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Prior research has demonstrated that counterintuitive laparoscopic surgical skills are enhanced by experience with video games. A similar relation with robotic surgical skills has not been tested. The purpose of this study was to determine whether prior video-game experience enhances the acquisition of robotic surgical skills.A series of 242 preclinical medical students completed a self-reported video-game questionnaire detailing the frequency, duration, and peak playing time. The 10 students with the highest and lowest video-game exposure completed a follow-up questionnaire further quantifying video game, sports, musical instrument, and craft and hobby exposure. Each subject viewed a training video demonstrating the use of the da Vinci surgical robot in tying knots, followed by 3 minutes of proctored practice time. Subjects then tied knots for 5 minutes while an independent blinded observer recorded the number of knots tied, missed knots, frayed sutures, broken sutures, and mechanical errors.The mean playing time for the 10 game players was 15,136 total hours (range 5,840-30,000 hours). Video-game players tied fewer knots than nonplayers (5.8 v 9.0; P = 0.04). Subjects who had played sports for at least 4 years had fewer mechanical errors (P = 0.04), broke fewer sutures (P = 0.01), and committed fewer total errors (P = 0.01). Similarly, those playing musical instruments longer than 5 years missed fewer knots (P = 0.05).In the extremes of video-game experience tested in this study, game playing was inversely correlated with the ability to learn robotic suturing. This study suggests that advanced surgical skills such as robotic suturing may be learned more quickly by athletes and musicians. Prior extensive video-game exposure had a negative impact on robotic performance.

Natural orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. The use of the ureter as a natural orifice for natural orifice translumenal endoscopic surgery (NOTES) nephrectomy has not been previously reported. The purpose of this study is to test the feasibility of transureteral laparoscopic NOTES nephrectomy.Three female farm pigs (29.2-30.8 kg) were placed into the lithotomy position. A cystoscopically placed extra-stiff guidewire was used to place a prototype dilating sheath into the left ureter. After dilation of the ureter and urethra, the sheath was exchanged for a 12-mm bariatric laparoscopic trocar. A 10.5-inch long 10-mm offset operating laparoscope with an internal 5-mm working port was used for the nephrectomy. One 2-mm and one 2/3-mm port were placed transabdominally to facilitate in situ morcellation. The kidney was cut into slices using the bipolar device and extracted via the ureteral port using the housing of a 12-mm bariatric stapling device.All three transureteral nephrectomies were successfully completed. The total mean operative time was 220 minutes (range 113-346 min). Component portions of the procedure were: Ureteral access (mean 21 min), nephrectomy (mean 70 min), and kidney morcellation (mean 103 min). Mean estimated blood loss was 20 mL (range 5-50 mL). There were no intraoperative complications.This nonsurvival porcine feasibility study demonstrates the successful performance of transureteral nephrectomy. This approach shows promise as a way to decrease the invasiveness of NOTES nephrectomy by using the ureteral orifice as an access site.

Significant bleeding necessitating use of a tamponade balloon, embolization, or renal exploration is a rare but catastrophic complication after percutaneous nephrolithotomy (PCNL). The purpose of this study is to review the success of a novel, minimally invasive technique for controlling percutaneous tract bleeding that is refractory to conventional measures.A retrospective review was performed on four patients with refractory tract hemorrhage that was managed with a novel gelatin matrix hemostatic sandwich technique. In this technique, a 5F angiographic reentry catheter was placed through the kidney into the bladder and a 22F Councill-tip catheter balloon was passed over this catheter and positioned so that the inflated balloon would occlude the inner surface of the nephrostomy tract. Next, a 16F Councill-tip catheter was placed over a second wire so that the uninflated balloon was just underneath the skin surface. Gelatin matrix hemostatic sealant was then injected to fill the tract. Inflation of the outer balloon completely sealed the tract, completing the hemostatic sandwich.This technique was successfully applied to four patients with tract bleeding that would not stop with pressure or a conventional nephrostomy tube alone. The average estimated blood loss was 562 mL, and three of four patients avoided transfusion. All postoperative hemoglobin values stabilized within 2 days of surgery. There were no major or minor complications after use of this technique. No patients needed angioembolization or renal exploration.This novel hemostatic sandwich technique should be considered as an option for the control of refractory tract hemorrhage after PCNL.

Although radiation exposure from CT and plain film imaging has been characterized, the radiation received by patients during modern-era fluoroscopy has not been well described. The purposes of this study were to measure absolute organ and tissue-specific radiation doses during ureteroscopy and to determine the influence of body mass index (BMI) and sex on these doses.Eight cadavers underwent a simulated left ureteroscopy. Using a modern C-arm with automatic exposure control settings, thermoluminescent dosimeters were exposed for a fluoroscopy time of 145 seconds (mean time of clinical ureteroscopies from 2006 to 2008). Total tissue exposures were compared by BMI and between sexes using the Wilcoxon signed ranks test and the Mann-Whitney test with p0.05 considered significant.Among all cadavers, radiation doses were significantly lower in all contralateral organs excluding the gonad (p0.012). Doses were similar bilaterally in the gonad in cadavers with BMI30, and in all organs in cadavers with BMI30 (p0.05). There were significantly higher mean bilateral gonadal doses in female cadavers (3.4 mGy left and 1.9 mGy right) compared with male cadavers (0.36 mGy left and 0.39 mGy right). The highest cancer risk increase was seen at the posterior skin equivalent to 104 additional cancers per 100,000 patients.Contralateral doses were lower for all organs except the gonad when the BMI was30. In contrast, when the BMI was30, there was no difference in radiation dose delivered to the ipsilateral and contralateral organs. Gonadal doses were significantly higher in female cadavers. Modern-era fluoroscopy remains a significant source of radiation exposure and steps should be taken to minimize exposure during ureteroscopy.

During laparoscopic surgery, scissors are used to cut a variety of tissue, including fibrotic or calcified tissue, sutures, and occasionally tissue containing staples. Disposable scissors may become dull and ineffective. The purpose of this study is to compare the durability and ergonomics of three different brands of laparoscopic scissors.Three different laparoscopic scissors (Applied Medical Direct Drive, Ethicon Endosurgery Endopath, U.S. Surgical Auto Suture Endo Shear) were used in this study. Six of each type were compared in a variety of objective and subjective tests. Subjective testing included two surgeons' ratings of the scissors' ability to cut fresh tissue and tissue with staples. Twenty blinded volunteers also rated the cutting ability and ergonomics of the scissors. Objective data included high-resolution digital photography and scanning electron microscopy of the scissor blades to quantify the number of imperfections after use.All three new scissors easily cut fresh tissue. The Direct Drive performed significantly better when cutting staples, when cutting tissues after cutting staples, and in the combined overall comparison. Volunteers rated the cutting ability and ergonomics of the Direct Drive more desirable than the other brands. Further, high-resolution digital photography and scanning electron microscopy demonstrated significantly less damage to the Direct Drive. Finally, a reusable handle on the Direct Drive scissor resulted in a 53% and 59% cost savings compared with the Endopath and Endo Shear, respectively.All three types of scissors cut fresh tissue easily. The Direct Drive was significantly more durable, had better ergonomics, and was less expensive compared with the other two brands.