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Background: The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging abdominal procedures, including pancreatojejunostomy. However, one of the major limitations of RAS stems from its lack of tactile feedback that can lead to pancreatic parenchyma laceration during knot tying or during traction on the suture. Moreover, a Wirsung-jejunostomy is not always easy to execute, especially in cases with small diameter duct. Herein, we describe and video-report the technical details of a robotic modified end-to-side invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture instead of the "classical" Wirsung-jejunostomy., Methods: The RmPJ technique consists of a double layer of absorbable monofilament running barbed suture (3-0 V-Loc), the outer layer is used to invaginate the pancreatic stump. Thereafter, a small enterotomy is made in the jejunum exactly opposite to the location of the pancreatic duct for stent insertion (usually 5 Fr) inside the duct. The internal layer provides a second barbed running suture placed between the pancreatic capsule/parenchyma and the jejunal seromuscular layer., Results: A total of 14 patients underwent robotic PD with RmPJ at our Institution. The mean console time was (281.36 ± 31.50 min), while the mean operative time for fashioning the RmPJ was 37.31 ± 7.80 min. Ten out of 14 patients were discharged within postoperative day 8. No clinically relevant pancreatic fistulas were encountered, while two patients developed biochemical leaks., Conclusions: RmPJ is feasible and reproducible irrespective of pancreatic duct size and parenchyma, and can enhance the surgical workflow of this operation. Specifically, the use of barbed sutures allows the exploitation of the potential advantages of the RAS, while minimizing the negative effect caused by the main disadvantage of the robotic approach, its absence of tactile feedback, by ensuring uniform tension on the continuous suture lines used, especially during the reconstructive phase of the operation.

Purpose: After closure of laparotomies, sutures may pull through tissue due to too high intra-abdominal pressure or suture tension, resulting in burst abdomen and incisional hernia. The objective of this study was to measure the suture tension in small and large bites with a new suture material., Methods: Closure of the linea alba was performed with small bites (i.e., 5 mm between two consecutive stitches and 5 mm distance from the incision) and large bites (i.e., 10 mm × 10 mm) with Duramesh™ size 0 (2 mm) and PDS II 2-0 in 24 experiments on six porcine abdominal walls. The abdominal wall was fixated on an artificial computer-controlled insufflatable abdomen, known as the 'AbdoMan'. A custom-made suture tension sensor was placed in the middle of the incision., Results: The suture tension was significantly lower with the small bites technique and Duramesh™ when compared with large bites (small bites 0.12 N (IQR 0.07-0.19) vs. large bites 0.57 N (IQR 0.23-0.92), p  < 0.025). This significant difference was also found in favour of the small bites with PDS II 2-0 (p  < 0.038). No macroscopic tissue failure was seen during or after the experiments., Conclusion: Closure of the abdominal wall with the small bites technique and Duramesh ™ was more efficient in dividing suture tension across the incision when compared to large bites. However, suture tension compared to a conventional suture material was not significantly different, contradicting an advantage of the new suture material in the prevention of burst abdomen and incisional hernia during the acute, postoperative phase.

Background: Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice., Methods: Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen., Results: A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08)., Conclusion: Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.

Background: As the field of laparoscopic surgery grows, the need for a valid assessment of laparoscopic surgical skills becomes apparent. The objective of this study was to identify laparoscopic suturing skills reflective of performing at an expert level., Methods: A Delphi Study was conducted with expert laparoscopic surgeons. Tasks were considered to meet criteria for consensus after 80% of survey participants answered "strongly agree." Results of the previous round of surveys were shared with participants at the start of the next round. The predefined endpoint for the Delphi was set as maximum of three rounds, reaching 80% consensus on each skill, or if > 50% of initial respondents fail to return for subsequent surveys., Results: After three rounds of surveys completed by 13 advanced laparoscopic surgeons, 8 observed skills met consensus (> 80% selected "strongly agree"): forehand suturing, continuous suturing, avoiding tissue trauma, achieving a technically acceptable final product (tight closure), tying a secure knot at the end of suturing, maintaining/checking for appropriate tightness of running suture, accurate depth perception, and loading the needle in < 3 attempts. Skills that approached consensus (with > 50% ranking them as "strongly agree") included correct penetration of target tissue, ability to create a surgeon's knot, awareness of needle tip position, confined space suturing, following the curve of the needle, smooth movements of instruments, loading the needle correctly, adjusting for tissue thickness, and bimanual dexterity., Conclusions: Using Delphi methodology, we identified the skills that are representative of expert laparoscopic suturing. This information can be used to create an assessment tool for this domain. Validation of such a tool will help advance the surgical field towards true competency-based assessment of expertise.

