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Purpose: The current operative report often inadequately reflects events occurring during laparoscopic cholecystectomy (LC). The addition of intraoperative video recording to the operative report has already proven to add important information. It was hypothesized that real-time intraoperative voice dictation (RIVD) can provide an equal or more complete overview of the operative procedure compared to the narrative operative report (NR) produced postoperatively. Methods: SONAR is a multicenter prospective observational trial, conducted at four surgical centers in the Netherlands. Elective LCs of patients aged 18 years and older were included. Participating surgeons were requested to dictate the essential steps of LC during surgery. RIVDs and NRs were reviewed according to the stepwise LC guideline of the Dutch Society for Surgery. The cumulative adequacy rates for RIVDs were compared with those of the postoperatively written NR. Results: 79 of 90 cases were eligible for inclusion and available for further analysis. RIVD resulted in a significantly higher adequacy rate compared to NR for the circumferential dissection of the cystic duct and artery (NR 32.5% vs. RIVD 61.0%, P = 0.016). NR had higher adequacy rates in reporting the transection of the cystic duct (NR 100% vs. RIVD 77.9%, P = < 0.001) and the removal of the gallbladder from the liver bed (NR 98.7% vs. RIVD 68.8%, P < 0.001). The total adequacy was not significantly different between the two reporting methods (NR 78.0% vs. RIVD 76.4%, P = 1.00). Conclusion: Overall, the adequacy of RIVD is comparable to the postoperatively written NR in reporting surgical steps in LC. However, the most essential surgical step, the circumferential dissection of the cystic duct and artery, was reported more adequately in RIVD. [ABSTRACT FROM AUTHOR]

Background: The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis. Methods: This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable. Results: The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010). Conclusion: Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis. [ABSTRACT FROM AUTHOR]

The availability of intraoperative multimedia recording is increasing. Considering the growing call for physicians' accountability, it is inevitable that multimedia will play an important role in aiding quality control by improving the adequacy of operative reporting. However, the perspectives of medical professionals on this matter are poorly known. In this cross-disciplinary survey, we aimed to investigate the current viewpoints concerning the use of multimedia recording in the operating room. We conducted an electronic survey among all affiliated members of the Association of Surgeons of the Netherlands, the Dutch Urological Association and the Dutch Society of Obstetrics and Gynecology containing questions regarding current use of intraoperative recording and the level of likelihood or objection for certain scenarios. The response rate was 27.8%. The survey encompasses 370 (54.5%) surgeons, 71 (10.5%) urologists, 80 (11.8%) gynecologists, and 158 (23.3%) residents in training. 52.4% of respondents feel that the currently used operative report is insufficient for future quality requirements. 58.5% think it is unlikely they would behave differently during surgery when intra-operative video recording is applied. 82.8% think it is unlikely that their surgical methods would be altered. 63.8% of respondents preferred only video registration when intraoperative recording is implemented. The majority of respondents agree that the current method of operative reporting is insufficient for future quality requirements. There is support for intraoperative video recording, however, legal transparency is needed before either intraoperative video or audio recording could be implemented to protect not only the patients, but also the healthcare providers. [ABSTRACT FROM AUTHOR]

