P072 ARTICULATED LAPAROSCOPIC INSTRUMENTS. BENEFITS ON LAPAROSCOPIC HERNIOPLASTY

Aim To present initial experience using 5 mm articulated laparoscopic instruments in tapp laparoscopic hernioplasty that emulated the benefits attributed to robotic surgery. Material and Methods We report data from the first 42 procedures using 5 mm articulating instruments. A retrospective analysis was performed in patients who underwent tapp laparoscopic hernioplasty using novel articulated graspers, needle holders, and scissors. The surgeons and surgical nurses were trained in the handling and operation of the articulating instruments, before the first surgical procedure. In all cases, articulating instruments were inserted through 5 mm trocars. Data collected included patient demographics, details related to the surgical procedure, postoperative outcomes, and complications. Results Over a period of one month, were repaired 78 inguinal hernias. 36 patients had a bilateral hernia, and the mean age was 45 years (SD 15.1), with a mean BMI of 28.6 (SD 6.1). 32 male and 4 female patients. The mean operative time was 90 min. The articulated head of the clamp allowed traction, dissection, and suture in different directions. In addition, was not detected a significant learning curve due to its intuitive applicability. Surgical complications included two serohematomas. All patients discharge during operation day. The procedures performing without intraoperative complications nor conversion to open surgery occurred. Conclusions The use of an articulated instrument has a promising future. It would meet some benefits of robotics without increasing costs. We need randomized comparative studies for a better conclusion.

Environmental impact and life cycle financial cost of hybrid (reusable/single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy

Background Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. The environmental and financial costs of such instruments have not previously been evaluated. Methods We used Life Cycle Assessment to evaluate the environmental impact of hybrid laparoscopic clip appliers, scissors, and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro and ReCiPe midpoint and endpoint methods to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis of products, taking into account unit cost, decontamination, and disposal costs. Results The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%. The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1756 g vs 7194 g CO2e per operation) and saved an estimated 1.13 e−5 DALYs (disability adjusted life years, 74% reduction), 2.37 e−8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated that environmental performance of hybrid instruments was better even if there was low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel-rich energy sources, or changing carbon intensity of instrument transportation. Total financial cost of using a combination of hybrid laparoscopic instruments was less than half that of single-use equivalents (GBP £131 vs £282). Conclusion Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery and also save money.

Intravesical repair of vesicovaginal fistula guided by cystoscopy

Background: Vesicovaginal fistulas (VVF) are an unusual problem that may significantly affect a patient’s quality of life. The main causes for this condition are labour complications (mostly in developing countries) and pelvic surgeries (in industrialised countries). Treatment may be conservative or surgical. Regarding surgical treatment, there is still debate about the best approach and surgical technique. Objective: To demonstrate a correction of a VVF guided by cystoscopy using intravesical laparoscopic instruments. Methods: Case report and surgical video of a recurrent VVF treated with a hybrid technique involving direct transvesical insertion of 3 mm laparoscopic trocars and instruments guided by cystoscopy. As far as we know, although there are some reported techniques that use a combination of transvesical laparoscopic instruments and cystoscopy, this is the least invasive and most ergonomic technique described. Results: Two years after surgery, the patient remains asymptomatic and with no fistula recurrence. Conclusion: The transvesical approach guided by cystoscopy seems to be an effective, safe and ergonomic minimally invasive procedure for VVF repair.

“LAPAROSCOPIC INTRAGASTRIC EXCISION OF POSTERIORLY LOCATED GASTRIC GIST USING CONVENTIONAL LAPAROSCOPIC INSTRUMENTS – A CASE REPORT”

Background: Gastro-intestinal stromal tumour (GIST) commonly involves stomach. Recently there has been an inclination towards managing these benign but potentially malignant lesions by minimal invasive techniques. Surgical excision of gastric GIST mostly requires anterior wall gastrostomy especially for intraluminal lesions. The size and location of the lesion are critical from technical point of view. Lesions located at gastro-esophageal junction requires larger anterior gastric wall opening to reach the site of tumour for excision. Endoscopic excision for such lesions is not always amenable. We performed excision of a posteriorly locat Methods: ed gastric GIST at GE junction by hitching the anterior gastric wall with the anterior abdominal wall and by directly creating pneumogastrium percutaneously for placing three intra-gastric trocars. Results: Patient was discharged on post-operative day 3 in a satisfactory condition. Histopathology revealed complete resection of GIST lesion with margins free from tumour. Immuno-histochemistry (IHC) conrmed it to be GIST with low malignant potential and patient was advised regular follow up. Laparoscopic intra-gastric excision of a posteriorly located gast Conclusion: ro-oesophageal junction GIST lesion after creating pneumogastrium and using conventional laparoscopic instruments is a safe procedure

