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Background: We examined the impact of tool complexity on surgeons' performance and evaluated the value of using a simulation-based program for reducing training cost., Methods: Three pairs of surgical graspers with increasing mechanical complexity, which were designed for open, laparoscopic, and endoscopic procedures, were used in performing a simple object transportation task. Task times and mental workload of 17 surgeons were compared using all 3 variations of the graspers to test the impact of tool complexity on surgical performance. Subsequently, 4 of these surgeons decided to enter a 3-week training phase and practiced with these 3 surgical instruments on a daily basis. Learning curves were plotted to examine the value of using simulation for proficiency training with these tools., Results: Task time was significantly prolonged as tool complexity increased. Practice in a simulated environment shortened the task time significantly and moderately reduced mental workloads. However, the difference in task time varied among the 3 types of tools. Between days 1 and 9, task times for each types of grasper were reduced by 55% (endoscopic), 42% (open), and 22% (laparoscopic)., Conclusions: Tool complexity may degrade a surgeon's performance. Extensive simulation training programs are important for surgeons to gain proficiency in handling a tool before they practice on patients., (© The Author(s) 2014.)

Background: Rectal tumors can be excised through a number of minimally invasive transanal techniques including transanal excision, transanal endoscopic microsurgery, and transanal minimally invasive surgery (TAMIS). Specialty training is often required to master the nuances of these approaches. This study aimed to create a reproducible transanal excision training model that is suited for laparoendoscopic techniques., Methods: Frozen porcine rectum and anus with intact perianal skin were commercially obtained. Thawed specimens were then cut to approximately 20 cm in length. The proximal end of the rectum was then everted and suction applied to the mucosa to create pseudopolyps of various sizes (sessile and pedunculated). Larger pedunculated lesions were made by tying the base of the pseudopolyps with 5-0 monofilament sutures to gather more tissue. Methylene blue dye was injected submucosally into the lesions to simulate tattoos. The proximal rectum was then closed with sutures. The model was suspended in a trainer box by clamping the distal end in a ringed clamp and the proximal end to the box. Transanal excisions using TAMIS were then performed. The procedures were done by trained community colorectal surgeons attending courses on transanal minimally invasive surgery., Results: Both partial- and full-thickness excisions of sessile and pedunculated rectal lesions were successfully performed during simulated TAMIS by trained community surgeons learning this laparoendoscopic technique., Conclusion: Transanal laparoendoscopic procedures to excise rectal tumors can be successfully and reproducibly performed in an ex vivo porcine anorectal model.

Background: The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task., Methods: A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors., Results: The endoscopy group was significantly faster than the control group at accessing the peritoneal cavity through the gastric incision (median 27 vs 78 s; P = .015), applying diathermy to the base of the appendix (median 103.5 vs 173 s; P = .014), and navigating to the gallbladder (median 76 vs 169.5 s; P = .049). Endoscopy participants completed the full NOTES procedure in a shorter time than the laparoscopy group (median 863 vs 2074 s; P < .001)., Conclusion: This study highlights the importance of endoscopic training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.

Background: Natural orifice translumenal endoscopic surgery (NOTES) is a new surgical concept that requires training before it is introduced into clinical practice. The endoscopic–laparoscopic interdisciplinary training entity (ELITE) is a training model for NOTES interventions. The latest research has concentrated on new materials for organs with realistic optical and haptic characteristics and the possibility of high-frequency dissection. This study aimed to assess both the ELITE model in a surgical training course and the construct validity of a newly developed NOTES appendectomy scenario., Methods: The 70 attendees of the 2010 Practical Course for Visceral Surgery (Warnemuende, Germany) took part in the study and performed a NOTES appendectomy via a transsigmoidal access. The primary end point was the total time required for the appendectomy, including retrieval of the appendix. Subjective evaluation of the model was performed using a questionnaire. Subgroups were analyzed according to laparoscopic and endoscopic experience., Results: The participants with endoscopic or laparoscopic experience completed the task significantly faster than the inexperienced participants (p = 0.009 and 0.019, respectively). Endoscopic experience was the strongest influencing factor, whereas laparoscopic experience had limited impact on the participants with previous endoscopic experience. As shown by the findings, 87.3% of the participants stated that the ELITE model was suitable for the NOTES training scenario, and 88.7% found the newly developed model anatomically realistic., Conclusions: This study was able to establish face and construct validity for the ELITE model with a large group of surgeons. The ELITE model seems to be well suited for the training of NOTES as a new surgical technique in an established gastrointestinal surgery skills course.

LESS and NOTES are the further step forward the "scarless" surgery recently, which have challenged the main principles of conventional multiport laparoscopy. To develop the surgical skills for these novel techniques, the guideline for training program should be neccesary for its clinical practice to reduce the complications. In this paper, we will summary the challenges of these new technique and introduce our experience of training courses.