Background: Considering recently published high-level evidence on the management of primary midline ventral hernias, we set out to review current practices and reevaluate the literature surrounding this topic., Methods: The Americas Hernia Society Quality Collaborative (AHSQC) was used to abstract all uncomplicated primary midline ventral hernias. The primary outcomes of interest were surgical approaches, including the use of mesh, the type and position of mesh, and the use of minimally invasive surgery (MIS)., Results: A total of 7030 met inclusion criteria; mean age of 52 ± 14, 71% male, with a median hernia width of 2 [1, 2]. A total 69% underwent mesh repair, while 31% underwent suture repair. The most commonly used mesh was permanent synthetic (98%), placed in either the intraperitoneal (46%) or preperitoneal (42%) spaces. The majority of repairs were performed through an open approach (72%). When mesh was used through an open approach (58%), the majority were patches (70%) placed in the preperitoneal space (50%). Through an MIS approach (95%), the majority were flat meshes (53%) placed in the intraperitoneal space (58%)., Conclusion: Recent high-level literature recommends the use of mesh repair (flat mesh) in all patients with hernia width ≥ 1 cm. This evidence is limited to the use of flat mesh through an open approach. While AHSQC surgeons do offer mesh repair in the majority of cases, this is most commonly using a mesh patch, and is selective towards larger hernias and obese patients. Further research is required to evaluate the safety of mesh patches, and a mesh repair should be offered to a young non-obese healthy patient, as they benefit similarly from the use of mesh.

Background: Robotic surgical platforms have seen increased use among minimally invasive gastrointestinal surgeons (von Fraunhofer et al. in J Biomed Mater Res 19(5):595-600, 1985. doi: 10.1002/jbm.820190511 ). However, these systems still suffer from lack of haptic feedback, which results in exertion of excessive force, often leading to suture failures (Barbash et al. in Ann Surg 259(1):1-6, 2014. doi: 10.1097/SLA.0b013e3182a5c8b8 ). This work catalogs tensile strength and failure load among commonly used sutures in an effort to prevent robotic surgical consoles from exceeding identified thresholds. Trials were thus conducted on common sutures varying in material type, gauge size, rate of pulling force, and method of applied force., Methods: Polydioxanone, Silk, Vicryl, and Prolene, gauges 5-0 to 1-0, were pulled till failure using a commercial mechanical testing system. 2-0 and 3-0 sutures were further tested for the effect of pull rate on failure load at rates of 50, 200, and 400 mm/min. 3-0 sutures were also pulled till failure using a da Vinci robotic surgical system in unlooped, looped, and at the needle body arrangements., Results: Generally, Vicryl and PDS sutures had the highest mechanical strength (47-179 kN/cm 2 ), while Silk had the lowest (40-106 kN/cm 2 ). Larger diameter sutures withstand higher total force, but finer gauges consistently show higher force per unit area. The difference between material types becomes increasingly significant as the diameters decrease. Comparisons of identical suture materials and gauges show 27-50% improvement in the tensile strength over data obtained in 1985 (Ballantyne in Surg Endosc Other Interv Tech 16(10):1389-1402, 2002. doi: 10.1007/s00464-001-8283-7 ). No significant differences were observed when sutures were pulled at different rates. Reduction in suture strength appeared to be strongly affected by the technique used to manipulate the suture., Conclusions: Availability of suture tensile strength and failure load data will help define software safety protocols for alerting a surgeon prior to suture failure during robotic surgery. Awareness of suture strength weakening with direct instrument manipulation may lead to the development of better techniques to further reduce intraoperative suture breakage.

