Learning practical skills

Practical, or procedural, skills in healthcare share many features with psychomotor skills in other unrelated disciplines. Since this is the case, we can refer to the published scientific literature on psychomotor skills in general in order to understand how best to teach procedural skills to students, and how best to assess them. It may then be possible to formulate the principles and objectives that govern a curriculum in procedural skills. These principles and objectives will dictate the requisite learning experiences to be included in the curriculum. Consideration may then be given to the types of training media appropriate for the objectives at each stage of the curriculum

Three-dimensional printing technology in surgery

Background: Three-dimensional printing has become an increasingly widespread technology, becoming more accessible to individuals, small businesses and organisations. It represents the ability to manufacture objects of various substrate material using computer aided 3D plans. This article aims to explore the various uses of this technology in medicine and surgery including future directions and applications Method: A generalised review of past and current articles was performed exploring the known uses of three-dimensional printing in medicine and surgery. Results: Broadly, the applications include; education for health professionals and patients, surgical planning and decision-making, custom prostheses, tissue scaffolds, and customised surgical instrument manufacturing. Future directions include bionic prostheses, live tissue grafts, and whole organ printing

Review : photochemical tissue bonding (PTB) methods for sutureless tissue adhesion

Every year more and more medical devices are being implanted in the human body. Sutures are currently the gold standard for attachment of these devices, but they have associated issues such as needle trauma, unsuitability for certain tissues, such as eye or lung, and require skilled surgeons. A variety of sutureless methods have been developed to overcome some of these issues. Sutureless methods developed include fibrin glue, cyanoacrylates, scaffolds and bio-inspired adhesives. A sutureless method that is receiving increasing attention is Photochemical Tissue Bonding (PTB). This method involves using photoactive dyes and light-activation to initiate a chemical reaction that forms cross-links with collagen. In this review, we describe the current status of PTB. A variety of dyes have been identified and the literature analysed to identify the most promising photoactive dyes for PTB. Rose Bengal appears to be the most promising of the dyes identified as it produces the strongest bonding of all the dyes and its use is associated with minimal thermal damage. Development of applications for Rose Bengal is an area of active research with multiple articles published in the last 5 years. The outlook is promising for PTB and Rose Bengal to provide clinically viable solutions for tissue adhesion

Superior mesenteric artery syndrome : diagnosis and treatment strategies

Introduction Superior mesenteric artery (SMA) syndrome is an unusual cause of vomiting and weight loss resulting from the compression of the third part of the duodenum by the SMA. Various medical and psychiatric conditions may result in the initial rapid weight loss which causes narrowing of the aortomesenteric angle. The vomiting and obstructive syndrome is then self-perpetuated regardless of the initiating factors. The young age and nonspecific symptoms often lead to a delay in diagnosis. Discussion A series of eight cases is presented reviewing the presentation, investigations, surgical treatment by division of duodenum and duodenojejunostomy, and outcomes. Conclusion SMA syndrome is a well-described entity which must be considered as a cause of vomiting associated with significant weight loss in young adults. Surgical treatment should be allied with psychological assessment to treat any underlying psychosocial abnormality

Pancreatitis from intra-gastric balloon insertion : case report and literature review

INTRODUCTION: Intra-Gastric Balloon (IGB) is increasingly used as a non-operative management strategy in bariatric patients. However, as IGB use has become more prevalent, new potentially life-threatening adverse effects have emerged. We report a case of IGB-related acute pancreatitis from a tertiary referral hospital. A literature review of electronic databases was conducted to identify other cases. PRESENTATION OF CASE: A 20-year-old female presented to the emergency department with acute onset ofepigastric pain on day-1 post-insertion of an IGB (Orbera®). The diagnosis of acute pancreatitis was made on the basis of the clinical picture, with radiological and serological confirmation. Complete resolution of symptoms promptly followed endoscopic removal of the balloon.DISCUSSION: We examine all prior reported cases of IGB associated pancreatitis in the literature, as well as the impact of the particular balloon subtypes. Mass effect of the device on the pancreas or dislodgementof the rigid catheter into the second part of the duodenum appear to be the underlying cause in all cases.While there were no deaths reported, major sequelae have been noted, including presence of mucosalischemia and failure to retrieve the balloon endoscopically, necessitating laparotomy.CONCLUSION: Although the incidence of IGB-induced pancreatitis is still rare, this complication which must be highlighted as a potentially serious adverse outcome

Characterisation of a novel light activated adhesive scaffold : potential for device attachment

