AUTUMN 2015

ALSGBI COUNCIL 2015

ALSGBI newsletter

Editor’s Introduction

ALSGBI ExecutivePresidentMr Mark N VipondPresident ElectMr Peter C SedmanHonorary SecretaryMr Simon PL DexterHonorary TreasurerMr Donald MenziesDirector of EducationMr Paul C Leeder

Members of ALSGBI CouncilMidlandsMr Martin S WadleyTrentMr Altaf Khan AwanIrelandMr Colm O’BoyleOxford & WessexMr Nicholas DaviesNorthern & YorkshireMr Sean Woodcock

North West & MerseyMr Milind S ShrotriScotlandMr Ahmad NassarNorth ThamesMr Tan ArulampalamAngliaMr Neil KeelingSouth ThamesMr A Mark GudgeonWalesMr Graham Whiteley

South & WestMr Nader FrancisAUGIS RepresentativeMr Ian J BeckinghamACPGBI RepresentativeProfessor Mark ColemanASiT RepresentativeMr Jonny WildALSGBI Representative at EuropeanAssociation of Endoscopic SurgeonsProfessor George HannaALTS ChairMrs Jane P Bradley-Hendricks

Mrs Sarah WilliamsDirector of Fundraisingswilliams@alsgbi.orgTel +44(0)20 7869 6940www.alsgbi.org

For our Autumn Newsletter we have areport from Professor Mark Colemanregarding the comprehensive SAGES2015 meeting in Nashville, USA and itsounds like some of the types ofinteractive and skill based sessions couldbe highly valuable for both trainees andtrainers in future UK meetings.

Please take time to read the article byMr Peter Sedman where he outlines theproposed new LapPass Certificationprocess which will be launched at theALSGBI ASM 2015. This is designed to be

a ticket for accelerated laparoscopic training for early years surgical trainees.It is intended to be both challenging and fun but will become recognisedboth in the UK and internationally as a mark of laparoscopic surgical skillattainment.

On the technology front we have a tantalising first impression of 4k screentechnology being used in theatres from the Colchester group. I am sure thatwe will see much more of this and other innovative advances at theforthcoming ALSGBI ASM in Southport. The exciting and full programme willinclude the popular interactive live operating links to local experts as well asinternationally renowned surgeons.

Mr Neil KeelingNewsletter Editor

President’s IntroductionWelcome to the Autumn 2015 edition of the ALSGBI newsletter. I am grateful to MrNeil Keeling in bringing together a bumper edition. You will find a number of articlesreporting on recent national and international meetings, travelling fellows report andassessment of 4K technology. The article by Mr Peter Sedman on the laparoscopicpassport (LapPass) outlines a new venture for ALSGBI to benchmark competenciesfor laparoscopic surgeons and will be of interest to trainees and trainers. We plan topilot its introduction at the forthcoming ASM.

Preparations for the ASM in Southport, 26 and 27 November are complete. Detailscan be found via the link on the ALSGBI website. There will be live operating on theThursday from Aintree Hospital with an excellent faculty delivering upper GI, colorectaland abdominal wall surgery. Our visiting BJS lecturer is Professor Steven DeMeesterfrom University of Southern California who will deliver his lecture on recurrent para-oesophageal hernia. He will also take part in a symposium on ‘the use and misuse ofmesh in abdominal surgery’ together with Mr Neil Smart (Exeter), Mr Bruce Tulloh(Edinburgh) and Dr Karen Ellison (MPS) who will provide a medico-legal perspective.

There is a laparoscopic surgery training day on the Wednesday preceding the ASM,free to trainees through competitive application. This will focus on laparoscopic suturingand stapling techniques. Places are limited to 24 and I would encourage early applications.

All in all, there is a balanced programmewith something for everyone. Please registerand encourage trainees and non-ALSGBIcolleagues to attend.

It will be my last meeting as President. Ithas been a privilege to hold the position forthe last two years and I would like to thankCouncil, all members and Jenny and Sarah forall their support. Mr Martin Wadley and MrMilind Shrotri will be demitting from Councilin November and elections will be held in theirrespective constituencies, Midlands and NorthWest & Mersey. I encourage you to put your name forward and get involved in thework of the ALSGBI and its future. I wish Mr Peter Sedman a successful presidencyand know the Association is in excellent hands and leadership.

Mr Mark N VipondPresident

Deputy ALTS ChairMs Alice E JonesEditorial SecretaryMr Neil KeelingAudit DirectorMr C Richard B WelbournResearch DirectorProfessor George HannaWebsite DirectorMr David MahonRCS MIS TutorMs Avril AP Chang

Association of Laparoscopic Surgeons of Great Britain & Ireland @ The Royal College of Surgeons, Room 505, 5th Floor, 35-43 Lincoln's Inn Fields, London WC2A 3PERegistered Charity Number: 1058455

Mrs Jenny TreglohanExecutive Directorjtreglohan@alsgbi.orgTel +44(0)20 7869 6941www.alsgbi.org

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SAGES 15-18 April 2015, Nashville, TN, USA

This year SAGES took place in Nashville, nick-named “Music City, USA”. As usual, the interestinglynamed Gaylord Opryland Convention Centeroffered a bewildering array of sessions. Notsurprisingly, the Americans found no regulatorybarriers to an enormous programme of cadaverworkshops in the hotel/convention centerbasement! Where in the UK could that happen?Innovation, patient safety and hands-on trainingare heavily emphasised in these meetings eachyear, but it is simply impossible to cover the range and scope of subjects on offer. Seehttp://www.sages2015.org/wp-content/uploads/2014/11/SAGES-2015-Advance-Program.pdf forprogramme details.

