Abstract

Technology has transformed the face of surgical technique among the disciplines of surgery. This revolution has created a strong demand from the public for the availability of minimally invasive surgical (MIS) interventions. Significant pressure has been placed on both industry and medicine to develop, test, and implement devices and procedures at a rapid pace. Unfortunately, this pace has at times surpassed the system's ability to train and prepare a corps of surgeons competent in both the technical and cognitive aspects of minimal access surgery. The economic constraints of surgical practice, coupled with recently introduced work-hour restrictions, have made the delivery of minimally invasive surgical education a challenging endeavor. Much work has been done in academic and private institutions to address this need. Solutions traversing the spectrum of technology have been developed, tested, and implemented in training. The purpose of this review is to highlight these solutions on the basis of their validity, utility, and overall contribution toward achieving the goal of producing competent minimally invasive surgeons. The body of literature suggests multiple valid training and assessment constructs exist. However, the overall utility of many validated "high-end" training technologies is limited by cost and access. Efforts should be aimed at creating valid training and assessment paradigms that can be applied by the broadest group of trainees, from medical students to surgeons, in active practice.

Abstract

Of the 40 million patients who undergo surgery each year in the United States, 20% may develop a postoperative nosocomial infection. Staphylococcus aureus (S. aureus) is the most common organism involved, and carriage of S. aureus in the anterior nares has been identified as a risk factor for these infections. Topical mupirocin applied to the anterior nares has been successful in eliminating S. aureus and decreasing nosocomial infections due to S. aureus. Concurrent use of preoperative chlorhexidine showers may further reduce the incidence of S. aureus surgical site infections (SSIs). In addition to treating the patient, active surveillance programs to eliminate nasal colonization in hospital surgical personnel have controlled outbreaks of S. aureus SSIs. Recently, a large study identified risk factors linked to S. aureus nasal colonization, which included obesity, male gender, and a history of a cerebrovascular accident. Protective factors included older age, current smoking, and alcohol use. Thus, by modulating these variables, investigators may create interventions aimed at reducing S. aureus nasal carriage and ultimately, postoperative nosocomial infections.

Abstract

Great strides in the understanding of regulation of the immune system have led to development of strategies to harness the potential of cellular immune responses for improving the outcome for cancer patients. To generate a cytotoxic T-lymphocyte (CTL) response to cancer cells requires tumor-specific antigens processed appropriately and displayed by major histocompatibility complex (MHC) molecules, T-lymphocytes with receptors of appropriate specificity, and co-stimulation delivered by antigen-presenting cells through members of the B7 family. In this review, the fundamental advances that have been made in tumor antigen discovery, and the novel vaccine approaches arising from these advances are discussed.

Abstract

Bipolar radiofrequency (RF) energy can successfully seal vascular structures up to 7 mm by fusing collagen and elastin in the lumen. Valleylab has created a system to expand this technology beyond vessel sealing with the development of a closed-loop, feedback-control RF generator that closely monitors tissue fusion. This generator, operating with a loop time of approximately 250 micros, continuously adjusts energy output, creating optimized soft-tissue fusion through structural protein amalgamation. In the first study, RF energy was applied to canine lung using the new-generation generator and lung-prototype device. A lobectomy was completed, sealing the lobar bronchus, parenchyma, and pulmonary vasculature. Chronic performance of the seals was evaluated at necropsy on postoperative days 7 and 14. In a second study, RF energy was applied to porcine small intestine using the same closed-loop generator and anastomosis prototype device. Acute tissue fusion was assessed qualitatively for hemostasis and seal quality. Terminal tissue evaluation was completed on postoperative day 7 and analyzed histopathologically. Histopathology confirmed acute and chronic tissue fusion in both the lung and intestine. Normal pathological healing was substantiated by angiogenesis, granulation, and proliferation of fibroblasts. Preliminary studies using canine lung and porcine small intestine demonstrate the potential of this closed-loop generator for soft-tissue amalgamation. Advanced monitoring capabilities make this fusion system applicable in many soft-tissue structures with adequate collagen and elastin. Further investigation of potential surgical applications needs to be completed.