Three Port Laparoscopic Cholecystectomy by a Modified Technique

Introduction:Since the introduction of laparoscopic cholecystectomy (LC) several modifications have been introduced to its procedure. Main aim of these modifications is to improve cosmesis & reduce pain. Several institutes are routinely performing conventional 3 ports laparoscopic. In modified 3 ports LC, the third port was moved from right hypochondrium to umbilicus, to conceal it in the umbilical scar, thereby giving the three port comfort to the surgeon and two port benefits to the patient. Methods: This observational study was conducted in the Department of Surgery of Shaheed Suhrawardy Medical College & Hospital from September 2015 to October 2016. After taking valid consent a total 45 patients were selected for modified 3 ports LC. Here we tried to see the safety and benefit of this modified technique by assessing operating time, intra-operative complications, open conversion rate, postoperative wound infection, post-operative hospital stay, pain score and satisfaction with cosmetic outcome. Results: 3 patients were excluded from study due to different reasons. So, among total 42 (N) patients 30 (71.4%) were female & 12 (28.6%) were male. Operative time was 58.48 ± 32.52 minutes (range 34 to 180 minutes). 2 patients required conversion to open surgery. Pain score was 2.07 ±1.71 and cosmetic score was 8.67 ± 1.99. Conclusion: Modified 3 port laparoscopic cholecystectomy can be performed safely with a higher cosmetic satisfaction in selected cases by expert surgeon. J Shaheed Suhrawardy Med Coll 2020; 12(2): 90-94

Obstetric hysterectomy: a retrospective study

Background: Obstetric hysterectomy (OH) is last resort usually opted to save life of a mother in critical obstetric conditions compromising her reproductive potential. With increasing caesarean deliveries incidence of morbidly adhered placenta is increasing, thus increasing need of OH. We aimed to study socio-demographic factors, incidence, indications, complications and feto-maternal outcomes associated with obstetric hysterectomy. Also, we aimed to study factors which affect the maternal and fetal outcome in obstetric hysterectomy case so as to minimize maternal and neonatal mortality and morbidity.Methods: We conducted a retrospective analytical study of 2 years 6 months in Department of Obstetrics and Gynecology at a tertiary and teaching institute of western Maharashtra.Results: The incidence of obstetric hysterectomy was 0.4%. Majority of women were between 25-35 years age group and parity two or more. Most common indication was postpartum haemorrhage (PPH) (41.1%) followed by uterine rupture (29.4%) and adhered placenta (23.5%). Most common risk factor found was previous caesarean delivery. Most common complication was need of intensive care unit (ICU) and vasopressor support.Conclusions: Proper antenatal care, screening for high-risk obstetric cases and registration of those patients at a well-equipped hospital and early referral and delivery at tertiary hospital by expert surgeon with timely decision, timely and adequate transfusions can prevent maternal and fetal complications.

Surgical repair of Vesico-Vaginal: Vaginal route versus abdominal route.

Objective: To determine outcomes and complications of vesico-vaginal fistula repair via vaginal and abdominal route. Study Design: Cross Sectional study. Setting: Department of Urology and Kidney Transplantation, Pir Abdul Qadir Institute of Medical Sciences Gambat. Period: January 2020 to December 2020. Material & Methods: Patients having vesicovaginal fistula irrespective of age and fulfilling our inclusion criteria were included in the study using non-probability consecutive sampling technique. Patients having very large fistula, fistula involving neck of urinary bladder, failure of previous operation, patients with malignancy or co-morbidities were excluded from the study. Vaginal and abdominal approaches were used for fistula repair depending upon the level of fistula. Those operated via vaginal route were kept in trans-vaginal group and those operated via abdominal route were assigned trans-abdominal group. Results: Total 35 cases were studied having age 16-45 years with mean age of 32.6 ± 4.2 years. Transvaginal fistula repair was done in 37.1% and transabdominal repair was done in 62.8% cases. Most common cause of VVF was previous gynecological surgery in 77% cases. Success rate was 100% in transvaginal fistula repair as compared to 95.4% success rate achieved in transabdominal repair of fistula. Conclusion: Trans abdominal and transvaginal route both are good approaches but Transvaginal route of fistula repair is associated with high success rate than transabdominal route with minimum complications and better outcomes but it needs expert surgeon.

Step-by-step illustrated guide to central neck dissection

Background The incidence of thyroid carcinoma has been increasing worldwide and surgery is the primary treatment. Central compartment dissection of the neck is a very delicate procedure given the risks of recurrent laryngeal nerve injury and hypoparathyroidism. Methods This paper gives a detailed description of this surgical technique in a patient affected by papillary carcinoma of the thyroid gland, supported by highly representative iconographic materials from a tertiary department. Results A stepwise description is provided, along with high-quality pictures and specific tips and tricks. Although neck dissection is a well-codified procedure, the fine details of this surgical technique are not currently available and are still the prerogative of the expert surgeon. Conclusion The central neck compartment contains several vulnerable structures; damage to these structures would affect patients’ lives, possibly permanently. Anatomical knowledge and standardisation are needed for all surgeons, particularly new surgeons (such as residents) who cannot rely simply on experience.