Background: Worldwide, music is commonly played in the operation room. The effect of music on surgical performance reportedly has varying results, while its effect on mental workload and key surgical stressor domains has only sparingly been investigated. Therefore, the aim is to assess the effect of recorded preferred music versus operating room noise on laparoscopic task performance and mental workload in a simulated setting. Methods: A four-sequence, four-period, two-treatment, randomized controlled crossover study design was used. Medical students, novices to laparoscopy, were eligible for inclusion. Participants were randomly allocated to one of four sequences, which decided the exposure order to music and operation room noise during the four periods. Laparoscopic task performance was assessed through motion analysis with a laparoscopic box simulator. Each period consisted of ten alternating peg transfer tasks. To account for the learning curve, a preparation phase was employed. Mental workload was assessed using the Surgery Task Load Index. This study was registered with the Netherlands Trial Register (NL7961). Results: From October 29, 2019 until March 12, 2020, 107 participants completed the study, with 97 included for analyzation. Laparoscopic task performance increased significantly during the preparation phase. No significant beneficial effect of music versus operating room noise was observed on time to task completion, path length, speed, or motion smoothness. Music significantly decreased mental workload, reflected by a lower score of the total weighted Surgery Task Load Index in all but one of the six workload dimensions. Conclusion: Music significantly reduced mental workload overall and of several previously identified key surgical stressor domains, and its use in the operating room is reportedly viewed favorably. Music did not significantly improve laparoscopic task performance of novice laparoscopists in a simulated setting. Although varying results have been reported previously, it seems that surgical experience and task demand are more determinative. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic paraesophageal hernia repair is an effective treatment for symptomatic paraesophageal hernias. To reduce recurrence rates, the use of prosthetics for the crural repair has been suggested. Mesh-related complications are rare but known to be disastrous. To address another form of crural repair, polypropylene strips are suggested. This study aimed to assess peri- and postoperative complications of reinforcement of cruroplasty with polypropylene strips. Methods: From 2013 to 2020, patients with a primary or recurrent type 2, 3, or 4 paraesophageal hernia that underwent cruroplasty with polypropylene strips were retrospectively reviewed. Intra- and postoperative complications were graded according to the Clavien-Dindo classification. The incidence of symptomatic recurrent hiatal hernia (CT or endoscopy proven) and hospital stay were assessed. Results: One hundred fifty-eight patients were included. Mean age was 65 years (standard deviation 10.4), and 119 patients were female (75.3%). Almost 50% of surgeries took place between 2018 and 2020. Median follow-up was 7 months (interquartile range 17.5). Mean operation time in the primary hernia group was 159 min (standard deviation 39.0), and length of stay was 4.4 days. In 3/158 patients (2.0%), intraoperative complications occurred. Two patients developed a grade 4 and seven patients a grade 3 postoperative complication. No mortality was recorded. Twelve recurrences (8.2%) were detected in the primary hernia group and one (9.1%) in the recurrent hernia group. Conclusion: There were no mesh-related complications seen and symptomatic recurrence rate was low, but longer follow-up is needed. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic surgery for colon cancer is associated with improved recovery and similar cancer outcomes at 3 and 5 years in comparison with open surgery. However, long-term survival rates have rarely been reported. Here, we present survival and recurrence rates of the Dutch patients included in the COlon cancer Laparoscopic or Open Resection (COLOR) trial at 10-year follow-up.Methods: Between March 1997 and March 2003, patients with non-metastatic colon cancer were recruited by 29 hospitals in eight countries and randomised to either laparoscopic or open surgery. Main inclusion criterion for the COLOR trial was solitary adenocarcinoma of the left or right colon. The primary outcome was disease-free survival at 3 years, and secondary outcomes included overall survival and recurrence. The 10-year follow-up data of all Dutch patients were collected. Analysis was by intention-to-treat. The trial was registered at ClinicalTrials.gov (NCT00387842).Results: In total, 1248 patients were randomised, of which 329 were Dutch. Fifty-eight Dutch patients were excluded and 15 were lost to follow-up, leaving 256 patients for 10-year analysis. Median follow-up was 112 months. Disease-free survival rates were 45.2 % in the laparoscopic group and 43.2 % in the open group (difference 2.0 %; 95 % confidence interval (CI) -10.3 to 14.3; p = 0.96). Overall survival rates were 48.4 and 46.7 %, respectively (difference 1.7 %; 95 % CI -10.6 to 14.0; p = 0.83). Stage-specific analysis revealed similar survival rates for both groups. Sixty-two patients were diagnosed with recurrent disease, accounting for 29.4 % in the laparoscopic group and 28.2 % in the open group (difference 1.2 %; 95 % CI -11.1 to 13.5; p = 0.73). Seven patients had port- or wound-site recurrences (laparoscopic n = 3 vs. open n = 4).Conclusions: Laparoscopic surgery for non-metastatic colon cancer is associated with similar rates of disease-free survival, overall survival and recurrences as open surgery at 10-year follow-up. [ABSTRACT FROM AUTHOR]

