Dynamic causal modeling for EEG during complex laparoscopic skill acquisition

Fundamentals of Laparoscopic Surgery (FLS) is a prerequisite for board certification in general surgery in the USA. It includes a motor skills portion with five psychomotor tasks of increasing task complexity: (i) pegboard transfers, (ii) pattern cutting, (iii) placement of a ligating loop, (iv) suturing with extracorporeal knot tying, and (v) suturing with intracorporal knot tying. Learning these tasks typically relies on extensive practice [1]. Nemani et al. [2] showed that the wavelet coherence based functional connectivity from functional near-infrared spectroscopy (fNIRS) data between the medial prefrontal cortex and the supplementary motor area (SMA) was lower for experts than novices during FLS pattern cutting task. Here, SMA is known for the plasticity of interhemispheric connectivity involving sensorimotor network [3] relevant in learning bimanual laparoscopic tasks; however, transcranial direct current (tDCS) of SMA resulted in more variability during FLS pegboard transfers than bilateral primary motor cortex tDCS. Here, it is essential to differentiate tDCS effects on the pre-SMA from SMA proper in the SMA complex during laparoscopic skill acquisition due to differences in their fiber tracts [4] and their relevance to motor task complexity. Prior work using fNIRS-based activation during most complex FLS suturing task with intracorporeal knot tying [5] showed the involvement of premotor/frontal module [4] related Brodmann areas (BA), shown in Figure 1c, including ventrolateral PFC (VLPFC; BA: 44, 45, 47), frontopolar (FP; BA: 10), dorsolateral PFC (DLPFC; BA: 9, 46) as well as a part of the orbitofrontal cortex (OFC; BA: 11) on the lateral brain surface in addition to SMA complex. However, the effective connectivity of this cognitive-motor control network was not investigated based on dynamic causal modeling (DCM) [6], where the temporal resolution of electroencephalogram (EEG) can capture fast interactions expected via short frontal lobe connections [4]. Therefore, our research aimed to identify hidden brain networks during FLS suturing with intracorporeal knot tying skill acquisition using DCM of EEG.

LAPRA-TY for laparoscopic repair of traumatic diaphragmatic hernia without intracorporeal knot tying

Case PresentationA 38-year-old man was brought in by ambulance as a trauma activation after sustaining a self-inflicted stab wound in the left upper quadrant with a kitchen knife. His primary survey was unremarkable and his vital signs were normal. Secondary survey revealed a 2 cm transverse stab wound inferior and medial to the left nipple. Extended focused assessment with sonography for trauma (FAST) did not show intra-abdominal or pericardial fluid and chest X-ray did not show a definite pneumothorax or hemothorax.What would you do?Wound exploration at bedside.Admit for observation and serial examinations.Exploratory laparotomy and open repair of traumatic diaphragmatic injury (TDI).Thoracotomy and open repair of TDI.Diagnostic laparoscopy and laparoscopic repair of TDI.

The Effect on Performance Time and Quality of the Knots after Mono or Bimanual Training of Laparoscopic Intracorporeal Knot Tying according to the Gladiator Rule Technique

Objective To assess whether the monomanual or bimanual training of laparoscopic suture following the same technique may interfere with the knots' performance time and/or quality. Methods A prospective observational study involving 41 resident students of gynecology/obstetrics and general surgery who attended a laparoscopic suture training for 2 days. The participants were divided into two groups. Group A performed the training using exclusively their dominant hand, and group B performed the training using both hands to tie the intracorporeal knot. All participants followed the same technique, called Romeo Gladiator Rule. At the end of the course, the participants were asked to perform three exercises to assess the time it took them to tie the knots, as well as the quality of the knots. Results A comparative analysis of the groups showed that there was no statistically significant difference (p = 0.334) between them regarding the length of time to tie one knot. However, when the time to tie 10 consecutive knots was compared, group A was faster than group B (p = 0.020). A comparison of the knot loosening average, in millimeters, revealed that the knots made by group B loosened less than those made by group A, but there was no statistically significant difference regarding the number of knots that became untied. Conclusion This study demonstrated that the knots from group B showed better quality than those from group A, with lower loosening measures and more strength necessary to untie the knots. The study also demonstrated that group A was faster than B when the time to tie ten consecutive knots was compared.

