patients in order to produce useful conclusions for everyday clinical practice.     

Can skills assessment on a virtual reality trainer predict a surgical trainee’s talent in laparoscopic surgery?

Background A number of studies have investigated several aspects of feasibility and validity of performance assessments with virtual reality surgical simulators. However, the validity of performance assessments is limited by the reliability of such measurements, and some issues of reliability still need to be addressed. This study aimed to evaluate the hypothesis that test subjects show logarithmic performance curves on repetitive trials for a component task of laparoscopic cholecystectomy on a virtual reality simulator, and that interindividual differences in performance after considerable training are significant. According to kinesiologic theory, logarithmic performance curves are expected and an individual’s learning capacity for a specific task can be extrapolated, allowing quantification of a person’s innate ability to develop task-specific skills. Methods In this study, 20 medical students at the University of Basel Medical School performed five trials of a standardized task on the LS 500 virtual reality simulator for laparoscopic surgery. Task completion time, number of errors, economy of instrument movements, and maximum speed of instrument movements were measured. Results The hypothesis was confirmed by the fact that the performance curves for some of the simulator measurements were very close to logarithmic curves, and there were significant interindividual differences in performance at the end of the repetitive trials. Conclusions Assessment of perceptual motor skills and the innate ability of an individual with no prior experience in laparoscopic surgery to develop such skills using the LS 500 VR surgical simulator is feasible and reliable.     

Stereoscopic augmented reality for da Vincii™ robotic biliary surgery

INTRODUCTIONNew laparoscopic techniques put distance between the surgeon and his patient.PRESENTATION OF CASE3D volume rendered images directly displayed in the da Vinci surgeon's console fill this gap by allowing the surgeon to fully immerse in its intervention.DISCUSSIONDuring the robotic operation the surgeon has a greater control on the procedure because he can stay more focused not being obliged to turn is sight out of his operative field. Moreover, thanks to depth perception of the rendered images he had a precise view of important anatomical structures.CONCLUSIONWe describe our preliminary experience in the quest of computer-assisted robotic surgery.     

Preconditioning in laparoscopic surgery—results of a virtual reality pilot study

Background

This prospective study investigated the effect of preconditioning in laparoscopic cholecystectomy (LC) and appendectomy (LA) based on pre- and postoperative virtual reality laparoscopy (VRL) performances, with specific regard to the impact of different motor skills, types of surgery and levels of experience.

Study design

Forty laparoscopic procedures (28 LC and 12 LA) were performed by 13 residents in the operating room. Participants completed a defined set of tasks on the VRL simulator directly prior to and after the operation: one preparational task (PT), a virtual procedural task with emphasis on fine preparation (VPT) and a navigational manoeuvre for instrument coordination (ICT). VRL performances were evaluated based on the assessed items of the simulator.

Results

Overall analysis of the surgeons’ performance demonstrated better postoperative results for PT and VPT in 28 and 26 cases (p?=?0.001 and p?=?0.034), respectively. No significant difference was found for ICT (p?=?0.638). Less-experienced residents had better postoperative results for PT and VPT (p?=?0.009 and p?=?0.041), whereas more-experienced surgeons had better postoperative results for PT only (p?=?0.030). LC resulted in better postoperative performance for PT (p?=?0.007). LA improved performance for PT and VPT (p?=?0.034 and p?=?0.006, respectively). Comparisons of surgeon’s experience demonstrated a significant advantage for more-experienced surgeons in ICT (p?=?0.033), while type of surgery showed an advantage for LA in VPT (p?=?0.022).

Conclusion

There is a preconditioning effect in laparoscopic surgery. The differing results related to LC and LA and the experience levels of surgeons suggest that differentiated warm-up strategies are required.     

What is the optimal time for laparoscopic cholecystectomy in gallbladder empyema?

Purpose

With the accumulating experience in laparoscopic surgery, early laparoscopic cholecystectomy (LC) is increasingly offered for acute cholecystitis. However, early LC without percutaneous transhepatic gallbladder drainage (PTGBD) for gallbladder empyema is still believed to be unsafe. The purpose of this study was to determine the optimal time for LC in gallbladder empyema.

Methods

A retrospective analysis was carried out of patients who underwent LC without PTGBD for gallbladder empyema between August 2007 and December 2010. All cases were confirmed by biopsy. The patients were divided into two groups on the basis of a cutoff of 72 h.

Results

LC for gallbladder empyema was performed without PTGBD in 61 patients during the study period. The overall conversion rate was 6.6 %. Based on the 72 h cutoff, there were 33 patients in the early group and 28 in the delayed group. There were no significant differences between early and late patients with respect to operation duration (75.5 vs. 71.4 min, p = 0.537), postoperative hospital stay (4.2 vs. 3.3 days, p = 0.109), conversion rate (12.1 vs. 0 %, p = 0.118), and complication rate (12.1 vs. 3.6 %, p = 0.363). However, the early group had a significantly shorter total hospital stay (5.3 vs. 8.7 days, p = 0.001).

Conclusions

Early LC without PTGBD is safe and feasible for gallbladder empyema and is associated with a low conversion rate. Delayed LC for gallbladder empyema has no advantages and results in longer total hospital stays. LC should be performed as soon as possible within 72 h after admission to decrease length of hospital stay.     

What are the results of laparoscopic re-operative rectal surgery?

IntroductionReoperative rectal surgery is challenging, performed selectively by experienced colorectal surgeons. The minimally invasive approach has not been well defined. This study reviewed the results of laparoscopy in this challenging setting.MethodsRetrospective analysis of patients who underwent trans-abdominal re-operative rectal surgery from 2010 to 2019 was performed.ResultsSeventy-eight patients [35 females (45%); BMI 25kg/m2) were included. Reasons for reoperation were recurrent cancer in 18 (43%) patients and anastomotic failure in 57 (73%). Twenty-two (28%) had laparoscopic surgery and 4 had attempted laparoscopy converted to laparotomy. A higher success rate was noted for laparoscopy with prior laparoscopic surgery. Benefits of laparoscopy included significant reduction in length of stay (6.7 vs 9.7 days, p = 0.012) and abdominal superficial surgical site infection (0% vs 25%, p < 0.001) and higher rate of achieving bowel continuity compared to laparotomy (77% vs 50%, p = 0.021)ConclusionsReoperative laparoscopic rectal surgery is safe and feasible in the context of a high-volume laparoscopic surgeon with substantial experience in redo proctectomies. It offers clear benefits including decreased surgical site infection rates and length of stay.