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AbstractBackground and Purpose: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.Materials and Methods: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 situmorcellation. 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.Results: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.Conclusions: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. [ABSTRACT FROM AUTHOR]

AbstractBackground and Purpose: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.Materials and Methods: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.Results: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.Conclusions: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. [ABSTRACT FROM AUTHOR]

Background and Purpose 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.Subjects and Methods 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.Results 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 v9.0; 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).Conclusions 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. [ABSTRACT FROM AUTHOR]