Creation of a High Fidelity, Cost Effective, Real World Surgical Simulation for Surgical Education

Background How do surgical residents learn to operate? What is a surgical plane? How does one learn to see and dissect the plane? How do surgical residents learn tissue handling and suturing (sewing)? One method to learn and practice performing surgery is through the use of simulation training. Surgical training models include laparoscopic box trainers (a plastic box with holes for instruments) with synthetic materials inside to simulate tissues, or computer-based virtual reality simulation for laparoscopic, endoscopic, and robotic techniques. These methods, however, do not use real tissues. They lack the haptic and kinesthetic feedback of real tissue. These simulations fail to recreate the fidelity of soft tissues, do not foster the ability to accurately see surgical planes, do not accurately mimic the act of dissecting surgical planes, do not allow for complex surgical procedures, and do not provide accurate experience to learn tissue handling and suturing. Despite their poor performance, these plastic and virtual trainers are extremely costly to purchase, maintain, and keep up to date - with prices starting at $700 for basic plastic training boxes to thousands of dollars for virtual simulation. Also, there are additional costs of maintenance and software curriculum. Despite the cost of software, virtual simulators do not include a simulation for every surgery. Our aim was to create a life-like surgical simulation as close to real world as possible that allows trainees to learn how to see and dissect surgical planes, learn how soft tissues move, and learn the dynamics of soft tissue manipulation. We created a laparoscopic simulator using porcine tissues for gallbladder removal, acid reflux surgery, and surgery to treat swallowing difficulties (cholecystectomy, Nissen fundoplication, and Heller myotomy, respectively). Second year general surgery residents were able to practice these procedures on real tissues, enabling them to learn the steps of each procedure, increase manual dexterity, improve use of laparoscopic equipment, all while maintaining life-like haptic, soft-tissue feedback and enabling them to develop the ability to see real surgical planes. Methods The abdomen was recreated by purchasing intact porcine liver, gallbladder, (Cholecystectomy simulation) and intact esophagus, stomach, and diaphragm (Nissen and Heller simulation) from a packing supplier. Each organ system was placed into a laparoscopic trainer box with the ability to re-create laparoscopic ports. Surgical residents were then able to perform the procedures using real laparoscopic instruments, laparoscopic camera/video imaging, and real-time electrocautery. The simulation included all critical steps of each procedure such as obtaining the critical view of safety and removing the gallbladder from the liver bed (cholecystectomy), wrapping the stomach around the esophagus and laparoscopic suturing (Nissen fundoplication), and dissecting the muscular portion of the esophageal wall (Heller myotomy). Because these porcine tissues were readily available, several stations were set-up to teach multiple residents during each session (10-12 residents / session). Discussion Surgeons develop haptic perception of soft tissues by cutaneous or tactile feedback and kinesthetic feedback (Okamura, 2009). Kinesthetic feedback is the force and pressure transmitted by the soft tissues along the shaft of the laparoscopic instruments (Okamura, 2009). This soft tissue simulation re-creates the ability to experience what soft tissue feedback feels like, outside a normal operative environment. Real tissue learning allows trainees to learn how to see surgical planes, learn how soft tissues feel and move, develop proficiency in surgical dissection, and learn how to suture laparoscopically. This is the only model that recreates the movement of soft tissues and visualization of dissection planes outside the operative environment. Because this model utilizes the laparoscopic instruments used in the operating room, residents also develop familiarity with laparoscopic instruments, thus, flattening another learning curve. A literature review found that this is the only real tissue simulation being performed for foregut procedures used specifically for resident training. By building a realistic, anatomical model with inherent accurate soft tissue surgical planes, surgical trainees can have a more realistic surgical experience and develop skills in a safe, low pressure environment without sacrificing the hepatic learning and surgical visualization that is critical to performing safe laparoscopic surgery. All residents that participated in the stimulation reported positive feedback and felt that is contributed to their surgical education.