New Technologies for the Surgical Curriculum

The aim of a surgical residency program is to produce competent professionals displaying the cognitive, technical, and personal skills required to meet the needs of society. Current changes to the delivery of healthcare necessitate the development of new models of training. These can be supported with the development of new technologies to train and assess surgical practitioners. This article describes recent developments within Imperial College London with regard to eye tracking, noninvasive brain imaging, and an innovative mentoring scheme for the new surgical curriculum. The concept of eye tracking is described, together with surgical application for this technique in terms of dexterity analysis during minimally invasive procedures. We have also begun to understand spatial localization within the brain cortex during surgical knot-tying tasks. The aim is to develop a map of the cortex with regard to surgical novices and experienced surgeons and then to develop the hypothesis that a translational process of cortical plasticity occurs during training. Finally, the article is intended to describe a training scheme that goes beyond dexterity, and moves toward the development of a successful surgeon through surgical mentoring. It is hoped that some of these tools will enhance the training of future surgeons in order to continue to provide a high-quality service to our patients.     

Planned cesarean section versus planned vaginal delivery: comparison of lower urinary tract symptoms

We compared the prevalence and risk of lower urinary tract symptoms in healthy primiparous women in relation to vaginal birth or elective cesarean section 9 months after delivery. We performed a prospective controlled cohort study including 220 women delivered by elective cesarean section and 215 by vaginal birth. All subjects received an identical questionnaire on lower urinary tract symptoms in late pregnancy, at 3 and 9 months postpartum. Two hundred twenty subjects underwent elective cesarean section, and 215 subjects underwent vaginal delivery. After childbirth, the 3-month questionnaire was completed by 389/435 subjects (89%) and the 9-month questionnaire by 376/435 subjects (86%). In the vaginal delivery cohort, all lower urinary tract symptoms increased significantly at 9 months follow-up. When compared to cesarean section, the prevalence of stress urinary incontinence (SUI) after vaginal delivery was significantly increased both at 3 (p < 0.001) and 9 months (p = 0.001) follow-up. In a multivariable risk model, vaginal delivery was the only obstetrical predictor for SUI [relative risk (RR) 8.9, 95% confidence interval (CI) 1.9–42] and for urinary urgency (RR 7.3 95% CI 1.7–32) at 9 months follow-up. A history of SUI before pregnancy (OR 5.2, 95% CI 1.5–19) and at 3 months follow-up (OR 3.9, 95% CI 1.7–8.5) were independent predictors for SUI at 9 months follow-up. Vaginal delivery is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective cesarean section.     

Physician attitudes to the concept of ‘men''s health’ in Asia

BackgroundMen's health is an emerging medical and public health concept, but it is confronted by special challenges in the Asia-Pacific medical and cultural context.MethodsA telephone survey was conducted with physicians in Korea, Taiwan and Singapore. The interview was conducted in Korean (Korea), Mandarin (Taiwan) or English (Singapore) by trained interviewers. The physicians interviewed were drawn from a variety of medical specialties including urology, primary care, endocrinology and cardiology.ResultsIn total, 810 physicians from various medical specialities took part in the survey. There was only broad general agreement (>50%) between the physicians in the various countries on a range of questions relating to men's health, such as the conditions most associated with men's health, the predictability of illness/disability with age etc, and physician willingness to discuss problems in sexual health.ConclusionsThe data from this survey suggest that, although not as clearly defined as women's health, the treatment of men's health cuts across many different medical specialties and takes in a broad spectrum of health conditions. Therefore, there is a clear opportunity for the medical community to define, refine and improve the treatment and understanding of men's health in Asia.     