Background: Hartmann's procedure for perforated diverticulitis can be characterised by high morbidity and mortality rates. While the scientific community focuses on laparoscopic lavage as an alternative for laparotomy, the option of laparoscopic sigmoidectomy seems overlooked. We compared morbidity and hospital stay following acute laparoscopic sigmoidectomy (LS) and open sigmoidectomy (OS) for perforated diverticulitis.Methods: This retrospective cohort parallel to the Ladies trial included patients from 28 Dutch academic or teaching hospitals between July 2010 and July 2014. Patients with LS were matched 1:2 to OS using the propensity score for age, gender, previous laparotomy, CRP level, gastrointestinal surgeon, and Hinchey classification.Results: The propensity-matched cohort consisted of 39 patients with LS and 78 patients with OS, selected from a sample of 307 consecutive patients with purulent or faecal perforated diverticulitis. In both groups, 66 % of the patients had Hartmann's procedure and 34 % had primary anastomosis. The hospital stay was shorter following LS (LS 7 vs OS 9 days; P = 0.016), and the postoperative morbidity rate was lower following LS (LS 44 % vs OS 66 %; P = 0.016). Mortality was low in both groups (LS 3 % vs OS 4 %; P = 0.685). The stoma reversal rate after Hartmann's procedure was higher following laparoscopy, with a probability of being stoma-free at 12 months of 88 and 62 % in the laparoscopic and open groups, respectively (P = 0.019). After primary anastomosis, the probability of reversal was 100 % in both groups.Conclusions: In this propensity score-matched cohort, laparoscopic sigmoidectomy is superior to open sigmoidectomy for perforated diverticulitis with regard to postoperative morbidity and hospital stay. [ABSTRACT FROM AUTHOR]

Background: Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated.Materials and Methods: A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018.Results: 90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation.Conclusion: Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic sigmoidectomy for diverticulitis has initially been confined to the elective setting. However, open acute sigmoidectomy for perforated diverticulitis is associated with high morbidity rates that might be reduced after laparoscopic surgery. The aim of this systematic review was to assess the feasibility of emergency laparoscopic sigmoidectomy for perforated diverticulitis. Methods: We performed a systematic search of PubMed, EMBASE and CENTRAL. All studies reporting on patients with perforated diverticulitis (Hinchey III-IV) treated by laparoscopic sigmoidectomy in the acute phase were included, regardless of design. Results: We included 4 case series and one cohort study (total of 104 patients) out of 1,706 references. Hartmann's procedure (HP) was performed in 84 patients and primary anastomosis in 20. The mean operating time varied between 115 and 200 min. The conversion rate varied from 0 to 19%. The mean length of hospital stay ranged between 6 and 16 days. Surgical re-intervention was necessary in 2 patients. In 20 patients operated upon without defunctioning ileostomy, no anastomotic leakage was reported. Three patients died during the postoperative period. Stoma reversal after HP was performed in 60 out of 79 evaluable patients (76%). Conclusions: Acute laparoscopic sigmoidectomy for the treatment of perforated diverticulitis is feasible in selected patients provided they are handled by experienced hands. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Operative notes are the gold standard for detecting adverse events and near misses and form the basis for scientific research. In order to guarantee safe patient care, operative notes must be objective, complete, and accurate. This study explores the current routine of note writing for laparoscopic cholecystectomy (LC) and the differences between the notes of attendings and residents. Methods: Attendings and residents were sent a DVD with footage of three LCs and were asked to 'write' the corresponding notes and to complete a questionnaire. Dictation tapes were transcribed and items in the notes were analyzed for each procedure ('item described' or 'item not described'). Fisher's exact tests were performed using SPSS 16.0 for Mac. Results: Thirteen sets of typewritten notes and 10 dictation tapes were returned. The results of the questionnaire showed that 16 of the 23 sets of notes were dictated. Eight participants found the current system for generating notes inadequate. 14 items (31 %) were included more often in the attendings' notes and 25 items (56 %) were included more often in the residents' notes. Overall, residents significantly more often described the location of the epigastric trocar ( P = 0.018), the size of both working trocars ( P = 0.019), the opening of the peritoneal envelope ( P = 0.002), Critical View of Safety reached ( P = 0.002), and the location for removing the gallbladder ( P = 0.019). With the exception of 'gallbladder perforation' (20 of 21 notes), complications were underreported. Conclusions: In this study residents described more items than attendings. All notes lacked information concerning complications in the procedure, which makes the notes subjective and incomplete. A procedure-specific template or black-box-based operative notes based on established guidelines could improve the quality of the notes of both attendings and residents. [ABSTRACT FROM AUTHOR]