Objective: This abstract profiles the comparison of correlations between previously validated Super Monkey Ball (SMB) and recently introduced Underground (U) video game on the Nintendo Wii U to multiple validated tasks used for developing basic and advanced laparoscopic skills., Methods: Sixty-eight participants, 53 residents and 15 attending surgeons, performed the Top Gun Pea Drop, FLS Peg Pass, intracorporeal suturing, and two video games (SMB and U). SMB is an over-the-counter game, and U was formulated for laparoscopic skill training., Results: Spearman's rank correlations were performed looking at performance comparing the three validated laparoscopic training tasks, and SMB/U. The SMB score had a moderate correlation with intracorporeal suturing (ρ = 0.39, p < 0.01), and the final score involving all three tasks (ρ = 0.39, p < 0.01), but low correlations with Pea Drop Drill and FLS Peg Transfer (ρ = 0.11, 0.18, p < 0.01). The U score had a small correlation with intracorporeal suturing and final score (ρ = 0.09, 0.13, p < 0.01). However, there were correlations between U score and Pea Drop Drill, and FLS Peg Transfer (ρ = 0.24, 0.27, p < 0.01, respectively)., Conclusion: In this study, SMB had a very significant correlation with intracorporeal suturing. U demonstrated more of a correlation with basic skills. At this point, our conclusion would be that both are effective for laparoscopic skill training, and they should be used in tandem rather than alone.

Background: The benefits of haptic feedback in laparoscopic surgery training simulators is a topic of debate in the literature. It is hypothesized that novice surgeons may not benefit from the haptic information, especially during the initial phase of learning a new task. Therefore, provision of haptic feedback to novice trainees in the early stage of training may be distracting and detrimental to learning. A controlled experiment was conducted to examine the effect of haptic feedback on the learning curve of a complex laparoscopic suturing and knot-tying task., Methods: The ProMIS and the MIST-VR surgical simulators were used to represent conditions with and without haptic feedback, respectively. A total of 20 novice subjects (10 per simulator) were trained to perform suturing and knot-tying and practiced the tasks in 18 sessions of 1 h each., Results: At the end of the 3-week training period, the subjects performed equally fast but more consistently with haptics (ProMIS) than without haptics (MIST-VR). The subjects showed a slightly higher learning rate and reached the first plateau of the learning curve earlier with haptic feedback., Conclusion: In general, learning with haptic feedback was significantly better than learning without it for a laparoscopic suturing and knot-tying task, but only during the first 5 h of training. Haptic feedback may not be warranted in laparoscopic surgical trainers. The benefits of a shorter time to the first performance plateau and more consistent initial performance should be balanced with the cost of implementing haptic feedback in surgical simulators.

Background: This study aimed to evaluate the surgeon performance and workload of a next-generation magnetically anchored camera compared with laparoscopic and flexible endoscopic imaging systems for laparoscopic and single-site laparoscopy (SSL) settings., Methods: The cameras included a 5-mm 30° laparoscope (LAP), a magnetically anchored (MAGS) camera, and a flexible endoscope (ENDO). The three camera systems were evaluated using standardized optical characteristic tests. Each system was used in random order for visualization during performance of a standardized suturing task by four surgeons. Each participant performed three to five consecutive repetitions as a surgeon and also served as a camera driver for other surgeons. Ex vivo testing was conducted in a laparoscopic multiport and SSL layout using a box trainer. In vivo testing was performed only in the multiport configuration and used a previously validated live porcine Nissen model., Results: Optical testing showed superior resolution for MAGS at 5 and 10 cm compared with LAP or ENDO. The field of view ranged from 39 to 99°. The depth of focus was almost three times greater for MAGS (6-270 mm) than for LAP (2-88 mm) or ENDO (1-93 mm). Both ex vivo and in vivo multiport combined surgeon performance was significantly better for LAP than for ENDO, but no significant differences were detected for MAGS. For multiport testing, workload ratings were significantly less ex vivo for LAP and MAGS than for ENDO and less in vivo for LAP than for MAGS or ENDO. For ex vivo SSL, no significant performance differences were detected, but camera drivers rated the workload significantly less for MAGS than for LAP or ENDO., Conclusion: The data suggest that the improved imaging element of the next-generation MAGS camera has optical and performance characteristics that meet or exceed those of the LAP or ENDO systems and that the MAGS camera may be especially useful for SSL. Further refinements of the MAGS camera are encouraged.

