Scandinavian Journal of Surgery

The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery.

This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills.

There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.

Treatment of occlusive femoro-popliteal artery disease has changed during the last decade because of intensive development of endovascular technology. The aim of this study was to evaluate patient treated endovascularly or surgically for femoro-popliteal atherosclerotic lesions and to assess perioperative and mid-term outcome.

This is a retrospective analysis of consecutive patients who had undergone prosthetic above-the-knee femoro-popliteal bypass or percutaneous transluminal angioplasty and stenting of superficial femoral artery stenosis or occlusion at Tampere University Hospital, Finland, between January 2007 and December 2009. Patients who were alive were re-evaluated in 2010. Primary and secondary patency and outcomes were assessed.

A total of 131 patients were treated; surgically 63 patients (69 procedures) and endovascularly 68 patients (74 procedures). The mean follow-up time was 17 months (SD ± 13 months). In the late follow-up visit, 8 (18%) patients in the bypass group suffered from claudication and 9 (20%) from critical limb ischemia. The corresponding figures for the endovascular group were 20 (36%) and 8 (20%), respectively. The primary patency was 60% at 2 years in the bypass group and 73% in the endovascular group (p = 0.092); the primary assisted patency was 62% versus 76%, respectively (p = 0.068). The secondary patency was 74% in the bypass group versus 79% in the endovascular group (p = 0.487).

According to current results following TASC II guideline, satisfied overall mid-term results can be achieved in the treatment of superficial femoral artery atherosclerotic disease.

The objective of this study was to compare the effectiveness and cosmetic results of tissue adhesive or surgical staples in thyroidectomy through a supraclavicular incision.

This was a prospective, randomized study of consecutive patients undergoing thyroidectomy by a supraclavicular approach. Eligible patients were randomized into two groups: one group had the incision closed with tissue adhesive (the experimental group) and the other with surgical staples (the control group). The main outcomes included operative time, early postoperative pain measured by Visual Analog Scale, incidence of wound dehiscence and infection, perceived cosmetic outcome, and overall patient satisfaction by using Patient Satisfaction Assessment Form.

There were 151 consecutive patients assessed for eligibility, and 132 patients were enrolled over 22 months. The clinical characteristics of the patients in the two groups were similar. Main outcomes were assessed in the first 24 h postoperatively, the first month, and the third month postoperatively. Operation time was longer in the experimental group (P = 0.027). Mean Visual Analog Scale scores for pain were lower in the experimental group in the early postoperative period (P < 0.001). No patients developed surgical site infections or wound dehiscence. Lower scores for scar assessment and higher overall satisfaction levels at the first month after surgery were found in the experimental group compared to the control group (P < 0.001). There was no significant difference between the two groups at the third month postoperatively in perceived cosmetic result (P = 0.052) or overall satisfaction (P = 0.059).

Tissue adhesive is effective and reliable in skin closure for thyroid surgery. While this closure may take somewhat longer to perform, it leads to less postoperative pain, more acceptable wound cosmesis, and higher patient satisfaction levels in short postoperative follow-up.

Nodal involvement is the most important prognostic factor in colon cancer. Although theoretically appealing, it is not known if wider mesenteric excision improves the oncological result. The aim of this retrospective study was to investigate whether wider mesenteric excision yields a superior oncological result.

Depending on the resection length, 333 cases of locally radical right-sided hemicolectomies due to adenocarcinoma were compared for perioperative morbidity and mortality, disease-free survival, and long-term survival.

Postoperative mortality was significantly higher in the quartile with the longest resections, p = 0.003. In a multivariate analysis adjusted for age, stage, emergency operation, adjuvant chemotherapy, and year of operation, a negative relationship between resection length and 5-year overall survival was noted, p = 0.01. No differences in the causes of death or in the incidence of local or distant recurrences were noted between groups.

Wider excision in right-sided hemicolectomies was not associated with any oncological benefit but an increased postoperative mortality and a decreased 5-year overall survival. These findings may suggest consideration to perform wide mesenteric resections routinely. Further research is warranted to define which patients benefit from wider resections.

This study assessed the timing of reversal of defunctioning stoma following low anterior resection of the rectum for cancer and risk factors for a defunctioning stoma becoming permanent in patients who were not reversed.

Patients who underwent low anterior resection with defunctioning stoma during a 12-year period were assessed with regard to timing of stoma reversal. Delayed reversal was defined as >4 months after low anterior resection. Patients with a defunctioning stoma that was never reversed were assessed regarding risk factors for permanent stoma.

A total of 134 patients were analyzed. Of 106 stoma reversals, 19% were reversed within 4 months of low anterior resection, while 81% were reversed later than 4 months. In 58% of these patients, the delay was to due to low medical priority given to this procedure. The other main reasons for delayed stoma reversal were nonsurgical complications (20%), symptomatic anastomotic leakage following low anterior resection (12%), and postoperative adjuvant chemotherapy (10%). Of all patients, 21% (28/134) ended up with a permanent stoma. Risk factors for a defunctioning stoma becoming permanent were stage IV cancer (P < 0.001) and symptomatic anastomotic leakage following low anterior resection (P < 0.001).

