The mental load of the laparoscopic surgeon might be highly optimized by continuous activity of the sympathetic nervous system. The question of what extent or quality of stress produces adverse effects remains unclear.
Conventional intramedullary nailing is not suitable for stabilisation of segmental fracture types with a short metaphyseal fracture fragment. New nails with proximal and distal interlocking in three different planes offer better stability. Bone vascularisation should not be endangered by the stabilisation procedure and optimal reduction of the fracture is an important prerequisite for uneventful fracture healing, especially in this difficult fracture configuration.
Laparoscopic colorectal surgery has become increasingly more common since first being described in a publication in 1990. Despite a multitude of studies about the learning curve in laparoscopic colon surgery, there are almost no such studies with regard to laparoscopic rectum surgery. This paper aims to describe a surgeon's learning curve with regard to laparoscopic rectum surgery. Based on data collected in a prospective observational study of 180 patients, it can be established that a surgeon experienced in open colorectal surgery, with basic experience in laparoscopic surgery, after suitable preparation and having a personal interest in minimally invasive surgery, needs to perform about 35 laparoscopic rectum resections within 200 laparoscopic colon resections until selection rate, operating time and rates of general and surgical complications reach a plateau. A selection of cases suited to a surgeon's personal level of operating experience, is a prerequisite for a low rate of conversions and complications and for oncological long-term results comparable to those achieved through open surgery. However, the learning curve is dependent on a multitude of factors that are partly unknown at this point. Its duration most certainly varies between individual surgeons. Every surgeon is required to critically evaluate his or her own laparoscopic experience and select cases accordingly. Supervision by surgeons more experienced in laparoscopic colorectal surgery prevents disadvantages for patients in the early phases of the surgeon's learning curve. Training in laparoscopic colorectal surgery should take place only in institutions with a sufficient number of cases treated and a continuity in experienced teachers. CAMIC's efforts in establishing centres of competence and reference are therefore to be commended and supported.
In the period from January 2003 to June 2009 923 complex laparoscopic colorectal procedures were performed by one surgeon. Data was assessed prospectively in a database including 152 variables. In 15 patients (10 f, 5 m), with a median age of 61 years (range: 35-83 years), discontinuity resection of the colon was performed including 3 patients with open discontinuity resection of the sigma and 12 patients with laparoscopic Hartmann procedures. In all cases continuity of the colon was recovered laparoscopically. Median operation time was 100 min, conversion to an open procedure was not necessary. No intra-operative complications occurred and only one wound infection (6.6 %) was recorded postoperatively with a median postoperative stay of 8 days. Although the laparoscopic approach to recover continuity of the colon is technically challenging, we conclude that the experienced bowel surgeon is able to perform the laparoscopic approach with a low morbidity and mortality by retaining the well known advantages of laparoscopic colonic surgery.
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