Use of resorbable collagen dural substitutes in the presence of cranial and spinal infections-report of 3 cases

BACKGROUND: Various allografts, xenografts, and synthetic materials are used in neurosurgery to repair dural defects when primary suture closure is impossible and autologous grafts are inadequate or inaccessible. When used in contaminated or infected wounds, however, nonautologous grafts promote chronic colonization and recurring infection. Recently, several resorbable dural substitutes that are broken down biologically and replaced by autologous tissues have been introduced. These include type 1 collagen matrix (DuraGen, Integra LifeSciences, Plainsboro, NJ) and a collagen implant derived from bovine skin (Durepair, Medtronic, Inc, Minneapolis, Minn), which can be applied as sutured or sutureless onlay grafts. The safety and efficacy of this material has not been reported in the setting of wound contamination or infection. CASE DESCRIPTIONS: We present 3 cases in which these new collagen dural substitutes were successfully used to close dural defects in the presence of wound contamination and infection. In one case, a lumbar dural defect was closed with DuraGen in the presence of a subdural empyema. In the second case, maceration of the cranial dura mater from extensive compound depressed skull fractures was repaired with DuraGen in the presence of a subgaleal abscess. In the third case, a large dural defect in the setting of frontal osteomyelitis was successfully closed with sutured Durepair. In all cases appropriate antibiotic coverage was provided for the infection, and the tissues healed with excellent biologic incorporation and without evidence of further infection. CONCLUSIONS: Resorbable collagen dural grafts appear to be effective alternatives to either primary dural closure or the use of autologous-harvested tissue grafts in the setting of grossly contaminated or infected wounds.     

Avoiding the operated on look in multiple face lifts

SUMMARY AIM: Reviewing 43 patients of ours who have had three or more face lifts, we wanted to demonstrate that it is possible to avoid the multi-operated on look. MATERIAL AND METHODS: Forty-three patients have been operated on three times or more: 42 females and one male. Thirty-six patients had three face lifts, six had four face lifts, one patient had five face lifts. The mean age at time of surgery was 50.3 years for the first face lift, 56.7 for the second, and 64.2 for the third face lift. These patients were operated on by the same surgeon using a technique which has evolved over the years but with the same basic goal of hiding the scars and of minimising hairline displacement. General appearance, scars and hairline displacement were evaluated in patients who had had three or more face lifts. RESULTS: The results of the evaluation of our 43 multi-operated on face lift patients were as follows: 35 patients did not appear to have had face lifts, eight patients did appear to have had face lifts, but with satisfactory appearance, 30 patients had no visible scars at a conversational distance, 10 patients had slightly visible scars when their hair was lifted, five had obvious scars when the hair was lifted, 34 patients had a normal hairline, six patients had a slightly receding hairline at the temporal level and three had hair loss at the level of the temporal scar. CONCLUSIONS: New technical improvements allow the preservation of a natural appearance, with well-hidden scars and a well-placed hairline. The common opinion that several repeated face lifts should be avoided because they give an unnatural appearance and severe sequelae in terms of scars and hairline displacement has not been confirmed by our clinical experience with 43 patients having undergone at least three face lifts.     

Preserved vision without growth retardation after laparoscopic Roux-en-Y gastric bypass in a morbidly obese child with pseudotumor cerebri: 36-month follow-up

A 12-year-old boy presented with a weight of 136 kg and a history of progressive vision loss associated with unremitting pseudotumor cerebri requiring bilateral optic nerve sheath decompression. He underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) without complication. At 36 months post-RYGBP, he has grown 5 cm since the time of surgery, his weight is 6.8 kg above his postoperative nadir weight of 68.2 kg, and his visual acuity has improved with OD 20/100 (preoperative, 20/200) and OS 20/70 (preoperative, 20/100). This case suggests that RYGBP can be performed safely and without stopping linear growth in carefully selected children.     

