A step-by-step laparoscopic suturing skills educational program for surgical resident trainees

Scop: Modelul educațional see one - do one – teach one s-a dovedit ca fiind ineficient în învățarea tehnicilor de chirurgie minim invaziva. Sutura laparoscopică este o tehnică esențială în chirurgia minim invazivă, dar în același timp dificil de învățat. Scopul studiului nostru este să dovedească necesitatea și fezabilitatea unui model de training etapizat pentru introducerea rezidenților din specialitățile chirurgicale în bazele suturii laparoscopice. Material și metode: Studiul nostru este un studiu prospectiv care a inclus rezidenți din specialități chirurgicale fără experiență anterioara în sutura laparoscopică. Au fost organizate trei sesiuni separate de training, pe diferite nivele de dificultate: aptitudini de baza în sutura laparoscopică: exerciții dedicate manipulării acului și efectuării nodurilor chirurgicale; aptitudini intermediare în sutura laparoscopică: suturi continue și întrerupte folosind fire monofilament, multifilament pe materiale sintetice și biologice; aptitudini avansate în sutura laparoscopică: efectuarea anastomozelor intestinale terminoterminale și laterolaterale. Rezultate: Douăzeci de participanți au fost incluși în primele două sesiuni, respectiv 10 participanți fiind incluși în a treia sesiune. Cinci participanți au fost înrolați consecutiv în toate cele 3 sesiuni de training. Comparativ cu participanții care nu au urmat programul etapizat, cei 5 participanți au avut timpi de execuție mai rapizi și tehnică chirurgicală de calitate mai bună, indiferent de anul de rezidențiat. Concluzii: Modelul de training propus permite participanților să învețe noile principii într-o manieră graduală, permițând învățarea eficientă a tehnicilor complexe de sutură, dovedind astfel eficacitatea modelului educațional.Aim: The see one - do one - teach one apprenticeship model has been proved to be ineffective in teaching minimally invasive surgical skills. Laparoscopic suturing is an essential technique for minimally invasive surgery, but as well a very difficult skill to learn. The aim of our study is to prove the necessity and the feasibility of a step-by-step training model for teaching surgical residents the basic of laparoscopic suturing. Methods: We have conducted a prospective study that included surgical residents without previous experience in laparoscopic suturing. Three separate training sessions were organized, based on different competency levels: basic skills in laparoscopic suturing: exercises for needle manipulation and knot tying; intermediate laparoscopic suturing skills: interrupted and continuous sutures using multifilament, monofilament, and barbed wires on synthetic and biologic material; advanced laparoscopic suturing skills: end-to-end and side-to-side intestinal anastomoses. The activity of the participants was evaluated by 5 trainers. Results: Twenty participants were enrolled in the first two sessions and 10 participants were enrolled in the third session. Five participants have consecutively participated in all three training sessions. Compared to the participants that did not follow the step-up program, the 5 participants had faster execution times and higher quality suturing, regardless of their year of study. Conclusions: Our proposed training model allows the trainee to get acquainted with the new patterns of movement in a gradual manner, allowing them to efficiently learn complex suturing skills, proving to be an effective teaching method