Background: It is generally assumed that safety of tissue manipulations during (laparoscopic) surgery is related to the magnitude of force that is exerted on the tissue. To provide trainees with performance feedback about tissue-handling skills, it is essential to define objective criteria for judging the safety of applied forces. To be of clinical relevance, these criteria should relate the applied forces to the risk of tissue damage. This experimental study was conducted to determine which tractive forces during suturing cause tissue damage in different types of porcine tissues., Methods: Tractive forces were applied on eight different tissue types (fascia, aorta, vena cava, peritoneum, small and large bowel, uterus, and fallopian tube) of 10 different pigs by placing increasingly higher loads on sutures in the tissue. We determined the load at what tissue damage occurred through visual inspection of the tissue. For each tissue sample, three consecutive measurements were performed., Results: The average maximum acceptable force varied between 11.43 N for fascia to 1.25 N for fallopian tube. The difference in allowable force between these two structures is almost tenfold. Small bowel can be handled with a tractive force almost 1.5-fold higher than large bowel., Conclusions: Each tissue type was found to have its own individual range of acceptable maximum forces before visual tissue damage occurs. With the results presented in this study, it is possible to provide clinically relevant and validated feedback to trainees about their tissue-handling skills.

Background: For dural plasty, several kinds of substitute materials are used clinically. Among these materials, pericranium is often used as a dural substitute since it is autologous and easy to harvest. However, it is rather thin and fragile, which makes it difficult to suture onto peripheral dura mater, especially when the defect is large., Objective: We present a simple method of reinforcing the pericranium with fibrin sealant, which facilitates easier handling and suturing of the pericranium., Methods: Fifteen patients who underwent surgical removal of meningioma, metastatic brain tumor and glioma attached to the dura mater were included in this analysis. To close the defects, we use 'fibrin-sealed pericranium'. Herein we describe the method we employed in these cases. First, a standard skin flap is made by dissecting the subgaleal layer, leaving the periosteum on the bone. Second, fibrin sealant is evenly applied to the pericranium. Finally, the pericranium is cut along the reinforced area and dissected from the bone. The harvested pericranium is then used for closure of the dural defect. Some of these patients received further treatment as needed according to each pathology. The fibrin-sealed pericranium was examined histopathologically., Results: Fibrin-sealing of pericranium made it durable enough to be handled and sutured easily. There were no significant complications or treatment failures, such as infection or CSF leakage., Conclusions: Reinforcement of the pericranium with fibrin sealant is a simple and easy method to reduce the stress of dural plasty.

Background: Knot-tying in the deep operative field is very complicated because of the narrow working space during endoscopic transsphenoidal surgery. We present a novel technique for tying deep knots called the "easy slip-knot," which was developed from a knot used to tie fishing lines., Method: After threading the dura, an easy slip-knot is made outside the nostril. One end of the string is pulled, the knot then naturally slips, and should reach the operative field without needing a knot-pusher., Findings: This method is not complicated, is easily applied to the operative field by slipping the knot into position, and is able to tie sutures securely., Conclusions: The easy slip-knot should be useful for endoscopic surgery.

Background: A unique endoscopic platform with two independent end-effectors, each with five degrees of freedom, and an ergonomic user interface has been developed to address the needs of complex endolumenal and natural orifice translumenal endoscopic surgery (NOTES) procedures. This study aimed to measure the amount this new platform would improve performance for bimanual coordination compared with a standard dual-channel scope using a benchtop simulation., Methods: Task 1 involved 12 individuals performing an identical bimanual coordination task with two different devices: a dual-channel endoscope (DCE) and the EndoSAMURAI prototype. The participants were separated into three groups with different levels of endoscopy and NOTES experience. A complex bimanual coordination task (pin transfer) was used. For this task, 12 pins had to be manipulated in a predetermined order. Performance was measured by movement speed, and accuracy. Comparisons were made between the two devices and the three groups of subjects. Task 2 required the same 12 participants to perform a standardized intracorporeal suture in a NOTES simulation., Results: In the pin transfer task, overall performance speed was significantly faster using the EndoSAMURAI (304 ± 125 s) rather than the DCE (867 ± 312 s; P < 0.001). The difference between the two operating systems was more pronounced in the student group than in the surgeon group: experts (226 ± 41 vs. 620 ± 277 s), surgeons (333 ± 152 vs. 930 ± 283 s), students (318 ± 83 vs. 1021 ± 423 s). Accuracy, as indicated by the number of pin drops, also was significantly better using the EndoSAMURAI (0.4) rather than the DCE (1.8 drops; P = 0.006). In addition, all 12 participants were able to complete a suture using the EndoSAMURAI, but none could complete a suture using the DCE., Conclusions: The EndoSAMURAI enhances performance times and accuracy in complex surgical tasks compared with the conventional therapeutic endoscope.

