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Establishing a curriculum for the acquisition of laparoscopic psychomotor skills in the virtual reality environment

This review published in the American Journal of Surgery aimed to evaluate the usefulness of specific psychomotor skills tasks and metrics, and how trainers might build an effective training curriculum. They find that the vast majority of Virtual Reality psychomotor skills tasks help improve time and motion parameters. In addition, distributed training schedules seem to be better than massed practice. However, it appears important to have a degree of supervision to counter the limitations of VR training. Such information is necessary to establish VR laparoscopic psychomotor skills curricula.

American Journal of Surgery 2012;doi:10.1016/j.amjsurg.2011.11.010



The adoption of advanced surgical techniques: are surgical masterclasses enough?

The aim of this questionnaire based study published in the American Journal of Surgery was to investigate the adoption of surgical techniques after attendance at a surgical master class.  They found that there was a significant adoption of colorectal procedures, from 33% to 79% and bariatric procedures, from 27% to 66% after attendance at the surgical master classes. This is the first study to demonstrate the effectiveness of the master class in terms of surgeons' adopting new techniques. However, this study does not investigate the patient safety related issues associated with adoption of such advanced surgical techniques.

American Journal of Surgery 2012;204(1):110-114



Development and Validation of a Comprehensive Curriculum to Teach an Advanced Minimally Invasive Procedure: A Randomized Controlled Trial

This prospective, single-blinded randomized controlled study published in the Annals of Surgery aimed to develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. The developed curriculum consisted of proficiency-based psychomotor training on a virtual reality simulator, cognitive training, and participation in a cadaver lab. The primary outcome measure in this study was surgical performance in the operating room. Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents; scored higher on the multiple-choice test and outperformed conventionally trained residents in 7 of 8 tasks on the simulator.

Annals of Surgery 2012;doi: 10.1097/SLA.0b013e318258f5aa






A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trial

This prospective single-blinded randomized trial published in the Annals of Surgery compared the effectiveness and cost of 2 ex vivo training curricula for laparoscopic suturing. Surgical residents were trained using either a virtual reality (VR) simulator or box trainer. All residents then placed intracorporeal laparoscopic stitches and technical proficiency was assessed. The performance of both groups was compared to that of conventionally trained residents and to fellowship-trained surgeons. After ex vivo training, no significant differences in laparoscopic suturing were found between the 2 groups with respect to time, global rating score or checklist score. Conventionally trained residents took 6 practice attempts to achieve the technical proficiency of the ex vivo trained groups. VR training was more efficient than box training (transfer effectiveness ratio of 2.31 vs 1.13). The annual cost of training 5 residents on the box trainer was $11,975.00, on the VR simulator was $77,500.00, and conventional residency training was $17,380.00. Training on either a VR simulator or on a box trainer significantly decreased the learning curve necessary to learn laparoscopic suturing. VR training, however, is the more efficient training modality, whereas box training is the more cost-effective option.

Annals of Surgery 2012;255(5):833–839



Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of inguinal hernia: a systematic review and meta-analysis

This meta-analysis published in Surgical Endoscopy aimed to compare mesh fixation using a fibrin sealant versus staple fixation in laparoscopic inguinal hernia and compare outcomes for hernia recurrence and chronic inguinal pain. Four studies were included in the review with a total of 662 repairs included, of which 394 were mesh fixed by staples or tacks, versus 268 with mesh fixed by fibrin glue. There was no difference in inguinal hernia recurrence with fixation of mesh by staples/tacks versus fibrin glue [OR 2.13; 95% CI 0.60-7.63]. Chronic inguinal pain (at 3 months) incidence was significantly higher with staple/tack fixation (OR 3.25; 95% CI 1.62-6.49). There was no significant difference in operative time, seroma formation, hospital stay, or time to return to normal activities. This meta-analysis does not show an advantage of staple fixation of mesh over fibrin glue fixation in laparoscopic total extraperitoneal inguinal hernia repair. As fibrin glue mesh fixation achieves similar hernia recurrence rates, but a decreased incidence of chronic inguinal pain, it may be the preferred technique.

Surgical Endoscopy 2012;26(5):1269-1278



A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia

A consensus on the outcomes of laparoscopic inguinal hernia repair (LIHR) when compared with open inguinal hernia repair OIHR for primary, unilateral, inguinal hernia has not been reached. This study in the Annals of Surgery performed a meta-analysis of all randomized controlled trials (RCTs) comparing OIHR and LIHR for primary unilateral inguinal hernia. Data were retrieved from 27 RCTs describing 7161 patients. An increased risk in hernia recurrence existed when LIHR was compared with OIHR (RR = 2.06, 95% CI = 1.26-3.37, P = 0.004). Transabdominal preperitoneal (TAPP) had equivalent recurrence but totally extraperitoneal (TEP) had increased risk of recurrence (RR = 3.72, 95% CI = 1.66-8.35, P = 0.001) relative to OIHR. LIHR was associated with a greater perioperative complication risk than OIHR (RR = 1.22, 95% CI = 1.04-1.42, P = 0.015). TAPP but not TEP was associated with this increased complication risk. LIHR was associated with reduced risk of chronic pain (RR = 0.66, 95% CI = 0.51-0.87, P = 0.003) and chronic numbness (RR = 0.27, 95% CI = 0.12-0.58, P < 0.001) relative to OIHR. For primary unilateral inguinal hernia, TEP is associated with an increased risk of recurrence. TAPP is associated with increased risk of perioperative complications. LIHR has a reduced risk of chronic pain and numbness relative to OIHR.

Annals of Surgery 2012;255(5):846–853


Laparoscopic vs Open Appendectomy in Obese Patients: Outcomes Using the American College of Surgeons National Surgical Quality Improvement Program Database

This study in the Journal of the American College of Surgeons compared short-term outcomes in obese patients after laparoscopic vs open appendectomy using the American College of Surgeons National Surgical Quality Improvement Program database. 13,330 obese patients (body mass index ≥30) who underwent an appendectomy were identified The association between surgical approach (laparoscopic vs open) and outcomes was evaluated using multivariable logistic regression. Laparoscopic appendectomy was associated with a 57% reduction in overall morbidity in all the obese patients after the multivariable risk-adjusted analysis (odds ratio = 0.43; 95% CI, 0.36-0.52; p < 0.0001). Mortality rates were the same. In obese patients, laparoscopicappendectomy had superior clinical outcomes compared with open appendectomy after accounting for preoperative risk factors.

Journal of the American College of Surgeons 2012; Doi:10.1016/j.jamcollsurg.2012.03.012


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