Background: Annually approximately 100.000 patients undergo a laparotomy in the Netherlands. About 15,000 of these patients will develop an incisional hernia. Both open and laparoscopic surgical repair have been proven to be safe. However, the most effective treatment of incisional hernias remains unclear. This study, the 'INCH-trial', comparing cost-effectiveness of open and laparoscopic incisional hernia repair, is therefore needed. Methods/Design: A randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisional hernia, eligible for laparoscopic and open incisional hernia repair. Only surgeons, experienced in both open and laparoscopic incisional hernia repair, will participate in the INCH trial. During incisional hernia repair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisional hernia repair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life. Our hypothesis is that laparoscopic incisional hernia repair comes with a significant shorter hospital stay compared to open incisional hernia repair. A difference of two days is considered significant. One-hunderd-and-thirty-five patients are enrolled in each treatment arm. The economic evaluation will be performed from a societal perspective. Primary outcomes are costs per patient related to time-to-recovery and quality of life. The main goal of the trial is to establish whether laparoscopic incisional hernia repair is superior to conventional open incisional hernia repair in terms of cost-effectiveness. This is measured through length of hospital stay and quality of life. Secondary endpoints are re-operation rate due to post-operative complications or recurrences, mortality and quality of life. Discussion: The difference in time to full recovery between the two treatment strategies is thought to be in favor of laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair is therefore expected to be a more cost-effective approach. [ABSTRACT FROM AUTHOR]

Background: With an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training 'before the job' on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed. Methods: The new embalming method Anubifix combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model. Results: Eleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills. Conclusion: The new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of 'training before the job.' [ABSTRACT FROM AUTHOR]

Background: Much has been published on the role of mechanical bowel preparation (MBP) in open colorectal resection; however, the current study shows little evidence on the use of MBP prior to laparoscopic colorectal resections. In contrast to open procedures, MBP could influence the diameter of the bowel and thus the exposure of the surgical field in laparoscopy. This study aimed to assess the current practice of Dutch laparoscopic surgeons regarding MBP prior to colorectal resections. Methods: In January 2010, members of the Dutch Association for Endoscopic Surgery were invited to fill out an online questionnaire investigating whether MBP is prescribed prior to laparoscopic colorectal surgery, and which considerations are taken into account when choosing or omitting MBP. Results: The 82 (49%) returned questionnaires showed that 20% of respondents prescribe MBP prior to colonic resections, while 63% prescribe MBP prior to rectal resections. The most common reasons for giving MBP were the construction of a protective ileostoma (22%), improvement of the surgical field exposure (16%), and 'other reasons' specified by free text (21%). The three most common reasons for conversion were inadequate surgical field exposure (88%), locally advanced tumor (68%), and adhesions (29%). Concerning the question which stages of the operation are influenced by MBP, 29% of respondents believed that the diameter of the small bowel was influenced by MBP, 29% indicated that the exposure of the surgical field was influenced by MBP, and 52% did not believe that any of the stages of the operation were influenced by MBP. Conclusion: The results of this questionnaire indicate that the implementation of MBP in laparoscopic colorectal surgery is based on individual preferences in the Netherlands. This emphasizes the need of new studies investigating the role of MBP on surgical field exposure in colorectal laparoscopic surgery. [ABSTRACT FROM AUTHOR]

Background: Postoperative bowel obstruction caused by intra-abdominal adhesions occurs after all types of abdominal surgery. It has been suggested that the laparoscopic technique should reduce the risk for adhesion formation and thus for postoperative bowel obstruction. This study was designed to compare the incidence of bowel obstruction in a randomized trial where laparoscopic and open resection for colon cancer was compared. Methods: A retrospective analysis was performed, collecting data of episodes of bowel obstruction with or without surgery. Only episodes treated in the hospital where the index surgery took place were included. Data for 786 patients were collected for the 5-year period after cancer surgery. Results: Baseline characteristics for the evaluated laparoscopic ( n = 383) and open ( n = 403) groups were comparable. The cumulative obstruction percentages at 5 years for the open and laparoscopic groups were 6.5 and 5.1% respectively and did not significantly differ from each other. Tumor stage seemed to influence the risk for bowel obstruction: 2.8% in stage I, 6.6% in stage II, and 7% in stage III, but the differences were not significant. Conclusions: This analysis does not support the hypothesis that laparoscopy leads to fewer episodes of bowel obstruction compared with open surgery. [ABSTRACT FROM AUTHOR]