Background: Minimal access surgery is associated with increased risk of complications, particularly early in a surgeon's laparoscopic career. This is mostly due to loss of depth cues, degraded tactile feedback from surgical instrument, and the "fulcrum effect". Degraded and restricted image on the monitor makes camera orientation very important. The objective of this study is to investigate the effects of camera rotation on laparoscopic performance., Methods: In two separate studies 100 laparoscopic novices and 7 experienced laparoscopic surgeons ([300 laparoscopic procedures) were asked to perform a simple laparoscopic cutting task and tie intracorporeal square-knots (respectively) under 0, 15, 45, 90, and 180 camera rotation., Results: In study 1 camera rotation significantly degraded performance of laparoscopic novices (p\0.00001) and also increased their error rate (p\0.00001). In study 2 camera rotation significantly increased the length of time it took surgeons to tie an intracorporeal square-knot (p\0.00001) and the number of errors made (p\0.0001)., Conclusions: Unintentional camera rotation during surgery should be avoided to eliminate one potential source for errors.

Background: To be an effective training tool, a laparoscopic simulator has to provide metrics that are meaningful and informative to the trainee. Time, path length and smoothness are often used parameters, but are not very informative on the quality of the performance. This study aims to validate a newly developed assessment method for laparoscopic suturing on the ProMIS augmented reality simulator, and compares it with scores of objective observers., Methods: Twenty-four participants practised their suturing skills on the augmented reality suturing module: experienced participants (n = 10), >50 clinical laparoscopic suturing experience; and novice participants (n = 14), without laparoscopic experience. The performances were recorded and assessed by two unrelated observers and compared with the assessment scores. The assessment score was a calculation of time spent in the correct area and quality (strength) of the knot. To test the accuracy of the individual assessment parameters, we compared these with each other., Results: The experienced participants had significantly higher performance scores than the novice participants in the beginner-level mode (mean 95.73 vs. 60.89, standard deviation 2.63 vs. 17.09, p < 0.001, independent t-test). The performance scores of the assessment method (n = 43) correlated significantly with the scorings of the objective observers (Spearman's rho 0.672; p < 0.001). The parameter time spent in correct area had a calculated significant correlation with the strength of the knot (n = 229, Spearman's rho 0.257, p < 0.001), but this was clinically irrelevant., Conclusion: This assessment method is a valid tool for objectively assessing laparoscopic suturing skills. Although assessment parameters can correlate, to provide informative feedback it is important to combine meaningful measurements in the assessment of suturing skills.

Background: The literature of endoluminal treatment of gastroesophageal reflux disease (GERD) widely varies in the level of evidence presented for analysis. Therefore there is a need for a comprehensive evidence-based medicine (EBM) analysis of the current literature evidence of the three FDA-approved modalities used for endoluminal treatment of GERD., Search Strategy: In January 2007, the MEDLINE database was searched for randomized controlled trials (RCTs), and controlled clinical trials of currently available endoluminal treatment of GERD. Database searches combined the specific endoluminal device keywords with the condition-specific keyword (e.g., GERD)., Data Collection and Analysis: All relevant studies have been categorized according to the evidence they provide according to the guidelines for Levels of Evidence and Grades of Recommendation supplied by the Oxford Centre for Evidence-Based Medicine. MAIN RESULTS AND AUTHORS' CONCLUSION: Sixteen studies met the inclusion criteria, representing 787 patients. The methodological quality of most of the included studies was average; four studies were grade 1b (individual randomized trial), 10 were grade 2b (individual cohort study), and two were grade 3b (individual case-control study) There is grade 1b and 2b evidence demonstrating the EndoCinch plication is effective in reducing GERD symptoms at short-term follow up. However, in the majority of the studies analyzed, the procedure does not significantly reduce the acid exposure in the distal esophagus. The majority of the studies with long-term outcome showed disappointing outcomes, probably due to suture loss in the majority of patients. There is grade 1b and 2b evidence demonstrating that the Stretta procedure is effective in reducing GERD symptoms at short- and mid-term follow up. However, in the majority of the studies analyzed, the procedure did not reduce significantly the acid exposure in the distal esophagus. There is grade 1b and 2b evidence demonstrating that full-thickness plication is effective in reducing GERD symptoms, and acid exposure in the distal esophagus.

