In the 30 years since laparoscopic cholecystectomy was introduced, the number of open cholecystectomies performed by general surgery residents has dropped 92% at two teaching hospitals in Texas, new research shows.

The drop in experience has some experts worried that, in coming years, few surgeons will be prepared to perform open surgeries for complicated gallbladder cases. With less experience in open procedures, surgeons may also hesitate to convert if they start a laparoscopic procedure and see that open surgery is needed.

"The average general surgery resident completing training in 2000 had performed 15.5 open cholecystectomies, versus 90 in the pre-laparoscopic era. This figure decreased to 12.6 by 2004," lead study author Kenneth R. Sirinek, MD, PhD, professor and vice-chairman of surgery at the University of Texas Health Science Center in San Antonio, said in a press release. "I fear that the next decade is going to be even worse."

Results were published online April 7 in the Journal of the American College of Surgeons.

Certain Cases Require Open Surgeries

Minimally invasive surgeries are the gold standard for gallbladder surgery, but certain cases — including patients with gallbladder cancer, Mirizzi syndrome with cholecystobiliary fistula, and cirrhosis — still may require open surgeries. Some laparoscopic procedures also need to be converted to open if unexpected complications are found.

To learn how the upswing in laparascopy has affected training, the researchers analyzed data from all patients undergoing a cholecystectomy at the University Hospital of the Bexar County Hospital District and the Audie L. Murphy Veterans Hospital in San Antonio during three decades: the prelaparoscopic era (1981 to 1990), the first laparoscopic decade (1991 to 2001), and 2004 to 2013.

They found the average number of open cholecystectomies performed per graduating chief general surgery resident dropped dramatically in both laparoscopic decades compared with the prelaparoscopic decade (70.4 vs 22.4 vs 3.6 procedures).

"Surgeons trained in the open cholecystectomy era alone are a dying breed," Dr Sirinek said. "All of the instruments used laparoscopically do not substitute for an open procedure, where we have tactile feedback from our hands, and a lot of the surgical dissection is done with our hands."

Similar Worries for Other Specialties

Gabriel Zada, MD, MS, assistant professor of neurosurgery, otolaryngology, and internal medicine at the University of Southern California (USC) in Los Angeles, says he was surprised by the amount of the decrease in open surgeries described in the study but not by the trend.

He told Medscape Medical News, "It's a generalized problem we're seeing in all surgical subspecialties. …Everything is on a trend toward minimal invasiveness, and more traditional open approaches are just not being performed as much, so the residents get much less exposure."

He trains other surgeons in BrainPath, a minimally invasive procedure that lets surgeons reach deeper parts of the brain through an opening about the size of a dime. The new procedure has been taught for only a few years, but he said it's possible the training for the much larger craniotomy will someday go the way of the open gallbladder skills.

"The ideal scenario is knowing how to do both and having the judgment upfront to say this should be done with a minimally invasive procedure or with an open procedure or convert if things don't go well." Those who can do both are already in high demand and that will increase, he said.

"I think what we'll find is that these open cases will be concentrated in centers of excellence…but in the majority of hospitals in the future, surgeons are only going to know how to master the minimally invasive procedures." That could result in a patient being moved if a laparoscopic procedure in a hospital without these experts needs to be converted to an open surgery.

He sees a similar trend in neurosurgery in aneurysms, which used to be clipped in open surgery through a craniotomy and now are coiled through the groin about 80% of the time, he said.

"The residents just don't know how to do the open surgeries anymore," he said.

At USC, he said, they are addressing the problem of diminishing experience in part with simulators, work on cadavers, and virtual reality. He added that simulation models are now being mandated more often in surgical residency programs.

Dr Sirinek and coauthors also propose simulation to teach open gallbladder surgery.

Additionally, they suggest that junior surgeons spend time participating in the American College of Surgeons' Transition to Practice Fellowship, which teaches laparoscopic and open cases or general pairing of junior and senior surgeons.

They also urge each residency program to build a video library of complicated open procedures.

Dr Zada said the minimally invasive trend may eventually mean changes in residency requirements by accrediting bodies.

"I've heard residents complain that they've only done 3 or 4 open gallbladder cases in their entire residency," he said.

The study authors and Dr Zada have disclosed no relevant financial relationships.

