A Stepwise Approach to Laparoscopic Nissen Fundoplication

Evans, Stephen; Jackson, Patrick G.; Czerniach, Donald R.; Kalan, Mohammed; Iglesias, Alberto R.

doi:10.1001/archsurg.135.6.723

Cited by 10 publications

(12 citation statements)

References 11 publications

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“…6,8,9 Early research focused on cognitive knowledge rather than technical skill, 6,9,10 but in the last five years there have been increasing reports of resident technical skill self-assessment in the operating room and in simulated environments. [11][12][13][14][15][16][17] Findings from these studies have focused on improving resident self-assessment, and the reliability and validity of instruments in measuring true and perceived performance.…”

Section: Introductionmentioning

confidence: 99%

Resident self-assessment versus faculty assessment of laparoscopic technical skills using a global rating scale

et al. 2010

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Objectives: Accurate self assessment of laparoscopic technical skill development can accelerate a trainee's learning growth and guide life-long development for surgeons. The aim of this study was to measure the accuracy of obstetrical and gynecology resident self assessments as compared to faculty assessments of laparoscopic technical skill performance using a technical skill global rating scale evaluation. Methods: 37 residents completed four laparoscopic procedures as part of a porcine simulation teaching laboratory: tubal ligation, ovarian cystectomy, salpingostomy and hysterectomy. At the conclusion of the session, residents and faculty completed global rating scale assessments for all laparoscopic procedures completed. Mann-Whitney U analysis was used to compare faculty and resident results. Results: Overall residents self assessment was lower than faculty evaluation (148 cases). Post Graduate Year 1's (n=8/n=31 cases) reported significantly lower scores on 5 of 10 items. Post Graduate Year 2's (n=8/n=35 cases) reported significantly higher scores in 6 of 10 items. Post Graduate Year 3's (n=10/n=39 cases) reported lower scores on all ten items (p<0.05). Post Graduate Year 4's (n=11/n=43 cases) reported significantly lower scores in 9 of 10 items. Conclusions: Residents are more critical of their performance than faculty when using a global rating scale during a laparoscopic simulation teaching session. Implications of inaccurate self perceptions can slow learning development of trainees. Further research is needed to examine the accuracy of resident self perceptions and faculty assessments of performance in the operating room.

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Section: Introductionmentioning

confidence: 99%

Resident self-assessment versus faculty assessment of laparoscopic technical skills using a global rating scale

et al. 2010

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“…[3][4][5][6] During the past 10 years, laparoscopic Nissen fundoplication (LNF) has become the preferred surgical approach. 5,7,8 A success rate of greater than 90% and very low morbidity and mortality figures 3,4,9,10 have resulted in a lower threshold for surgical referral. 2,11 Many patients decide to undergo an operative intervention to avoid the lifelong need for daily medications or to improve minimal reflux symptoms.…”

Section: Discussionmentioning

confidence: 99%

“…Although intraoperative complications are minimal in experienced hands, postoperative sequelae such as recurrent GERD, gas bloat, and delayed gastric emptying still occur with the same frequency. 3,10 Moreover, troublesome persistent dysphagia remains a major nemesis for patients and surgeons. Although relatively rare, severe dysphagia adversely affects patients' quality of life and satisfaction, and may result in dangerous food impactions and aspirations.…”

Section: Discussionmentioning

confidence: 99%

“…The subsequently observed reduction in dysphagia rates may have been due to the increased diameter (floppiness) of the wrap, rather than the presence of the bougie itself. Many authors today routinely use smaller (Ͻ50F, 23 52F, 6,23 54F, 10 and 56F 1,2 ) stents with an equal success rate. The reported timing and duration of the bougie insertion vary from esophageal dissection 15 to sizing of the hiatal closure 10 to, most commonly, sizing and creation of a fundoplication wrap.…”

Section: Commentmentioning

confidence: 99%

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Is the Use of a Bougie Necessary for Laparoscopic Nissen Fundoplication?

Novitsky¹

2002

Arch Surg

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Hypothesis: Esophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) is commonly used to prevent an excessively tight wrap. However, a bougie may cause intraoperative gastric and esophageal perforations. We hypothesized that LNF is safe and effective when performed without a bougie.Design: Retrospective review of 102 consecutive patients who underwent LNF without a bougie.Setting: Tertiary care university hospital.Patients: All patients presented with symptoms of reflux disease. Mean (± SD) percentage of time with pH of less than 4 was 12.6%±9.4%. Mean DeMeester score was 47.8. Mean (± SD) resting lower esophageal sphincter pressure was 15.0± 9.4 mm Hg. Mean (± SD) distal esophageal amplitude was 69.4 ± 39.2 mm Hg.Intervention: During LNF, we obtained 2 to 3 cm of intra-abdominal esophagus, divided all short gastric vessels, reapproximated the crura, and performed a loose 360°fundoplication without a bougie. Main Outcome Measures:Postoperative rates of dysphagia, gas bloat, and recurrent reflux.Results: In the early postoperative period, 50 patients (49.0%) complained of mild, 11 (10.8%) of moderate, and 7 (6.9%) of severe dysphagia. Average (± SD) duration of early dysphagia was 4.6 ± 2.1 weeks. Dysphagia resolved in 61 (89.7%) of 68 patients within 6 weeks. Late resolution of dysphagia was noted in 4 (5.8%) patients. Three patients were successfully treated with esophageal dilatations. Persistent dysphagia was found in 1 patient. Thirty patients (29.4%) had transient gas bloat. Mild persistent reflux, requiring daily medication, was noted in 5 (4.9%) patients.Conclusions: Performance of LNF without a bougie offers a safe and effective therapy for gastroesophageal reflux disease. While avoiding the potential risks for gastric and esophageal injury, it may provide low rates of long-term postoperative dysphagia and reflux recurrence.