A New Needle Holder Design to Facilitate Intracorporeal Knot Tying

Purpose. Intracorporeal knot tying in laparoscopic surgery continues to be a problem especially for beginners and inexperienced surgeons. A wide-angle needle holder was designed to make the knot maneuver easier while also ensuring that the knot does not come out of the needle holder. In this study, it was planned to compare the wide-angle needle holder with the classic needle holder in regard to knot tying time. Material and method. A total of 11 male volunteers were randomly selected from freshmen students of the faculty of medicine, who had no experience of surgery or laparoscopic surgery. After the required training and practice, candidates were asked to tie 3 knots each in the training box using a classic needle holder and a wide-angle needle holder. Their knot tying times were recorded. Results. Although the students had no experience, it was observed that they tied knots more easily and more comfortably using the wide-angle needle holder. It was found that the knot tying times with the wide-angle needle holder were quite short compared with the classic needle holder in all candidates. This difference was also statistically significant ( P = .01). Conclusion. We believe and claim that the use of a wide-angle needle holder during knot tying in laparoscopic surgery can facilitate knot tying and shorten the duration of the knotting, especially for inexperienced surgeons.

Impact of Training on Three-Dimensional versus Two-Dimensional Laparoscopic Systems on Acquisition of Laparoscopic Skills in Novices: A Prospective Comparative Pilot Study

In this prospective educational study, 10 medical students (novices) were randomized to practice two basic laparoscopic tasks from the MISTELS program, namely, Pegboard Transfer (PT) and Intracorporeal Knot Tying (IKT) tasks, using either a 2D or a 3D laparoscopic platform. There was no significant difference between both groups in the baseline assessments (PT task: 130.8 ± 18.7 versus 151.5 ± 33.4; p=0.35) (IKT task: 123.9 ± 41.0 versus 122.9 ± 44.9; p=0.986). Following two training sessions, there was a significant increase in the scores of PT task for the 2D (130.8 ± 18.7 versus 222.6 ± 7.0; p = 0.0004) and the 3D groups (151.5 ± 33.4 versus 211.7 ± 16.2; p = 0.0001). Similarly, there was a significant increase in the scores of IKT task for the 2D (123.9 ± 41.0 versus 373.3 ± 47.2; p = 0.003) and the 3D groups (122.9 ± 44.9 versus 338.8 ± 28.6; p = 0.0005). However, there was no significant difference in the final assessment scores between 2D and 3D groups for both tasks (p > 0.05). Therefore, 3D laparoscopic systems do not provide an advantage over 2D systems for training novices in basic laparoscopic skills.

A Comparative Study in Learning Curves of Two Different Intracorporeal Knot Tying Techniques

Objectives. In our study we are aiming to analyse the learning curves in our surgical trainees by using two standard methods of intracorporeal knot tying.Material and Method. Two randomized groups of trainees are trained with two different intracorporeal knot tying techniques (loop and winding) by single surgeon for eight sessions. In each session participants were allowed to make as many numbers of knots in thirty minutes. The duration for each set of knots and the number of knots for each session were calculated. At the end each session, participants were asked about their frustration level, difficulty in making knot, and dexterity.Results. In winding method the number of knots tied was increasing significantly in each session with less frustration and less difficulty level.Discussion. The suturing and knotting skill improved in every session in both groups. But group B (winding method) trainees made significantly higher number of knots and they took less time for each set of knots than group A (loop method). Although both knotting methods are standard methods, the learning curve is better in loop method.Conclusion. The winding method of knotting is simpler and easier to perform, especially for the surgeons who have limited laparoscopic experience.