Background: In the last one hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. The reason for reviewing the literature was evaluating most common ideas on how to treat perforated peptic ulcers (PPU) in general, opinions on conservative treatment and surgical treatment and summarizing ideas about necessary pre-, per- and postoperative proceedings. Method: All relevant articles found by Medline, Ovid and PubMed search were used. Results: A hundred articles written between 1929 and 2009 were reviewed. Of these, 9 were about the history of treatment, 7 about conservative treatment, and 26 were about the surgical procedure of which 8 were addressing laparoscopic correction. Overall there is no consensus, but some advice is given. For conservative treatment there are only a few indications. Use of an omental patch is recommended, irrigation and drainage are not. Laparoscopic correction of PPU as well as for definitive ulcer surgery has many advantages. Conclusions: Surgery for PPU is still a subject of debate despite more than an era of published expertise, indicating the need for establishing guidelines. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy. The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). Methods/Design: In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVAarm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVAarm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs. Discussion: The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis. Trial registration: Nederlands Trial Register NTR2037 [ABSTRACT FROM AUTHOR]

Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open approach. It remains unclear, however, if this benefit is observed after laparoscopic correction of perforated peptic ulcer (PPU). The goal of the present study was to evaluate whether laparoscopic closure of a PPU is as safe as conventional open correction. The study was based on a randomized controlled trial in which nine medical centers from the Netherlands participated. A total of 109 patients with symptoms of PPU and evidence of air under the diaphragm were scheduled to receive a PPU repair. After exclusion of 8 patients during the operation, outcomes were analyzed for laparotomy ( n = 49) and for the laparoscopic procedure ( n = 52). Operating time in the laparoscopy group was significantly longer than in the open group (75 min versus 50 min). Differences regarding postoperative dosage of opiates and the visual analog scale (VAS) for pain scoring system were in favor of the laparoscopic procedure. The VAS score on postoperative days 1, 3, and 7 was significant lower ( P < 0.05) in the laparoscopic group. Complications were equally distributed. Hospital stay was also comparable: 6.5 days in the laparoscopic group versus 8.0 days in the open group ( P = 0.235). Laparoscopic repair of PPU is a safe procedure compared with open repair. The results considering postoperative pain favor the laparoscopic procedure. [ABSTRACT FROM AUTHOR]

Background: With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction. The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs. Methods/design: The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007. Discussion: The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease. Trial registration: Nederlands Trial Register NTR1150 [ABSTRACT FROM AUTHOR]

Background: Training of skills in simulators is preferred over learning on patients so as to avoid undue injury to patients and to allow more efficient use of resources. Most simulators are costly and require a dedicated space. The aim of this study was to evaluate a simple desktop simulator, the Mirror Trainer.Methods: Thirty medical students were randomly assigned to three groups. One group was taught laparoscopic suturing in the Mirror Trainer, the second group used a pelvic training box, while the third group served as a control group and did not receive any training. All suture attempts during training were recorded on video. A blinded, independent investigator analyzed the videos. At the completion of training, the suturing skills of each participant were evaluated in an animal model.Results: Training with the Mirror Trainer required less time than with the pelvic trainer (p < 0.001). Compared with the control group, the Mirror Trainer group and the pelvic trainer group were significantly faster at creating three knots in the pig (p = 0.001 and p = 0.004, respectively). Both training groups performed equally well on the animal model (p = 0.99).Conclusion: The Mirror Trainer and the pelvic trainer are equally effective in teaching laparoscopic suturing skills but training with the Mirror Trainer requires less time, can be done on any desktop, and is less costly. [ABSTRACT FROM AUTHOR]

A response by Marietta Bertleff and Johan Lange to a letter to the editor about their article "Laparoscopic Correction of Perforated Peptic Ulcer: First Choice? A Review of Literature" in a previous issue is presented.