INTRODUCTION:With the rapidly evolving techniques for minimally invasive surgery (MIS), general surgeons are challenged to incorporate advanced procedures into their practices. We therefore carried out a study to assess the state of MIS practice in Ontario.METHODS:A questionnaire was mailed to 390 general surgeons in Ontario. It addressed the surgeon's practice demographics, performance of both basic and advanced MIS procedures, the factors influencing this practice and the means of obtaining MIS training.RESULTS:Of the 390 general surgeons surveyed, 309 (79%) responded. Thirty-six of these were retired and were excluded from the analysis, leaving 273 available for study. The average age in the study group was 49.7 years; 247 (90%) were men. Of 272 who responded to the question, 116 (43%) had subspecialty training. The average surgeon's operating room (OR) time was 1.5 d/wk and the average waiting time for elective procedures was 4 weeks. We found that 257 (94%) respondents performed basic laparoscopic procedures, and 164 (60%) performed appendectomy; 135 (49%) performed at least 1 advanced laparoscopic procedure in their practice, although only 30 (22%) of these performed inguinal hernia repair. Using a Likert scale, we found that the most important factors influencing the incorporation of advanced laparoscopic procedures into surgical practice were a lack of OR time (median 4), lack of OR financial resources (median 4) and lack of training opportunities (median 4). Of surgeons responding to questions, 161 (64%) of 251 felt that the present medical environment did not allow them to meet standard-of-care requirements; they felt that it was the responsibility of academic surgical departments (214 [80%] of 268), the Canadian Association of General Surgeons (177 [68%] of 262) and the Ontario Association of General Surgeons (141 [53%] of 264) to provide continuing medical education courses for MIS training.CONCLUSION:The ability of practising general surgeons to incorporate advanced MIS procedures into their surgical practice remains a complex issue.

Background: Although the short-term benefits of laparoscopic splenectomy (LS) have been well documented, long-term follow-up data of patients who have undergone LS for ITP are scarce. We report our long-term follow-up data in patients who underwent LS for idiopathic thrombocytopenic purpura (ITP). Methods: Data were obtained from a prospectively collected computer database of 52 patients who underwent LS between October 1992 and December 2000 for medically refractory ITP. Patients and their referring hematologist were contacted, and follow-up information was obtained for 45 patients. Results: Fifty-two patients (27 women and 25 men) underwent LS for ITP. Median operative time was 160 min (range, 70–335); and median blood loss was 100 cc (range, 20–1500). There were seven cases of intraoperative hemorrhage (13.7%), resulting in one conversion. A second case was converted due to inadequate working space in a patient with a 26-cm spleen. Accessory spleens were found in 17 patients (32.7%). Postoperative complications occurred in three patients (5.9%). There were no deaths. Median length of hospital stay was 2 days (range, 1–12). Follow-up data were obtained in 45 patients (86.5%), with a median follow-up of 51 months. Six patients did not respond to surgery initially, and another two patients developed recurrent disease, for a remission rate of 82.2%. Nine patients underwent a damaged red blood cell scan. This group included the two patients who suffered recurrences. A positive scan was obtained in three patients (33%), one of whom was a patient with recurrent disease. This patient underwent an uneventful laparoscopic excision of residual splenic tissue but continues to require intermittent steroids to maintain platelet counts. The two other patients with a positive scan remain in remission. Conclusions: Laparoscopic splenectomy for ITP is safe and associated with low morbidity and a short hospital stay. Long-term follow-up showed that remission rates of ITP following LS are comparable to those reported in the literature on open surgery.