As essentially all operations performed with open laparotomy can be completed with minimal access, surgeons and industry continue to push the boundaries of minimally invasive surgery. New and controversial approaches, such as natural orifice translumenal endoscopic surgery (NOTES) and single incision or single port surgery are being explored with the goal of reduced surgical morbidity. The fundamental idea of single port surgery is therefore to minimize the number of abdominal wall incisions and allow access for all laparoscopic instruments through one skin incision. Several techniques in use require specialized equipment with multiple ports through one umbilical incision or one multichannel port. For single port surgery to be widely adopted surgeons must demonstrate safety, efficacy and reproducibility of the technique across a wide range of patients and clinical scenarios. In order to meet these requirements concerns about well-founded surgical training and quality monitoring must be addressed as with any major technical advance.

"Scarfree" surgery is a desired goal in the world of laparoscopy and interventional endoscopy. One possibility to achieve this goal is abdominal access via a natural orifice (natural orifice transluminal endoscopic surgery, NOTES); however, this procedure and its applications lack an appropriate platform. Further possibilities are reduced port techniques or single port access surgery, which result in minimal scarring. Development and continued growth in this area cover a broad spectrum. Although acceptance has been demonstrated, the technique must be adopted in a safe and effective manner and must be economically and ecologically safe. This article gives an overview of the development of the technique, the learning curve, and new applications for this new technique. An English full-text version of this article is available at SpringerLink as supplemental.

Skill training is an essential part of surgical education. Every physician has to get familiar with the various operation techniques and needs to handle the different instruments. However, mechanical and computer-based VR-simulators offer only one specific procedure, either laparoscopic or endoscopic. We designed the universal training system ELITE (endoscopic-laparoscopic interdisciplinary training entity) which is a new full synthetic ex vivo surgical training model for laparoscopic surgery, combined endoluminal/endocavitary procedures ("hybrid surgery") and NOTES. The aim of the current investigation was to integrate respiration and electro dissection into the model, and the evaluation of both innovations. The ELITE is a full-size replica of a human female torso including a gas-tight abdominal wall and offering various accesses to the abdomen. A complete organ package including liver, gallbladder, spleen, gastrointestinal tract, including the mesentery and omentum is available for this system. Cholecystectomy and appendectomy can be simulated realistically with this new training system. For more realistic conditions during operations breathing-induced organ motion could be integrated into this system. Two latex balloons were inserted into the system to imitate the function of the diaphragm. They are inflated and deflated according to the respiration cycle and move the artificial organs in a natural way. Physicians, including endoscopic/laparoscopic novices and experts, were asked to train different NOTES procedures on the model. Performance of their training and subjective appraisal of the model itself were evaluated. The opportunity of electrodissection of the gallbladder and appendix and simulation of breath excursion of the diaphragm could successfully be implemented into the training system. One recently published study showed that ELITE is a suitable tool to train different surgical procedures. All subjects (novices and endoscopic/laparoscopic experts) showed a significant learning curve during the assessment. Experts could be reliably differentiated from novices. The actual evaluation of the model showed that 97% of the subjects considered the ELITE as a useful simulator for NOTES. ELITE was validated to be a suitable tool to train different NOTES procedures. As a step by step training of NOTES is highly recommended, this training system offers the opportunity by degrees that animal experiments can be replaced, especially, for learning of basic techniques and thus costs can be significantly reduced.

Background: Natural orifice transluminal endoscopic surgery (NOTES) is the anticipated progression of minimally invasive surgery. As it approaches, surgeons will need to develop the fundamental skills and spatial orientation needed to perform safely in this new field. The Natural Orifice Surgery Consortium for Assessment and Research has established several fundamental challenges to the safe introduction of NOTES. Our institutional experience with laparoscopic-assisted endoluminal surgery is reviewed to display the techniques and efficacy of procedures that address many of these challenges and may provide a safe transition for the general surgeon to NOTES or as an alternative to pure NOTES., Methods: A retrospective review of all laparoscopic-assisted endoluminal surgeries from 1991 to 2007 was performed. Patients had been referred to the institution and selected after either unsuccessful attempts from traditional endoscopic resection of pathology by a gastroenterologist or being deemed an unfavorable candidate for traditional endoscopic resection. All procedures involved establishment of pneumoperitoneum, placement of trochar ports under laparoscopic visualization, balloon ports in gastric cases combined with endoscopy, intraluminal insufflation, coordinated resection of intraluminal pathology using both the endoscopic and laparoscopic instruments, and closure of the intraluminal port sites with intracorporeal suturing., Results: A total of 175 procedures were performed from 1991 to 2007 using these techniques. These procedures varied and included laparoscopic monitored colonoscopic polypectomy, resection of gastric polyps, intraluminal cystgastrostomy, gastric ulcer resection, and foreign body removal. The average age was 55 years (range 38 to 75 y), length of operation 95 minutes (range 60 to 137 min), hospital stay 3.5 days, and 5 complications (2.8%). Of the total procedures, 18 (10.2%) patients were found to have malignancy on frozen section and preceded with a formal resection. There are no cancer recurrences to date with a mean follow up of 74 months (6 to 196 mo)., Conclusions: Our institutional experience with these procedures seems to be a natural transition to developing skills for NOTES procedures and displays a safe and effective approach to a wide range of intraluminal pathology. The general surgeon in practice can use this union of laparoscopy and endoscopy using current instruments and technology for safe transition into the emerging field of NOTES, or even as an alternative to pure NOTES. Mastery of intraoperative endoscopy and intraluminal surgery will be essential to this transition.