Background: Process measures describing the generation of movement are useful for evaluation and performance feedback purposes. This study aimed to identify process measures that differ between novice and advanced laparoscopists while completing a suturing skill., Methods: A group of junior and a group of senior residents and fellows in surgery (n = 6) placed 10 laparoscopic sutures in a synthetic model. Process measures were quantified using an opto-electric motion/force sensor assembly that recorded: instrument rotation, applied forces, time, and time delays between force application and instrument rotation., Results: Advanced trainees showed increased instrument rotation, higher peak applied force, and faster performance compared to novices (alll p < .01). However, over trials, only novices showed adaptations for instrument rotation and total time (interactions at p < .01) with no adaptation for the force application. The difference between the moments of force application and instrument rotation was not sensitive to participant training., Conclusions: Movement process measures can enhance our understanding of early adaptation processes and how such factors might be used as feedback to facilitate skill acquisition.

Background: The use of simulation for minimally invasive surgery (MIS) skills training has many advantages over current traditional methods. One advantage of simulation is that it enables an objective assessment of technical performance. The purpose of this study was to determine whether the ProMIS augmented reality simulator could objectively distinguish between levels of performance skills on a complex laparoscopic suturing task., Methods: Ten subjects--five laparoscopic experts and five laparoscopic novices--were assessed for baseline perceptual, visio-spatial, and psychomotor abilities using validated tests. After three trials of a novel laparoscopic suturing task were performed on the simulator, measures for time, smoothness of movement, and path distance were analyzed for each trial. Accuracy and errors were evaluated separately by two blinded reviewers to an interrater reliability of >0.8. Comparisons of mean performance measures were made between the two groups using a Mann-Whitney U test. Internal consistency of ProMIS measures was assessed with coefficient alpha., Results: The psychomotor performance of the experts was superior at baseline assessment (p < 0.001). On the laparoscopic suturing task, the experts performed significantly better than the novices across all three trials (p < 0.001). They performed the tasks between three and four times faster (p < 0.0001), had three times shorter instrument path length (p < 0.0001), and had four times greater smoothness of instrument movement (p < 0.009). Experts also showed greater consistency in their performance, as demonstrated by SDs across all measures, which were four times smaller than the novice group. Observed internal consistency of ProMIS measures was high (alpha = 0.95, p < 0.00001)., Conclusions: Preliminary results of construct validation efforts of the ProMIS simulator show that it can distinguish between experts and novices and has promising psychometric properties. The attractive feature of ProMIS is that a wide variety of MIS tasks can be used to train and assess technical skills.

Background: The assessment of technical skills should provide objective feedback and judge suitability of progress during training. The aim of this study was to validate two objective assessment techniques for laparoscopic suturing and demonstrate a correlation between them., Methods: Six experts, seven surgeons skilled in laparoscopic suturing, and 13 with no laparoscopic suturing skills were asked to place two or three intracorporeal sutures on a synthetic suture pad. The latter group was given video-based instructions prior to the execution of the sutures. Ergonomic conditions were standardized for all subjects. The procedures were recorded on videotape and two blinded observers rated the first suture of each subject on a 29-point checklist. A motion analysis system, Imperial College Surgical Assessment Device, was used to assess psychomotor skills., Results: There was a significant difference in the time taken (p = 0.000) and total path length (p = 0.000) per suture across the groups. There were also a significant difference in the total checklist score (p = 0.000) and its individual categories. The was a strong correlation between the total path length and the total checklist score (coefficient, 0.78; p < 0.001)., Conclusions: A combination of the motion analysis system and the checklist would make the process of formative feedback during the learning of intracorporeal suturing objective and comprehensive.