J Am Coll Surg. Published online April 7, 2016

da Vinci Surgery
Intuitive Surgical Research Grants Program for 2017

Dear da Vinci surgeons and researchers:

Intuitive Surgical is currently accepting letters of intent for our 2017 Clinical Research Grant and Technology Research Grant Programs for Robotic-assisted Surgery. All awards are conferred on a competitive basis by submission of a grant application. The deadline for submitting letters of intent for the both grants programs is June 3, 2016.

Clinical Research Grant and Technology Research Grant Programs will address important clinical questions or support clinically relevant technology development related to robotic-assisted surgery. The Clinical Research grant will focus on the following clinical areas: Colorectal Surgery, General Surgery, Thoracic Surgery, Cost Analysis, and Training/Education. We will also be focused on Urology research from outside of the United States.

Available Funding:

Grant monies can be used to fund salary, equipment, supplies and/or travel required to support the proposed research project for a period of up to one year.

Applicants for the Clinical Research Grant for robotic-assisted surgery have two funding options for the upcoming grant cycle:

Applicants may apply for grant funding up to $50,000 per project (US dollars, total costs).
Applicants may apply for grant funding up to $20,000 (US dollars, total costs) plus a 12 month loan of a Surgeon Console and Skills Simulator.
Applicants for the Technology Research Grant may apply for grant funding up to $50,000 per project (US dollars, total costs).

Please visit our website for detailed instructions for the Intuitive Surgical Research Grant Programs:

Clinical: http://www.intuitivesurgical.com/company/educational-grants/research_grants.html
Technology: http://www.intuitivesurgical.com/company/educational-grants/technology_grants.html
Application Submission Timing Information for Clinical and Technology Research Grants:

We are asking interested applicants to submit a Letter of Intent by June 3, 2016. Invitations to submit full grant applications will be sent by July 18, 2016 (this invitation will include grant application guidelines and forms).
The deadline for submitting a full, invited grant application is September 16, 2016. Only complete application packets will be considered. Awardees will be notified by October 21, 2016. Grant monies must be used to support research expenses which occur from January 1, 2017 – December 30, 2017.
We are very excited to offer these grant programs and we hope that you will consider submitting an application.

Sincerely,

Myriam Curet, MD Dale Bergman
Chief Medical Advisor Project Manager, Medical Research
Intuitive Surgical, Inc Intuitive Surgical, Inc

TransEnterix is developing robotic controlled devices that can be used instead of traditional laparoscopy, a procedure that is done through a patient's belly to find problems such as cysts or infection.

Although robotic systems have been on the market for years, they haven't made big inroads against laparoscopy and as a result, there are still more than 6 million laparoscopic procedures done in the U.S. and EU every year.

So far, the inability of robotic systems to displace laparoscopy stems from robotics' higher per-procedure cost and the learning curve that's associated with using them. Because robotic systems are expensive and insurers reimburse at the same rate regardless of whether a robotic system is used, these systems are less profitable per procedure for hospitals. Robotics are also complex systems that have drawbacks that keep time-strapped surgeons from embracing them.

Enter TransEnterix's SurgiBot and ALF-X, two systems TransEnterix is launching to drive down per-procedure expenses and address surgeons' concerns.

SurgiBot could win FDA approval in the next few months and if it does, then TransEnterix plans to market it with a capital cost that's 75% lower than other systems already on the market. A lower price could encourage more hospitals to buy the system, but it's SurgiBot's features that may encourage more surgeons to demand them.

SurgiBot is a single-port robotic system that can easily be moved in and out of operating rooms and it features flexible instruments that can be used via a single patient incision. It also offers a high-definition 3D display with an articulating camera and tactile feedback so that surgeons can feel exactly what the instrument is feeling. SurgiBot also allows surgeons to perform procedures bedside in the sterile field, rather than from behind a console, which many surgeons may prefer.

Meanwhile, in markets that accept the CE Mark of approval, sales of the ALF-X system should kick off this year, and a launch of the system in the U.S. could come as soon as 2017.

ALF-X is a multi-port platform that lets hospitals reuse both traditional lap instruments and robotic instruments in order to lower their costs. Similar to the SurgiBot, the ALF-X features haptic feedback, but it also includes a camera that's controlled by the surgeon's eye movement and it allows for patient repositioning, which may give it an edge over Intuitive Surgical, too.

