Crowdsourcing surgical skills assessment yielded rapid inexpensive agreement with global performance scores given by expert surgeon graders. The crowdsourcing method may provide surgical educators and medical institutions with a boundless number of procedural skills assessors to efficiently quantify technical skills for use in trainee advancement and hospital quality improvement.

The primary objective was to compare carbon dioxide (CO 2 ) absorption rates in patients undergoing gynecologic laparoscopy with a standard versus valveless insufflation system (AirSeal; ConMed, Utica, NY) at intraabdominal pressures (IAPs) of 10 and 15 mm Hg. Secondary objectives were assessment of surgeons' visualization of the operative field, anesthesiologists' ability to maintain adequate end-tidal CO 2 (etCO 2 ), and patients' report of postoperative shoulder pain. Design: A randomized controlled trial using an equal allocation ratio into 4 arms: standard insufflation/IAP 10 mm Hg, standard insufflation/IAP 15 mm Hg, valveless insufflation/IAP 10 mm Hg, and valveless insufflation/IAP 15 mm Hg. Setting: Single tertiary care academic institution. Patients: Women ≥ 18 years old undergoing nonemergent conventional or robotic gynecologic laparoscopic surgery. Interventions: A standard or valveless insufflation system at IAPs of 10 or 15 mm Hg. Measurements and Main Results: One hundred thirty-two patients were enrolled and randomized with 33 patients per group. There were 84 robotic cases and 47 conventional laparoscopic cases. CO 2 absorption rates (mL/kg*min) did not differ across groups with mean rates of 4.00 § 1.3 in the valveless insufflation groups and 4.00 § 1.1 in the standard insufflation groups. The surgeons' rating of overall visualization of the operative field on a 10-point Likert scale favored the valveless insufflation system (median visualization, 9.0 § 2.0 cm and 9.5 § 1.8 cm at 10 and 15 mm Hg, respectively) over standard insufflation (7.0 § 3.0 cm and 7.0 § 2.0 cm at 10 and 15 mm Hg, respectively; p <.001). The anesthesiologists' ability to maintain adequate etCO 2 was similar across groups (p = .417). Postoperative shoulder pain scores were low overall with no significant difference across groups (p >.05). Conclusion: CO 2 absorption rates, anesthesiologists' ability to maintain adequate etCO 2 , and postoperative shoulder pain did not differ based on insufflation system type or IAP. Surgeons' rating of visualization of the operative field was significantly improved when using the valveless over the standard insufflation system.

There is great interest in new adhesion prevention technologies, but new agents are unlikely to be available for clinical use for many years. High-quality effectiveness and outcomes-related research is still needed.

Gradually increasing latency has a growing impact on performances. Measurable deterioration of performance begins at 300 ms. Delays higher than 700 ms are difficult to manage especially in more complex tasks. Surgeons showed the potential to adapt to delay and may be trained to improve their telesurgical performance at lower-latency levels.