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

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

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

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

The effects of 6-weeks program of physical therapeutic exergames on cognitive flexibility focused by reaction times in relation to manual and podal motor abilities

The main purpose of the study was to identify the level of improvement in cognitive flexi-bility manifested by choice and cognition reaction times in relation to manual and podal skills as a result of the implementation of a program of therapeutic exergame exercises, for a time interval of 6 weeks at the level of students. 511 students participated in the cross-sectional study, of which 279 male (54.6%) and 232 female (45.4%), divided into two groups: the experimental group 266 (521%) subjects and the control group 245 (48%) sub-jects. The implementation of the experimental program comprising of 8 physical thera-peutic exergames took place for 6 weeks, in one session per week, within the physical edu-cation lessons, only for the male and female experimental groups. In the initial and final testing session, 2 standardized tests were applied: TMT part A, B and 2 tests adapted for this study: Square Test and 25 Squares Test. The progress registered by the male and fe-male experimental groups was statistically significant. In all tests, the experimental groups showed higher progress compared to the control groups. Depending on the gender differences, it was found that the male experimental and control groups made better pro-gress compared to the female groups in the following tests: TMT part A, Square Test, 25 Squares Tests. The implementation of a physical therapeutic exergame program deter-mined the improvement of cognitive flexibility man-ifested by choice and cognitive reac-tion times in conditions of manual and podal motor skills, demonstrating the effective-ness of exergame technologies adapted and implemented for prophy-lactic purpose

Non-resectional management of splenic injuries in laparoscopic surgery

Introducere: Leziunile splenice iatrogene în chirurgia abdominală reprezintă o complicație subestimată și este important să fie recunoscute intraoperator pentru a se asigura un management adecvat. Dintre procedurile chirurgicale cu cea mai mare rată a leziunilor splenice se numără: hemicolectomia stângă (1-8%), procedeele antireflux în chirurgia deschisă (3-20%), nefrectomia stângă (4-13%) și reconstrucția aortei abdominale proximale și a ramurilor acesteia (21-60%). Pentru a gestiona acest tip de complicație, poate fi necesară splenectomia, dar tratamentul conservator prin orice mijloace, cu scopul de a obține o hemostază adecvată, ar trebui utilizat în orice situație. Serie de cazuri: Vom prezenta trei cazuri clinice care au constat în diferite leziuni splenice apărute în timpul procedurilor laparoscopice, care au fost gestionate conservator, fără a fi necesară efectuarea splenectomiei. Primul caz a constat într-o efracție splenică la un pacient cirotic în timpul unei rectosigmoidectomii laparoscopice, al doilea pacient a suferit o hemoragie prin decapsulare splenică în timpul unei cure laparoscopice a herniei hiatale, iar în ultimul caz am gestionat o leziune splenică apărută la introducerea trocarelor pentru o suprarenalectomie dreaptă laparoscopică la un pacient cu obezitate morbidă. Discuții: Seria de cazuri prezentate sunt foarte ilustrative pentru un tratament non-rezecțional efectuat laparoscopic în managementul adecvat al leziunilor splenice iatrogene. Hemostaza a fost realizată printr-o combinație de presiune locală aplicată cu o meșă, electrochirurgie și materiale șau substanțe hemostatice. Concluzie: În concluzie, considerăm că managementul conservator al hemoragiilor splenice ce pot apărea în timpul intervențiilor chirurgicale laparoscopice ar trebui stăpânit de orice chirurg generalist, și de preferință, realizat laparoscopic.Background: Splenic iatrogenic injuries in abdominal surgery represent an underestimated complication and it is important to be recognised intraoperatively to assure a proper management. Among surgical procedures with the highest rate of splenic injuries the following are to be mentioned: left hemicolectomy (1-8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and reconstruction of the proximal abdominal aorta and its branches (21-60%). In order to manage this type of complication, splenectomy may be required, but conservative treatment by any means with the aim of acquiring proper haemostasis should be employed at any chance. Case series: We are going to present three clinical cases which consisted of different splenic injuries during laparoscopic procedures, which were managed conservatively, without needing to perform a splenectomy. First case consisted of a splenic effraction in a cirrhotic patient during a laparoscopic rectosigmoidectomy, the second patient suffered a bleeding by splenic decapsulation during a routine laparoscopic hiatal hernia repair, and in the last case we have encountered a splenic injury when inserting the trocars for a laparoscopic right adrenalectomy in a patient with morbid obesity. Discussion: The case series presented are very illustrative of a non-resectional treatment performed laparoscopically for a proper management of splenic iatrogenic injuries. Haemostasis was established by a combination of application pressure with a mesh, electrosurgery and haemostatic materials or substances. Conclusion: In summary, we consider that conservative management of splenic bleedings which may occur during laparoscopic intervention should be mastered by any general surgeon and preferably established laparoscopically

Klatskin Tumor: A Survival Analysis According to Tumor Characteristics and Inflammatory Ratios

Background and Objectives: The aim was to evaluate the association of inflammatory biomarkers with resectability and overall survival in hilar cholangiocarcinoma. Materials and Methods: We conducted a retrospective cohort study over 72 consecutive surgical cases of Klatskin tumor over an 11-year period. The sample was divided into two groups: 42 surgical resection cases and 30 unresectable tumors. Values of inflammatory ratios were compared according to the resectability. Log-rank test, univariate, and multivariate Cox proportional hazards models were used to evaluate the overall survival. Results: Subjects were between 42–87 years old (average age of 64.91 ± 9.15 years). According to the procedure: 58.33% benefited from resection (with a 30.95% R0 resection rate) and 41.66% had palliative surgery. Elevated NLR (neutrophil to lymphocyte ratio), PLR (platelet to lymphocyte ratio), and SII (systemic immune-inflammation index), and lower LMR (lymphocyte to monocyte ratio) at admission were associated with unresectable tumors (p < 0.01). For the multivariate Cox proportional hazard models, increased absolute values of NLR, PLR, and SII were associated with lower survival; no differences were observed for LMR absolute value. The cut-off value of NLR ≥ 6 was associated with lower survival. The median survival time for all subjects was 442 days, with 774 days for the resection group and 147 days for the group with palliative surgery. Conclusions: In hilar cholangiocarcinoma, inflammatory ratios are associated with tumor resectability. Tumor excision conferred an important advantage in survival. Elevated NLR, PLR, and SII values at admission significantly increased the hazard ratio. LMR had no influence on survival