Laparoscopic Sleeve Gastrectomy without an Over-Sewing of the Staple Line

Background  In the past few years, laparoscopic sleeve gastrectomy (LSG) became a widely used bariatric method. Based on results of recent LSG studies, LSG is being increasingly used even as a single bariatric method. On contrary with some other reports, we do not reinforce the LSG staple line with over-sewing. Our pilot study presents treatment outcomes and results 18 months after LSG. Methods  Sixty-one consecutive morbidly obese (MO) patients (19 male and 42 female) who underwent LSG from January 2006 to May 2008 were included into the study. The mean age, height, and weight were 37.3 years (29–57), 168 cm (151–187), and 118 kg (97–181), respectively, while mean body mass index (BMI) was 41.8 (36.1–60.4). LSG started at 6 cm from pylorus and ended at the angle of Hiss. For gastric sleeve calibration 38F, intragastric tube was used. All 61 LSG were performed without over-sewing of the staple line. In the last 24 cases, the staple line was covered with Surgicel™ strips, which were however placed without any fixation to the underlying gastric tissue. Results  Mean operating time was 105 min (80–170) and no conversion to open surgery. An 18-month follow-up was recorded in 39 MO patients. The mean weight loss was 31.3 (range, 21–67 kg) and mean % excess BMI loss reached 72% (range, 64–97%). Neither leak nor disruptions of the staple line and/or sleeve dilatation were recorded. Conclusion  LSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience.     

Open vs laparoscopic repair of congenital duodenal obstructions: a concurrent series

Objective

The advantages of using laparoscopy for repair of congenital duodenal obstructions (CDO) are unclear because of scant data about complications and outcomes. Nitinol U-clips (Medtronic Surgical, Minneapolis, Minn) were developed to assist in the creation of vascular anastomoses in small vessels. Because of their ability to approximate tissue tightly with little tissue damage, we have begun to use these U-clips for laparoscopic repair of CDO. In this report, we investigate the impact of laparoscopic U-clip repair of CDO compared to the traditional open repair.

Methods

With institutional review board approval, a retrospective analysis of all patients undergoing repair of CDO from January 2003 to July 2007 was performed. During this study period, patients who underwent open repair of CDO (group 1) were compared with patients that underwent laparoscopic repair using the U-clip technique (group 2).

Results

Twenty-nine patients underwent repair of CDO. Fourteen patients (11 atresia, 3 stenosis) were in group 1 and 15 patients (11 atresia, 4 stenosis) in group 2. A female sex bias existed in group 1 (female-male [9:5]) compared to group 2 (female-male [7:8]). There was no difference in birth weight, age at operation, chromosomal anomalies, or congenital heart disease between the groups. There were no duodenal anastomotic leaks in either group. Operative times were similar between groups (96 vs 126 minutes; P = .06). The length of postoperative hospitalization (20.1 vs 12.9 days; P = .01), time to initial feeding (11.3 vs 5.4 days; P = .002), and time to full oral intake (16.9 vs 9 days; P = .007) were all statistically shorter in group 2.

Conclusions

The laparoscopic approach to CDO repair using U-clips is safe and efficacious. In addition, patients undergoing laparoscopic repair of CDO had a shorter length of hospitalization and more rapid advancement to full feeding compared to babies undergoing the open approach. We feel that in the hands of experienced laparoscopic surgeons, the preferred technique for correction of CDO will become the laparoscopic U-clip repair.     

Closed gastroschisis: total parenteral nutrition-free survival with aggressive attempts at bowel preservation and intestinal adaptation

Background

In infants with gastroschisis antenatal closure of the umbilical defect results in a proximal atresia with ischemia and/or volvulus of the extracorporeal midgut. It has been described as “closed gastroschisis” or “vanishing midgut.”

Methods

A 10-year review of 219 gastroschisis patients identified 10 infants with this rare complication.

Results

In these 10 infants, the extracorporeal midgut was invariably matted and fibrosed. In 3 cases, the midgut had completely “vanished.” In the remaining 7 cases, the remnant midgut was surgically reduced into the abdominal cavity with care not to compromise the diminutive vascular pedicle. Abdominal exploration was performed several weeks later to reestablish bowel continuity; 4 required an ostomy and 2 underwent a serial transverse enteroplasty. Mean residual length of salvaged small bowel was 79 cm with retention of the distal half of the colon. Eight infants survived the initial hospitalization, with a mean length of stay of 121 days and mean hospital charge of $287,094. Six of the 7 long-term survivors have been completely weaned off total parenteral nutrition.

Conclusion

A nihilistic attitude toward infants with closed gastroschisis may not be uniformly supported because in the majority of these infants' long-term independence from total parenteral nutrition was achieved.