MIS continues to evolve with the introduction of new techniques and technology. This report discusses the use of "needlescopic" technology in the surgical management of achalasia. Heller myotomy procedures performed between January 1, 1997, and July 1, 2000, were analyzed and the results of 14 needlescopic procedures were compared with 15 laparoscopic procedures. Demographic and short-term outcome data were compared for each group using chi(2), Fisher exact, and Student t tests where appropriate. Both groups were similar in age and gender. However, the needlescopic group weighed less (72.2 vs. 83.5 kg; P = 0.05). Intraoperatively, the needlescopic procedures were shorter (98.2 vs. 131.9 minutes; P = 0.03). There were no conversions to open surgery or differences in the number of intraoperative complications for either group. Postoperatively, the groups had similar complications, time to normal diet, and analgesia requirements. Nonetheless, the needlescopic group had a shorter length of stay in hospital (1.1 vs. 2.0 days; P = 0.04). Needlescopic Heller myotomy appears to be a safe treatment option, resulting in a decreased length of stay and improved wound cosmesis.

Background: The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments. Methods: A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments. Results: Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5). Conclusion: The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

Background The training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy (LS). Methods Data were obtained from a prospectively collected database of patients who underwent LS from August 1994 to November 1999. Outcomes of the last 25 cases, performed by fellows under supervision, were compared to 25 cases performed by staff surgeons prior to the introduction of fellows. Results Patient demographics, preoperative platelet count, and splenic size were similar for the two groups. Outcome measures comparing the staff and the fellows group including operative time (151 vs 178 min, p =0.055), blood loss (214 vs 162 ml, p =0.40), intraoperative complications (3 vs 2, p =1.0), need for transfusion (2 vs 3, p =1.0), conversions (1 vs 0, p =1.0), length of hospital stay (3.3 vs 2.5 days, p =0.13), and postoperative complications (1 vs 2, p =1.0) were similar for the two groups. Conclusion When performed by a fellow under supervision, LS has the same outcomes as when the procedure is performed by the teaching staff surgeon.

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview.Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200-398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5-13 days). Median follow-up was 24 months (range, 6-66 months). The median number of day and night bowel movements was 6.0 (range, 3-10) and 1.0 (range, 0-3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.

BACKGROUND The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments. METHODS A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments. RESULTS Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5). CONCLUSION The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

Minimally invasive surgical techniques and procedures continue to evolve with the trend toward fewer and smaller instruments. To our knowledge, this is the first reported case of sigmoid colon resection utilizing needlescopic technology. The patient was a 53-year-old woman diagnosed with a malignant lesion in the midsigmoid colon at 30 cm. A subsequent needlescopic sigmoid colon resection was performed and the patient was discharged home after an uneventful postoperative course. This case demonstrates that colon procedures that require major reconstruction may be performed needlescopically in selected patients.

Background: Minimally invasive surgery continues to evolve, with an emphasis on developing new techniques and applying new technology to surgical procedures. The purpose of this study was to compare the short-term outcomes of needlescopic fundoplication with those of conventional laparoscopic fundoplication.Methods: Between January 1999 and June 2000, 38 needlescopic fundoplications were performed. and the short-term outcomes for these patients were compared with those for a contemporary matched cohort of patients who had undergone a conventional laparoscopic fundoplication.Results: There was a nonsignificant trend toward decreased operative time (143.4 to 127 min; p = 0.13), blood loss (54.3 to 48 ml; p = 0.30), narcotic requirements (29.5 to 19.5 morphine equivalents: p 0.32), and length of hospital stay (1.78 to 1.49 days; p = 0.10) in the needlescopic group. There were no significant differences in intraoperative complications (2.6% vs 2.6%; p = 1.0). Two needlescopic cases were converted to laparoscopic cases because of obesity. Postoperatively, there were no significant differences in rates of early dysphagia (7.9% vs 7.9%), bloating (13.2% vs 5.3%; p = 0.43). or other complications (5.3% vs 5.3%) between the groups. There was a significant reduction in mean operative time for needlescopic fundoplication after the first four cases (166 +/- 44 vs 120 +/- 32 min; p = 0.03).Conclusions: Needlescopic fundoplication poses no disadvantage, and it offers the added cosmetic benefit of smaller incisions.