Iatrogenic bile duct injuries – the road to consensus

Scop: Leziunile iatrogene de cale biliară după colecistectomia laparoscopică reprezintă o problemă serioasă care trebuie manageriată corect din punct de vedere diagnostic și al unui tratament prompt. Multiple clasificări au fost dezvoltate și utilizate pentru descrierea acestor leziuni. Material și metode: Studiul nostru este un studiu de tip retrospectiv descriptiv cu scopul de a identifica rolul unei clasificări uniforme și complete, dar și implicarea acesteia în managementul leziunilor de cale biliară. Au fost incluși pacienți referați în centru nostru terțiar, pentru tratamentul leziunilor de cale biliară survenite după colecistectomia laparoscopică, pe o perioadă de 10 ani (2011-2020). Rezultate: O sută de pacienți au fost incluși în studiu; 15% din leziuni au fost întâmpinate la cazuri operate primar în serviciul nostru. În 73% din cazuri, leziunile nu au fost clasificate, în 23% din cazuri s-a utilizat clasificarea Strasberg, în 3% din cazuri clasificarea Bismuth, iar în 1% din cazuri clasificarea ATOM. După reclasificarea retrospectivă a tuturor cazurilor, s-a observat că clasificarea Straberg, dar chiar și clasificarea Hannover suprasimplifică complexitatea leziunii. Tratamentul în majoritatea cazurilor a fost derivația biliodigestivă (60% din cazuri). Concluzii: Clasificarea ATOM realizează o descriere comprehensivă a leziunilor biliare, putând ghida astfel tratamentul corespunzător în funcție de severitatea fiecărei leziuni. O clasificare uniformă ar trebui adoptată la scară largă pentru a asigura un limbaj comun în discuția referitoare la leziunile de cale biliară.Aim: Iatrogenic bile duct injuries after laparoscopic cholecystectomy represent a significant problem, that needs to be addressed correctly in terms of diagnosis and prompt treatment. Several classifications have been developed and used to describe these lesions. Methods: Our study is a retrospective descriptive study that aims to identify the role of an uniform and comprehensive classification and its implication on the consecutive management of the bile duct injury. We have included patients diagnosed with bile duct injury after laparoscopic cholecystectomy, referred to a tertiary centre, in a ten-year period (2011-2020). Results: We included in our study 100 patients; 15% of the BDI occurred in our center. No classification system was used in 73% of patients; 23% of the BDI were classified by the Strasberg system, 3% were classified by the Bismuth classification, 1% being classified by the ATOM classification. After retrospectively classifying all BDI, we observed that especially the Strasberg classification, as well as Hannover, over-simplifies the characteristics of the injury. Most main bile duct injuries underwent a bilio-digestive anastomosis (60%), as a definitive treatment. Conclusions: The ATOM classification performs a comprehensive description of the bile duct injury and subsequent guidance of the correct treatment according to the severity of each lesion. A consistent classification should be adopted, in order to assure a uniform discussion on iatrogenic bile duct injuries

Challenges and controversies in open pancreatoduodenectomies

Duodenopancreatectomia cefalopancreatica este o procedura intricata, ce necesita o inalta precizie datorita proximitatii structurilor vitale, sustinuta prin expertiza. O data cu evolutia chirurgiei si aparitia de instrumente inovatoare, mortalitatea a scazut sub 5%, dar morbiditatea a ramas la 30%, in special datorita fistulelor de anastomoza si a evenimentelor hemoragice. In acest sens, chirurgia deschisa confera rezultate mai bune, cu o curba de invatare rezonabila. Cu atat mai mult, cu cat efectuarea de trialuri clinice este dificila in acest domeniu, atat in chirurgia deschisa, cat si minim invaziva, pentru a obtine evidente valoroase, astfel subiectul ramane unul de dezbatere.Whipple procedure is intricate and demands high precision due to the proximity of critical structures, which requires an achieved expertise. With the innovative instruments and evolution of surgery, the perioperative morbidity still stands at 30% with a mortality lower than 5%, primary because of anastomotic leaks and haemorrhagic events. Therefore open surgery provides better outcomes with a decent learning curve. Furthermore, it is challenging to conduct clinical trials in the field of pancreatic surgery both open or minimally-invasive to obtain high-level evidence, remaining a subject open to debate

Laparoscopic approach of acute pancreatitis collections: a serie of four cases

Introduction: Acute pancreatitis (AP) is one of the most unpredictable pathologies of the digestive system. AP can be associated with multiple local or systemic complications. Approximately 15-20% of patients develop moderate severe or severe pancreatitis. The moderate severe form of disease is associated with local complications, as necrosis of the pancreatic and/or peripancreatic tissue and transient organ failure. One of the most common local complications in AP is the development of peripancreatic fluid collections (PFC). Proper management of PFC necessitates accurate diagnosis and treatment by a multidisciplinary team. Moreover, tratment has turned from open surgery (associated with high mortality and morbidity), therefore the latest literature shows data justifying the use of minimally invasive procedures. Case presentantion: We present a serie of 4 patients, with ages comprised between 54 and 70 years old with peripancreatic fluid collections, more precisely, walled-off necrosis (WON), infected WON in the lesser sac and one with ANC treated laparoscopically. Conclusion: Minimally invasive procedures of PFC, especially for acute necrotic collections (ANC) include radiological, endoscopic or surgical approach. Formerly, a primary necrosectomy was the frontrunner treatment, however it is associated with high rates of mortality and morbidity. At the present moment the step-up approach management is preferred. The main and most common issue of all minimally invasive procedures is the difficult removal of the necrotic debris and the adequate drainage of the collection in one procedure. To conclude, even though pancreatitis has an unforeseeable evolution, the minimally invasive techniques seem to be promising in the managament of PFC. Case particularities: This present paper presents a serie of four cases of AP complicated with PFC admitted to the Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca. All cases were managed pure laparoscopically