Applications of Haptic Technology, Virtual Reality, and Artificial Intelligence in Medical Training During the COVID-19 Pandemic

This paper examines how haptic technology, virtual reality, and artificial intelligence help to reduce the physical contact in medical training during the COVID-19 Pandemic. Notably, any mistake made by the trainees during the education process might lead to undesired complications for the patient. Therefore, training of the medical skills to the trainees have always been a challenging issue for the expert surgeons, and this is even more challenging in pandemics. The current method of surgery training needs the novice surgeons to attend some courses, watch some procedure, and conduct their initial operations under the direct supervision of an expert surgeon. Owing to the requirement of physical contact in this method of medical training, the involved people including the novice and expert surgeons confront a potential risk of infection to the virus. This survey paper reviews recent technological breakthroughs along with new areas in which assistive technologies might provide a viable solution to reduce the physical contact in the medical institutes during the COVID-19 pandemic and similar crises.

A data-driven performance dashboard for surgical dissection

Surgical error and resulting complication have significant patient and economic consequences. Inappropriate exertion of tool-tissue force is a common variable for such error, that can be objectively monitored by sensorized tools. The rich digital output establishes a powerful skill assessment and sharing platform for surgical performance and training. Here we present SmartForceps data app incorporating an Expert Room environment for tracking and analysing the objective performance and surgical finesse through multiple interfaces specific for surgeons and data scientists. The app is enriched by incoming geospatial information, data distribution for engineered features, performance dashboard compared to expert surgeon, and interactive skill prediction and task recognition tools to develop artificial intelligence models. The study launches the concept of democratizing surgical data through a connectivity interface between surgeons with a broad and deep capability of geographic reach through mobile devices with highly interactive infographics and tools for performance monitoring, comparison, and improvement.

Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high Tibial osteotomy

Background The purpose of this study was to compare the degree of accuracy of coronal alignment correction with use of the “alignment adjustment under valgus stress technique” between expert and novice surgeons during medial opening-wedge high tibial osteotomy (MOWHTO). Methods Forty-eight patients who underwent MOWHTO performed by an expert surgeon (expert group) and 29 by a novice surgeon (novice group) were enrolled in analysis. During surgery, lower-extremity alignment was corrected using the “alignment adjustment under valgus stress technique”. Normocorrection was defined as a weight-bearing line ratio between 55 and 70% and the correction accuracy was compared between expert and novice groups using the ratio of normocorrection to outliers. The clinical outcomes were also compared using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year after surgery. Results The undercorrection rate was 14.6% in the expert group and 13.8% in the novice group, while the overcorrection rate was 2.1% in the expert group and 3.4% in the novice group. In the ratio of normocorrection to outliers, no difference was found between the two groups at the one-year follow-up visit (83.3% in the expert group vs. 82.8% in the novice group; p > 0.05). Also, no significant differences were seen in WOMAC subscores immediately preoperatively and at 1 year after surgery (all p > 0.05). Conclusion Adhering to the “alignment adjustment under valgus stress technique” protocol enabled novice surgeons to achieve similar surgical accuracy as that of an expert surgeon in coronal alignment during MOWHTO. Level of evidence Level III.

Think before you cut! Is surgery about ‘doing’ or about ‘thinking’?

Is surgery about ‘doing’ or about ‘thinking’? The question is pertinent, because only if we know what we are trying to achieve can we hope to use the right educational method to reach our goal! It could be argued that surgery is an inextricable combination of doing, thinking and interacting with others. Educational theory teaches us that there are three main models of teaching: behaviourism (learning by ‘doing’), cognitivism (learning by ‘thinking’) or social constructivism (learning by ‘interacting’). Furthermore, most education systems advocate the models to be used in that order, with behaviourist techniques for the novice and constructivism reserved for the expert. Yet on reflection, today's medical students start their learning in a lecture theatre, spend core training years revising for exams and only the last few years of training actually ‘doing’ surgery – quite the opposite of what educational theory mandates. If the expert surgeon ‘does’ while the novice only ‘knows’, then is it not time to start teaching in reverse? Rather than surgical training beginning with a period of ‘thinking’ in isolation, an integrated curriculum incorporating ‘doing’ from the outset should allow trainee surgeons to reach their goal of ‘doing’ more efficiently and effectively.

The impact of patient body mass index on surgeon posture during simulated laparoscopy

Laparoscopy is a cornerstone of modern surgical care. Despite clear advantages for the patients, it has been associated with inducing upper body musculoskeletal disorders amongst surgeons due to the propensity of non-neutral postures. Furthermore, there is a perception that patients with obesity exacerbate these factors. Therefore, novice, intermediate and expert surgeon upper body posture was objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess the subsequent postural data during laparoscopic training on patient models that simulated BMI’s of 20, 30, 40 and 50 kg/m2. In all experience groups, the posture of the upper body significantly worsened during simulated surgery on the BMI 50 kg/m2 model as compared to on the baseline BMI model of 20 kg/m2. These findings suggest that performing laparoscopic surgery on patients with severe obesity increases the prevalence of non-neutral upper body posture and may further increase the risk of musculoskeletal disorders in surgeons.