Mounting its threat
Last year, TransEnterix hired former Intuitive Surgical sales leaders to head up its own sales efforts, and their experience may jump-start the company's attempt to carve away at Intuitive Surgical's sales, which totaled $2.4 billion last year, up 12% year over year.

However, investors should remember that Intuitive Surgical's existing customers have made significant investments to buy their systems and therefore may be unwilling to switch horses midstream.

Instead, TransEnterix's biggest opportunity may come from expanding the market for robotic surgery to include providers with more limited budgets. According to TransEnterix, 75% of small hospitals have yet to buy a robotic surgical system and cost is likely the biggest reason why.

Admittedly, market demand for robotic surgery may not materialize as quickly as some might hope, but given that laparoscopy is common and the overall penetration of robotics in surgical procedures remains in the low- to mid-single-digit percentages, there's a lot of potential for upside. TransEnterix estimates that the market for abdominal robotic surgery is already worth $2 billion annually and it could grow to $10 billion to $13 billion annually over the next six to eight years!

Obviously, only time will tell if TransEnterix can capture a meaningful share of that growth, but if it does, then it could make the company worth more than its current $361 million market cap. Nevertheless, TransEnterix has yet to post any revenue or profit, so it's a high-risk bet. Therefore, all but the most risk tolerant of investors might be best suited watching this stock and tracking its sales and profit progress.

Ministry of Health & Family Welfare, Government of India has issued travel advisory that pregnant women or women who are trying to become pregnant should defer/ cancel their travel to the affected areas.

All pregnant women travelling to the affected countries/ areas have been advised to strictly follow personal protective measures, especially during day time, to prevent mosquito bites and if they fall sick within two weeks of return from an affected country, they should report to the nearest health facility.

Advisory has also been issued that pregnant women who have travelled to areas with Zika virus transmission should mention about their travel during pregnancy check-up visits in order to be assessed and monitored appropriately at the health facility.

Guidelines for integrated vector management to prevent transmission by Aedes mosquito have been issued to all the States. These guidelines include vector surveillance, both for larva and adults; effective vector control through environmental management methods, personnel protection, biological control such as using larvivorous fish and using chemicals that kill adult and larval form of this mosquito. Vector surveillance and capacity building have also been done at International Airports and ports.

Technical guidelines and travel advisory were issued and disseminated and also made available on the website of the Ministry. States where Dengue transmission is prevalent, namely Maharashtra, Kerala, Tamil Nadu, and UT of Puducherry have been alerted. National Centre for Disease Control (NCDC), Delhi has been identified as the nodal agency for investigation of outbreak in any part of the country. Fifteen International Airports and nine major ports have displayed signages providing information for travelers on Zika virus disease and advising the travellers to report if they are returning from any of the affected countries and suffering from febrile illness. Immigration authorities at these Airports have been sensitized. Directorate General of Civil Aviation, Ministry of Civil Aviation has issued instruction to all international airlines to follow the recommended aircraft disinsection guidelines. Vector control measures have been implemented at International Airports and Ports. National Centre for Disease Control, Delhi and National Institute of Virology (NIV), Pune, have established the capacity to provide laboratory diagnosis of Zika virus disease in acute febrile stage. National Vector Borne Disease Control Programme has alerted all its field units for enhanced vector ( Aedes mosquitoes) control. National AIDS Control Organization has issued advisory for blood banks and potential blood donors to prevent transmission of Zika virus infection by blood transfusion. A 24x7 control room cum Help Line has started functioning from Dte GHS. Public has been made aware about Zika virus disease through press releases issued by Ministry of Health and Family Welfare. The situation is being monitored regularly.

There is no specific treatment for Zika virus Disease. People sick with Zika virus are advised to take plenty of rest, drink enough fluids, and treat pain and fever with paracetamol. They are also advised to take personal protective measures against mosquito bite.

National Centre for Disease Control, Delhi and National Institute of Virology (NIV), Pune, are the identified laboratories to test clinical samples and to support the outbreak investigation. No special provision is required to admit and treat a Zika virus disease patient except for provision of mosquito net. However, severe forms of disease requiring hospitalization is uncommon and fatalities are rare.