The most common methods for attaching a device to the internal tissues of the human body are via sutures, clips or staples. These attachment techniques require penetration and manipulation of the tissue. Tears and leaks can often be a complication post-attachment, and scarring usually occurs around the attachment sites. To resolve these issues, it is proposed to develop a soft tissue scaffold impregnated with Rose Bengal/Chitosan solution (RBC-scaffold, 0.01% w/v Rose Bengal, 1.7% w/v Medium Molecular Weight Chitosan). This scaffold will initially attach to the tissue via a light activation method. The light activates the dye in the scaffold which causes cross-links to form between the scaffold and tissue, thus adhering them together. This is done without mechanically manipulating the surrounding tissue, thus avoiding the issues associated with current techniques. Eventually, the scaffold will be resorbed and tissue will integrate for long-term attachment. A variety of tests were performed to characterise the RBC-scaffold. Porosity, interconnectivity, and mechanical strength were measured. Light activation was performed with a broad spectrum (380-780 nm) 10 W LED lamp exposed to various time lengths (2-15 min, Fluence range 0.4-3 J/cm2 ). Adhesive strength of the light-activated bond was measured with lap-shear tests performed on porcine stomach tissue. Cell culture viability was also assessed to confirm tissue integration potential. These properties were compared to Variotis™, an aliphatic polyester soft tissue scaffold which has proven to be viable for soft tissue regeneration. The RBC-scaffolds were found to have high porosity (86.46±2.95%) and connectivity, showing rapid fluid movement. The elastic modulus of the RBC-scaffolds (3.55±1.28 MPa) was found to be significantly higher than the controls (0.15±0.058 MPa, p0.01) and approached reported values for human gastrointestinal tissue (2.3 MPa). The maximum adhesion strength achieved of the RBC-scaffolds was 8.61±2.81 kPa after 15 min of light activation, this is comparable to the adhesion strength of fibrin glue on scaffolds. Cell attachment was seen to be similar to the controls, but cells appeared to have better cell survivability. In conclusion, the RBC-scaffolds show promise for use as a novel light activated attachment device with potential applications in attaching an anti-reflux valve in the lower oesophagus and also in wound healing applications for stomach ulcers

Preoperative chemical component relaxation using Botulinum toxin A : enabling laparoscopic repair of complex ventral hernia

Background: Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair. Methods: This was a prospective observational study of 32 patients who underwent ultrasound-guided injections of BTA to the lateral abdominal wall muscles prior to elective repair of complex ventral hernia between January 2013 and December 2015. Serial non-contrast abdominal CT imaging was performed to measure changes in fascial defect size, abdominal wall muscle length and thickness. All hernias were repaired laparoscopically or laparoscopic-assisted with placement of intra-peritoneal mesh. Results: Thirty-two patients received BTA injections which were well tolerated with no complications. A comparison of baseline (preBTA) CT imaging with postBTA imaging demonstrated an increase in mean baseline abdominal wall length from 16.4 to 20.4 cm per side (p < 0.0001), which translates to a gain in mean transverse length of the unstretched anterolateral abdominal wall muscles of 4.0 cm/side (range 0–11.7 cm/side). Fascial closure was achieved in all cases, with no instances of raised intra-abdominal pressures or its sequelae, and there have been no hernia recurrences to date. Conclusions: Preoperative BTA injection to the muscles of the anterolateral abdominal wall is a safe and effective technique for the preoperative preparation of patients prior to laparoscopic mesh repair of complex ventral hernia. This technique elongates and thins the contracted and retracted musculature, enabling closure of large defects

Expression of S100A2 calcium-binding protein predicts response to pancreatectomy for pancreatic cancer

Background & Aims Current methods of preoperative staging and predicting outcome following pancreatectomy for pancreatic cancer (PC) are inadequate. We evaluated the utility of multiple biomarkers from distinct biologic pathways as potential predictive markers of response to pancreatectomy and patient survival. Methods We assessed the relationship of candidate biomarkers known, or suspected, to be aberrantly expressed in PC, with disease-specific survival and response to therapy in a cohort of 601 patients. Results Of the 17 candidate biomarkers examined, only elevated expression of S100A2 was an independent predictor of survival in both the training (n = 162) and validation sets (n = 439; hazard ratio [HR], 2.19; 95% confidence interval [CI]: 1.48–3.25; P < .0001) when assessed in a multivariate model with clinical variables. Patients with high S100A2 expressing tumors had no survival benefit with pancreatectomy compared with those with locally advanced disease, whereas those without high S100A2 expression had a survival advantage of 10.6 months (19.4 vs 8.8 months, respectively) and a HR of 3.23 (95% CI: 2.39–4.33; P < .0001). Of significance, patients with S100A2-negative tumors had a significant survival benefit from pancreatectomy even in the presence of involved surgical margins (median, 15.7 months; P = .0007) or lymph node metastases (median, 17.4 months; P = .0002). Conclusions S100A2 expression is a good predictor of response to pancreatectomy for PC and suggests that high S100A2 expression may be a marker of a metastatic phenotype. Prospective measurement of S100A2 expression in diagnostic biopsy samples has potential clinical utility as a predictive marker of response to pancreatectomy and other therapies that target locoregional disease