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“…Naqueles pacientes com operação prévia no andar superior de abdome e na ausência da agulha de Verres, o pneumoperitônio era realizado pela técnica aberta. Os passos da cirurgia estão enumerados a seguir, conforme previamente descritos por Evans et al 15 . O tempo cirúrgico foi mensurado desde a incisão na pele até o completo fechamento da mesma (tempo cirúrgico total).…”

Section: Técnica Operatóriaunclassified

Curva de aprendizado na fundoplicatura laparoscópica durante a residência médica em cirurgia geral

Kondo

García

Ivano

et al. 2006

Rev. Col. Bras. Cir.

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(92,7 vs. 76,7 minutos, p=0,003), no tempo operatório para a operação de 7 vs. 68,4 minutos, p=0,00006) e no tempo para a liberação dos vasos gástricos curtos (22 vs. 13,1 minutos, p=0,00005). As complicações intra-operatórias foram maiores no primeiro grupo de pacientes, mas a diferença não foi estatisticamente significativa (p=0,2). Todos os procedimentos foram concluídos com sucesso por vídeo-laparoscopia em ambos os grupos, e a mortalidade foi nula nesta série. A alta hospitalar ocorreu em média no primeiro dia de pós-operatório em ambos os grupos (p=0,06). Conclusão: A fundoplicatura laparoscópica pode ser realizada com segurança por um cirurgião em formação, sob supervisão direta de um titular, com mínima morbidade para os pacientes. A curva de aprendizado foi demonstrada, avaliando-se principalmente, o tempo operatório do procedimento (Rev. Col. Bras. Cir. 2006; 33(2): 96-100 INTRODUÇÃOA doença do refluxo gastroesofágico é muito comum e a maioria dos pacientes são tratados clinicamente com inibidores de bomba de prótons e agentes pró-cinéticos 1 . Cerca de 20% dos pacientes que desenvolvem complicações ou apresentam recorrência dos sintomas após a interrupção do uso da medicação necessitam de tratamento cirúrgico 2,3 . O tratamento cirúrgico por via aberta ou por laparoscopia da doença do refluxo gastro-esofágico por meio da fundoplicatura é efetivo, duradouro e, em alguns aspectos, superior ao tratamento medicamentoso 4-8 . Estudos demonstrando custo reduzido 9 , menor tempo de permanência hospitalar e retorno precoce ao trabalho 9-10 comparando as fundoplicaturas laparoscópicas com as abertas têm sido relatados, e são em parte responsáveis pela popularização deste procedimento.A literatura mostra que uma curva de aprendizado de 20 cirurgias por cirurgião e de 50 procedimentos por instituição é necessária para o sucesso da fundoplicatura laparoscópica [11][12][13][14] , embora se saiba que a progressão individual do cirurgião ocorre em diferentes velocidades. MÉTODOFoi realizada uma análise retrospectiva dos prontuá-rios de 60 pacientes submetidos à correção cirúrgica laparoscópica da doença do refluxo gastroesofágico durante o período de março a outubro de 2005. Todos os pacientes foram operados pelo mesmo residente de Cirurgia Geral em treinamento, sob supervisão direta do cirurgião titular.As indicações para a cirurgia anti-refluxo foram: presença de sintomas refratários ao tratamento clínico, identificação de complicações decorrentes da doença do refluxo gastro-esofágico e o desejo do paciente de descontinuar o tratamento clínico 1 . A válvula anti-refluxo à 360º foi realizada em todos os pacientes, com ou sem liberação dos vasos curtos, técnicas de Nissen e Nissen-Rossetti respectivamente, de acordo com a preferência individual de cada médico titular.

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A Stepwise Approach to Laparoscopic Nissen Fundoplication

Cited by 10 publications

References 11 publications

Resident self-assessment versus faculty assessment of laparoscopic technical skills using a global rating scale

Resident self-assessment versus faculty assessment of laparoscopic technical skills using a global rating scale

Is the Use of a Bougie Necessary for Laparoscopic Nissen Fundoplication?

Curva de aprendizado na fundoplicatura laparoscópica durante a residência médica em cirurgia geral

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