Background: Needleholders with in-line handles (ILH) and those with pistol-grip handles (PGH) were compared in terms of operative end-product quality (OEPQ), procedure effectiveness (PE), and surgeon forearm workload (SFWL) during suturing in a laparoscopic simulator., Methods: A 90% power crossover design at alpha 0.05 required 46 surgeons. Block randomization generated ILH-PGH or PGH-ILH sequence allocation. The task involved suturing a perforated ulcer on a foam stomach in a simulator. In this study, OEPQ was measured by tissue damage, accuracy error, water leak; PE by operating time and motion analysis including goal-directed actions (GDA) and non-goal-directed actions (NGDA); and SFWL by electromyogram (EMG) of six forearm and thumb muscles., Results: The 46 surgeons performed the tasks as allocated. All the variables but two were significantly different between the first and second tasks, ignoring the handle type. There was no evidence of an unequal carryover effect when the comparison was stratified by ILH-PGH or PGH-ILH sequence. As compared with ILH, PGH tissue damage (0.1 vs 0.2 mm; p = 0.06) and NGDA (1 vs 1 p = 0.09) were different, whereas accuracy error, leak rates, operating time, GDA, and EMG were not., Conclusions: As compared with ILH needleholders, the use of PGH needleholders led to increased tissue damage and non-goal-directed actions during a suturing task in a simulator.

Background: Laparoscopic suturing is required to develop competency in advanced laparoscopy., Methods: Manuals detailing laparoscopic suturing were give to 17 Surgery residents. One week later they performed a suture on a training model. Time (s), accuracy (mm), and knot strength (lb) were recorded. The residents were blindly randomized to intervention (n = 9) and control (n = 8) groups. The intervention residents attended a 60-min course with lecture, video, and individual proctoring. Two weeks later they performed a stitch with standard laparoscopic instruments and a stitch with a suturing assist device. Statistical analysis included a Wilcoxon rank-sum test., Results: The intervention residents decreased their suturing time from the first to the second stitich (732.4-257.6s), the control and residents decreased their time from 500.2 s to 421.8 s. The time required to perform the second stitch showed no significant difference between the two groups (p = 0.46), but the difference in reduced time between the first and second stitch was significant (p = 0.001). Using the suturing assist device for the third suture, the intervention and control groups both decreased their times significantly. The control residents performed almost as quickly as the intervention residents with the suturing; device (p = 0.11). Accuracy and knot strength were not different in any test., Conclusions: Residents can improve suturing skill with a short didactic course and individual proctoring. A suturing assist device decreases time required by inexperienced surgeons to device perform an intracorporeal tie.

Background: Fixation of the mesh is crucial for the successful laparoscopic repair of incisional hernias. In the present experimental study, we used a pig model to compare the tensile strengths of mesh fixation with helical titanium coils (tackers) and transabdominal wall sutures., Methods: Thirty-six full-thickness specimens (5 x 7 cm) of the anterior abdominal wall of nine pig cadavers were randomized for fixation of a polypropylene mesh (7 x 7 cm) by either tackers or transabdominal wall sutures. The number of fixation points varied from one to five per 7-cm tissue length, with distances between fixation points of 2.3, 1.8, 1.4, and 1.2 cm, respectively. The force required to disrupt the mesh fixation (tensile strength) was measured by a dynamometer. Statistical analysis was performed using the Wilcoxon test and the Spearman rank correlation test., Results: The mean tensile strength of mesh fixation by transabdominal sutures was significantly greater than that by tackers for each number of fixation points: 67 N vs 28 N for a single fixation point (p <0.001), 115 N vs 42 N for two fixation points (p <0.001), 150 N vs 63 N for three fixation points (p <0.05), 151 N vs 73 N for four fixation points (p <0.05), and 150 N vs 82 N for five fixation points (p <0.05). Increasing the number of fixation points over three per 7 cm (distance between fixation points of 1.8 cm) did not improve tensile strength., Conclusion: The tensile strength of transabdominal sutures is up to 2.5 times greater than the tensile strength of tackers. Therefore, the use of transabdominal sutures for mesh fixation appears to be preferable for laparoscopic incisional hernia repair.

