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BACKGROUND: Video game experience (VGE) has been identified as a possible predictive factor for surgical skill. We hypothesized that surgical novices with previous VGE would acquire new surgical skills faster than those without. METHODS: Fourth-year medical students (M4) and first-year surgical residents (PG-1) completed a survey asking about standard demographic data and previous VGE. Gamers had high VGE, defined as more than 3 h per week of videogame playing. Nongamers had little or no VGE. Both groups trained to proficiency on two tasks (AcquirePlace and Traversal) of the MIST-VR simulator, with proficiency defined as meeting previously validated criteria on two consecutive trials. The number of trials required to achieve proficiency for each task was recorded. RESULTS: The 26 participants included 11 M4s and 15 PG-1s: 17 males (8 gamers/9 nongamers) and 9 females (3 gamers/6 nongamers), mean age 27.8 years. There were no differences in time to proficiency between the M4 and PG-1 residents, and there were no significant differences in the relative number of gamers per gender. All participants eventually met proficiency criteria. The 11 gamers reached proficiency more quickly than the 15 nongamers (median 0 trials versus 6 trials, p = 0.01). Gamers scored lower than nongamers on their initial attempts. Women overall took longer to reach proficiency than did men (median 10 trials versus 0 trials, p = 0.002). When stratified according to VGE, female nongamers took longer to reach proficiency than male nongamers (median 11 trials versus 1 trial, p = 0.006) but among gamers, there was no difference between females and males (median 0 trials versus 0.5 trials, NS). CONCLUSION: Previous VGE shortens time to achieve proficiency on two tasks on a validated surgical simulator. The possibility that VGE may ameliorate gender differences in length of time required to acquire surgical skills should be explored further.

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OBJECTIVE: Reports of long-term outcomes for laparoscopic Heller myotomy (LHM) are scarce. In this work, outcomes of LHM for achalasia in patients who underwent surgery more than 10 years prior were investigated. METHODS: A cohort of patients treated with LHM and partial fundoplication for achalasia between 1993 and 1996 was followed for long-term outcomes, which were compared to baseline data at presentation. RESULTS: Thirty-two consecutive patients were identified, and follow-up information was obtained for 20 patients (62.5%). Mean follow-up was 11.2 years (range 10.3 to 12.3 years). Three patients (9.4%) were deceased (mean of 40 months postoperation). Of the 17 living patients, dysphagia was rated as severe in one (5.9%), mild to moderate in eight (47.1%), and absent in eight (47.1%). This was a significant improvement from preoperative scores in which dysphagia was rated as severe in 42.9%, mild to moderate in 57.1%, and absent in 0% (p < 0.05). In addition, 10-year dysphagia scores were unchanged from those at short-term follow-up (mean 27 months, p = 0.84). Other symptoms of heartburn, chest pain, voice symptoms, cough, and asthma were reported in fewer than 30% of patients at 10 years. Esophageal dilation following surgery was required in three patients, and two patients required repeat operations (esophagectomy in one patient, hiatal hernia in one patient). Satisfaction with the operation was reported by 16 patients (94.1%) at 10 years. CONCLUSIONS: Most patients who underwent LHM with partial fundoplication reported satisfaction 10 years after the operation. A small number of patients required additional intervention. Dysphagia scores at 10 years were not different from those collected at short-term follow-up. Our data suggest that the efficacy of LHM is sustained at 10-year follow-up.

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BACKGROUND: A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago. METHODS: Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from 166 patients at a mean of 11.0 +/- 1.2 years. Eight additional patients who underwent reoperation were lost to follow-up but are included. Failure is broadly defined as any reoperation, lack of satisfaction, or any severe symptoms at follow-up. Potential predictors evaluated included sex, age, body-mass index (BMI), response to acid reducing medications (ARM), psychiatric history, typical versus atypical symptoms, manometry, esophageal pH, and others. Logistic regression was used to assess significance of predictors in univariate analysis. RESULTS: Of 174 known outcomes, 131 were classified as successful (75.3%), while 43 were failures (24.7%): 26 reoperations, 13 unsatisfied, and 13 with severe symptoms. Response and lack of response to ARM were associated with 77.1% and 56.0% success rates respectively (P = 0.035). Eighty five percent of patients with typical symptoms had a successful outcome, compared to only 41% with atypical symptoms (P < 0.001). Preoperative morbid obesity (BMI > 35 kg/m2) was associated with failure (P = 0.036), while obesity (BMI 30-34.9 kg/m2) was not. A history of psychiatric illness trended toward significance (P = 0.06). CONCLUSIONS: In a cohort with 11 years follow-up after LNF, factors predictive of a successful outcome include preoperative response to ARM, typical symptoms, and BMI < 35 kg/m2. Patients with atypical symptoms, no response to ARM, or morbid obesity should be informed of their higher risk of failure. Some patients in these groups do have successful outcomes, and further research may clarify which of these patients can benefit from LNF.

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Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1-13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of -4.9 (range -12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results.

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Appendicitis and pregnancy are both common conditions, and when they co-exist, both the general surgeon and obstetrician are presented with unique challenges. Acute appendicitis is the most common cause of the acute abdomen during pregnancy, effecting 0.1-0.3 per cent of pregnancies each year. With an estimated 4 million deliveries per year in the United States, there are potentially as many as 12,000 cases of acute appendicitis to be managed by the general surgeon during pregnancy (Eur J Surg 1992;158:603-6; Curr Surg 2003;60:164-73). Laparoscopic appendectomy has become a routine procedure and is now widely performed in North America. Although laparoscopic appendectomy has been discussed during pregnancy, limited data is available on the role of laparoscopic appendectomy in the third trimester of pregnancy. In fact, some authors have advocated a gestational age of 26-28 weeks to be the upper gestational limit for successful completion of laparoscopic surgery (Obstet Gynecol Surg 2001;56:50-9). In this paper, we present two recent cases of successful laparoscopic appendectomy during late pregnancy without immediate complication to mother or fetus and a description of our operative technique.

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