Dr. Samstein, the new chief of liver transplantation and hepato-biliary surgery at Weill Cornell Medicine, has so far performed the laparoscopic procedure on about 30 organ donors. He hopes that the new approach will increase the number of liver transplants and save lives. "One of the challenges is that most donors don't spontaneously come to the center; somebody has to approach them," Dr. Samstein observes. "If you have to undergo surgery and a recovery that will take two to three months, I'm less likely to ask you to donate an organ. If that recovery is shortened to two weeks, I'm more likely to ask."

As the risk and recovery time for the donor decreases, Dr. Samstein explains, patients feel more comfortable accepting an organ from a stranger or asking an acquaintance or a coworker for help if close relatives cannot donate — and those people will be more willing to oblige. That's what happened with kidney donation, where more than a third of transplants come from living donors, and where laparoscopic surgery is now routine. "Liver transplant has less experience than kidney transplant," Dr. Samstein says, noting that the first successful kidney transplant took place in 1954, with a living donor. While the first liver was transplanted in 1963, the organ came from a deceased donor. Moreover, the operation only became routine in the '80s, and the first liver transplant from a living donor didn't happen until 1989. "I think of liver transplant as being about 30 years more junior to kidney transplantation," says Dr. Samstein, an undergraduate alumnus of the Ithaca campus. "That's why, I think, there is so little knowledge, and why some doctors might not even present living donation as an option."



Kinder cut: An image of the left and right hepatic veins, and (in red) the line of transection for liver transplant.
Image credit: Dr. Benjamin Samstein

NewYork-Presbyterian is currently the only hospital system in the United States to offer laparoscopic surgery for liver donors, but Dr. Samstein hopes that distinction will not last. He and his team recently published a paper in Annals of Surgery documenting their success, and they've been working to understand how the procedure might be made less technically challenging, so it could be performed at more centers. That would encourage more donations and allow more people in need to get livers — good news for the 18,000 patients on the national waiting list for livers from deceased donors. Every year, some 1,500 people die waiting for a liver. "The need for organs far outstrips our access," Dr. Samstein says. "Our overarching goal is to increase the number of transpla

Abu Dhabi: A panel of doctors at Al-Ain Hospital successfully removed a 5-cm-long nail piece from the stomach of a 16-month-old baby.

They screened the toddler and discovered the nail which was causing pain in his abdomen.

A multi-disciplinary team managed to remove the nail without surgery, using the laparoscopy medical technology, reported Arabic daily Albayan.

Researchers prospectively collected data on 595 patients who underwent primary hip arthroscopy, with a minimum 2-year follow-up. Investigators used radiographs to determine measurements for the Tönnis angle, the lateral center-edge angle of Wiberg, joint space at lowest point, ischial prominence size, crossover sign, alpha angle and offset.

Preoperatively and at follow-up visits at 3 months, 1-year, 2 years and 3 years patients were evaluated. The Non-Arthritic Hip Score (NAHS), Hip Outcome Score – Activities of Daily Living and Hip Outcome Score – Specific Subscale was used to assess patients.

Discuss in OrthoMind
Discuss in OrthoMind
Findings showed all scores had improved from preoperative to postoperatively at the 2-year follow-up. The patient satisfaction overall was 7.86 at the final follow-up. Investigators noted 54 patients underwent total hip arthropalsty or a hip resurfacing procedure. Revision hip arthroscopy was performed in 47 patients.

According to multiregression analysis results, there was a significant chance for conversion to THA, revision arthroscopy and a change in NAHS <10 points with increased age at time of procedure. Age was a significant factor for three types of failure. Acute injury, acetabuloplasty, iliopsoas release and sex were significant factors in two out of the three failure types, according to researchers.‒ by Monica Jaramillo

Over 500 oncology surgeons from India on Wednesday took part in a conference to discuss the role of Robotic surgery in lung cancer.

According to the doctors, robotic surgeries play a major role in medically advanced Western nations in treating lung cancer.

In India, lung cancer constitutes 6.9 percent of all new cancer cases and 9.3 percent of all cancer related deaths.

Every year, over a lakh cancer patients are diagnosed in India. One of the major causes behind rising lung cancer is rising air pollution and toxic air.

The event was organised by the Asian Institute of Oncology.

"The meeting provided a discussion point on how to improve the treatment procedures for lung cancer," said Sanjay Sharma, a senior oncologist who participated in the event, told IANS.