Background: Few comparative studies have evaluated conventional and laparoscopic knots. The objective of this study was to evaluate laparoscopic knot reliability and identify which type of knot is most secure., Methods: Seven types of knots were compared; each one was conventionally tied with four and six throws and similarly by laparoscopy. Dinsmore nomenclature for knots was used. A tension meter was used to evaluate knot reliability, using the loop method, and percentage of failure by slipping and tensile strength was calculated for each group., Results: When S=S=S=S and S=S=S=S=S=S geometry are excluded, there was no difference between laparoscopic and conventional knot. A significant difference between four- and six-throw knots was shown. Excluding S=S=S=S=S=S geometry, all knots in the conventional six-throw group were secure. Intracorporeal 2X1X1X1X1 and 1X1X1X1X1X1 and extracorporeal SXS#SXS#SXS six-throw laparoscopic group knots were secure., Conclusions: Laparoscopic knots are as secure as conventional knots. All knots must be made with six throws because security is maximized.

Background: Laparoscopic suturing is technically a demanding skill in laparoscopic surgery. Ergonomic experimental studies provide objective information on the important factors and variables that govern optimal endoscopic suturing. Our objective was to determine the optimum physical alignment, visual display, and direction of intracorporeal laparoscopic bowel suturing using infrared motion analysis and telemetric electromyography (EMG) systems., Methods: Ten surgeons participated in the study; each sutured 50-mm porcine small bowel enterotomies toward and away from the surgeon in the vertical and horizontal bowel plane with either isoplanar (image display corresponds with actual lie of the bowel) or nonisoplanar (bowel displayed horizontally but mounted vertically in the trainer and vice versa) display. The end points were the placement error score, execution time, leakage pressure, motion analysis, and telemetric EMG parameters of the surgeon's dominant upper limb., Results: Suturing was demonstrably easier in the vertical than in the horizontal plane, resulting in a better task quality (placement error score, p < 0.0001; leakage pressure, p < 0.005) and shorter execution time (p < 0.05). Nonisoplanar display of the surgical anatomy degrades performance in terms of both task efficiency and task quality. On motion analysis, a wider angle of excursion and lower angular velocity were observed during the vertical suturing with isoplaner display. Compared to horizontal suturing, supination at the wrist was significantly greater during vertical than horizontal suturing (p < 0.05). Within each category (vertical vs horizontal suturing), the direction of suturing (toward/away from the surgeon) did not influence the extent of pronation/ supination at the wrist. In line with the degraded performance, significantly more muscle work was expended during horizontal suturing. This affected the forearm flexors (p < 0.05), arm flexors and extensors (p < 0.005 and p < 0.05, respectively), and deltoid muscles (p < 0.005) and was accompanied by significantly more fatigue in the related muscles. Small bowel enterotomies sutured toward the surgeon in both the vertical and the horizontal planes exhibited less placement error score than when sutured away from the surgeon, with no significant difference in the motion analysis and EMG parameters., Conclusions: Optimal laparoscopic suturing (better task quality and reduced execution time) is achieved with vertical suturing toward the surgeon with isoplanar monitor display of the operative field. The poorer task performance observed during horizontal suturing is accompanied by more muscle work and fatigue, and it is not improved by monitor display of the enterotomy in the vertical plane.

In 11 mongrel dogs in propiophenylpromazine-pentobarbital-anaesthesia the influence of forced respiration on the load of puncture channels of a suture was investigated. For this horizontal suture in the upper abdominal wall, threads No. 3 USP and round needles No. ECT-4 were used. The experiments were carried out in supine position with stretched hindlegs, in supine position with relaxed hindlegs, in lateral position, and in hanging abdominal position. Measurements were performed with a selfconstructed resistance strain gauge element. Rising forced respiration pressure increased the inspiratory load of puncture channels, but there were no significant differences between spontaneous breathing and forced respiration with pressure of 10 cm H2O. In contrary to this there were highly significant differences between spontaneous breathing and forced respiration with pressure of 20 and 30 cm H2O (multiple variance analysis). For instance the load during forced respiration with a pressure of 30 cm H2O in supine position with relaxed hindlegs rose about 67% above pressure values of spontaneous breathing. It could be shown that the expiratory load in the puncture channels was not influenced by forced respiration pressure, but depended on the body position; in dogs it was minimal in side position (45-48 g), higher in supine position with relaxed hindlegs (67-71 g), even higher in supine position with stretched hindlegs (88-92 g), and maximal in hanging abdominal position (109-113 g). By this investigation the increase of load in the puncture channels during forced respiration with pressures of 20 and 30 cm H2O was quantified.