Enhanced laser thermal ablation for the in vitro treatment of liver cancer by specific delivery of multiwalled carbon nanotubes functionalized with human serum albumin

The main goal of this investigation was to develop and test a new method of treatment for human hepatocellular carcinoma (HCC). We present a method of carbon nanotube-enhanced laser thermal ablation of HepG2 cells (human hepatocellular liver carcinoma cell line) based on a simple multiwalled carbon nanotube (MWCNT) carrier system, such as human serum albumin (HSA), and demonstrate its selective therapeutic efficacy compared with normal hepatocyte cells. Both HepG2 cells and hepatocytes were treated with HSA–MWCNTs at various concentrations and at various incubation times and further irradiated using a 2 W, 808 nm laser beam. Transmission electron, phase contrast, and confocal microscopy combined with immunochemical staining were used to demonstrate the selective internalization of HSA–MWCNTs via Gp60 receptors and the caveolin-mediated endocytosis inside HepG2 cells. The postirradiation apoptotic rate of HepG2 cells treated with HSA–MWCNTs ranged from 88.24% (for 50 mg/L) at 60 sec to 92.34% (for 50 mg/L) at 30 min. Significantly lower necrotic rates were obtained when human hepatocytes were treated with HSA–MWCNTs in a similar manner. Our results clearly show that HSA–MWCNTs selectively attach on the albondin (aka Gp60) receptor located on the HepG2 membrane, followed by an uptake through a caveolin-dependent endocytosis process. These unique results may represent a major step in liver cancer treatment using nanolocalized thermal ablation by laser heating

Selective ex-vivo photothermal ablation of human pancreatic cancer with albumin functionalized multiwalled carbon nanotubes

The process of laser-mediated ablation of cancer cells marked with biofunctionalized carbon nanotubes is frequently called “nanophotothermolysis”. We herein present a method of selective nanophotothermolisys of pancreatic cancer (PC) using multiwalled carbon nanotubes (MWCNTs) functionalized with human serum albumin (HSA). With the purpose of testing the therapeutic value of these nanobioconjugates, we have developed an ex-vivo experimental platform. Surgically resected specimens from patients with PC were preserved in a cold medium and kept alive via intra-arterial perfusion. Additionally, the HSA-MWCNTs have been intra-arterially administered in the greater pancreatic artery under ultrasound guidance. Confocal and transmission electron microscopy combined with immunohistochemical staining have confirmed the selective accumulation of HSA-MWCNTs inside the human PC tissue. The external laser irradiation of the specimen has significantly produced extensive necrosis of the malign tissue after the intra-arterial administration of HSA-MWCNTs, without any harmful effects on the surrounding healthy parenchyma. We have obtained a selective photothermal ablation of the malign tissue based on the selective internalization of MWCNTs with HSA cargo inside the pancreatic adenocarcinoma after the ex-vivo intra-arterial perfusion

Recent Trends in Non-Invasive Methods of Diagnosis and Evaluation of Inflammatory Bowel Disease: A Short Review

Inflammatory bowel diseases are a conglomerate of disorders causing inflammation of the gastrointestinal tract, which have gained a significant increase in prevalence in the 21st century. As they present a challenge in the terms of diagnosis as well as treatment, IBDs can present an overwhelming impact on the individual and can take a toll on healthcare costs. Thus, a quick and precise diagnosis is required in order to prevent the high number of complications that can arise from a late diagnosis as well as a misdiagnosis. Although endoscopy remains the primary method of evaluation for IBD, recent trends have highlighted various non-invasive methods of diagnosis as well as reevaluating previous ones. This review focused on the current non-invasive methods in the diagnosis of IBD, exploring their possible implementation in the near future, with the goal of achieving earlier, feasible, and cheap methods of diagnosis as well as prognosis in IBD