Four in five patients experienced a delayed stoma reversal, in a majority because of the low priority given to this surgical procedure.

Curative resection is the treatment of choice for gastric cancer. Although it has been concluded that D2 lymphadenectomy plus para-aortic nodal dissection does not improve survival rate in curable gastric cancer, it is unclear whether D2 plus para-aortic nodal dissection has a benefit in some groups of patients. We conducted a retrospective study in our hospital, in which we compared D2 with D2 plus para-aortic nodal dissection lymphadenectomy for gastric cancer in subgroups of each clinical characteristic in terms of long-term survival after surgery.

We selected 1792 patients who had undergone the treatment with curative intent between 1990 and 2007, 1344 in the D2 group and 448 in the D2 plus para-aortic nodal dissection group. Each procedure was verified by pathological analyses. The primary end points were 5-year overall survival.

Median follow-up periods were 50 months for patients assigned to D2 group and 54 months for patients assigned to D2 plus para-aortic nodal dissection group. Overall 5-year survival was not significantly higher in patients assigned to D2 plus para-aortic nodal dissection surgery compared to those assigned to D2 surgery (31.2% (95% confidence interval: 19.8%–42.6%) vs 26.6% (95% confidence interval: 20.3%–32.9%); log-rank p = 0.433). D2 plus para-aortic nodal dissection surgery should only be used for curable gastric cancer of T3-4 and N2 stage and should not be used for T1 disease and total gastrectomy.

Operative treatment is often indicated in unstable pediatric diaphyseal forearm fractures. Recently minimally invasive reduction and elastic stable intramedullary nailing have been of increasing interest, instead of open reduction and internal fixation with plates. There are several disadvantages of metallic intramedullary implants, such as soft-tissue irritation and a risk of disturbing later imaging. Thus, they are generally removed in later operations. We aimed to develop a new technique to stabilize pediatric forearm fractures by the bioabsorbable intramedullary nailing.

We developed a new, two-stage mini-invasive surgical technique to stabilize the unstable diaphyseal fractures in children. The procedure is bioabsorbable elastic stable intramedullary nailing. Ultra-high-strength bioabsorbable intramedullary nails of poly(lactide-co-glycolide) were manufactured for our purpose. The material has been widely proven to be biocompatible and stable enough for fracture treatment as screws and pins. We have used the new technique in the unstable both-bone diaphyseal forearm fractures in children between the ages of 5 and 15 years. We report the technique and our clinical experience in the series of those three cases that have been followed up for at least 12 months. The present series has been randomized for the procedure instead for titanium elastic stable intramedullary nailing, and the series represents a part of ongoing randomized trial.

The reported cases operated by the new technique referred good union in the fractured bones and acceptable alignment in the follow-up. Removal of the implants was not required. No troubles with the procedure or implant per se were noticed, indicating good feasibility. One high-energy refracture occurred half year after the primary trauma. Traditional titanium implants were used to control the refracture.

We report our preliminary experience of a new surgical mini-invasive procedure to stabilize the unstable pediatric forearm shaft fractures by bioabsorbable elastic stable intramedullary nailing. Our clinical experience suggests that the procedure combined with long-arm casting is feasible in treating the pediatric forearm fractures. The technique may bring benefits to handling these challenging fractures. The disadvantages of metallic implants may be avoided. In addition, removal of the implant will not be required. There was one refracture in the series, but it was due to new high-energy trauma. According to our understanding, it was not related to the type of former osteosynthesis. However, ignoring the good preliminary experience, still we do not have results of the superiority of the procedure over traditional elastic stable intramedullary nailing. Our ongoing randomized multicenter study is aimed to determine its long-term outcome against the present golden standard. Nevertheless, due to encouraging preliminary results, we see it necessary to report the technique.

Loss of femoral bone stock in elective revision total hip arthroplasty poses unique and substantial challenges. Structural onlay allografts may provide mechanical stability for the cementless revision prosthesis and increase bone stock.

At least one cortical onlay allograft was used in 40 elective total hip arthroplasty revisions (40 patients) to reconstruct femoral bone defects. The operations were performed between January 1999 and August 2010 in the Turku University Hospital, Finland. The mean follow-up time was 52 months (range: 12–125 months).

The allografts were incorporated into the bone tissue in 37 of 40 (92.5%) patients. Cementless revision stems healed in 36 of 40 (90.0%) patients, but these patients were not exactly the same patients whose allografts were successfully incorporated. One or more surgical complications were experienced by 14 of 40 (35.0%) patients during follow-up. In all, 4 of 40 (10.0%) patients (all women) had hip infections during follow-up. Of the 7 patients with rheumatoid arthritis, 4 (57.1%) had at least one complication.

The use of the cortical onlay allografts provides a feasible option for restoring the integrity of the proximal femur in revision total hip arthroplasty, but the complication rate is high, particularly in female patients with rheumatoid arthritis.