What struck me most at SAGES was theemphasis on interactive panel discussions andhands-on training sessions. There were plenty ofdidactic lectures of course, but these were eitherto inspire (Ed Viesturs – one of the only men who has climbed the world’s ‘above 8000m’mountains) or inform (Horacio Absun on

spreading laparoscopic surgery to developingcountries). Overall I was highly impressed by the‘delegate-focused’ programme and the seriousattention to learning outcomes. Flying the flagfor Britain at this year’s SAGES included

presentations by Mr Ian Jenkins from St Markson colorectal anastomosis and Mr DaniloMiskovic from Leeds on total mesorectal excision.

This year’s incoming SAGES President (2015-6)is Dr Brian Dunkin from the Houston MethodistCenter, Texas. He invited a faculty of LAPCOtrainers over to coach the SAGES cadaver facultythe day before a hands-on laparoscopic incisionalhernia workshop. The course was intensivelyevaluated by faculty and delegates alike andnoted to be a great success in improving theperformance of the faculty. More to follow butthe Americans really buy into the English LAPCOTrain the Trainers Course and want to roll it outin the ‘States.

Away from the congress, a few Brits andfriends spent a highly enjoyable evening at the BBKing Rhythm and Blues Club in Nashville. The food,the company and the live music were memorable.

Next year’s meeting will take place in Boston,16-19 March 2016 and abstract submissions arealready open. Go to http://www.sages.org/meetings/abstracts/for more information.

Professor Mark ColemanACPGBI Representative

Delegates and faculty at the SAGES Lapco TTcourse 2015

An enjoyable evening at the BB King Blues ClubNashville

1 Benchtop testing in porcine stomach tissue. Mean peak load required to pull tissue from the clamped jaws of ECHELON FLEX™ Powered Plus Stapler (PSEE60A) and ECHELON Reload with GST vs ENDO GIA™ ULTRA

Handle (EGIAUSTND) and Endo GIA™

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4k Laparoscopic Surgery: Our First Experience at Colchester General HospitalIntroductionThe progression of surgical technology availablein laparoscopy over the past 20 years hasrevolutionised the procedures we can offer ourpatients and the outcomes they can expect. Oneof the latest advances is the use of a 4k video, atechnology more associated with home cinemasystems than the operating theatre. We had theopportunity to trial the SynergyUHD4 stacksystem from Arthrex at Colchester Hospital inJuly of this year, and we are able to share thefeedback of our laparoscopic surgeons.

High Definition (HD) versus 4kResolution is one of the most common andrecognisable metrics used to describe videoquality, defined as the number of distinct pixelsthat a feed can display in each dimension.Although definitions differ across the World, themajority of laparoscopic theatres are equippedwith 'full' HD systems, such as the Storz IMAGE1SPIESTM or Olympus VISERA ELITETM. Thesesystems project an image with a resolution of1920 x 1080 pixels, however the new generationof 'ultra' HD systems are able to project 3840 x2160 pixels (described as 4k given that there arein the region of 4000 horizontal pixels). Assumingthe other facets to video quality remainunchanged, there is an assumption that thisimproved resolution would aid the surgeon inundertaking the highest quality procedure.

Evaluation of the 4k System at ColchesterColchester is a specialist laparoscopic unit witha 10 strong consultant team across general,colorectal and benign upper GI surgery. TheSynergyUHD4 system was trialled for a period offour weeks in the elective setting, with a beforeand after evaluation from any senior registrar orconsultant who operated using it. We wereinterested in seeing how the new system felt tothe surgeon and whether it had the potential toimprove surgical quality.

OutcomesIn advance of this trial, our surgeons wererelatively inexperienced with 4k laparoscopy.They were all 'satisfied' or 'very satisfied' with thecurrent standard HD system with some believingboth depth perception and light reflection couldbe improved. Feedback following use of the 4ksystem was mixed, but certainly positive.Approximately two thirds of surgeons noticed animprovement in image quality with manycommenting that it improved their depthperception and the ease of dissection. However,it did appear that light reflection was more of anissue as was the assistant complaining of havingto hold a rather hot camera head!

Comments and Considerations for the FutureThis trial of 4k laparoscopy was certainly excitingwith some interesting outcomes. Resolution isonly one of several factors that contribute

towards imagequality, howeverwe were surprisedat quite how manysurgeons reportedan improvement inthe ease withwhich they could operate. Unfortunately, it isbeyond the scope of this work to determinewhether or not this could improve efficiency(through avoidance of unnecessary operativesteps) or reduce mistakes in structureidentification; but this is certainly a researchquestion of interest. The issues such as glare anda hot camera head need some work, however, ourexperience indicates a 4k system may represent atechnological progression, which will deliverbenefits to the surgeons and consequently ourpatients. This would need to be confirmed usingsuch a system more comprehensively including acomparison with other emerging technologiesincluding 3D laparoscopy.

Mr Sam MasonCore Trainee and Faculty, ICENI Centre, Colchester

Mr Tan ArulampalamClinical Director, ICENI Centre, Colchester

DisclosureThe authors received no funding from Arthrex forthis work.

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The ALSGBI continues with its commitment toits trainee members by providing high qualityhands-on training events free of charge inaddition to supporting trainees financiallythrough various bursaries such as the ALSGBItravelling fellowships and the “Support aTrainee” scheme. On 26 November 2014, 24trainees attended the internationally renownedCushieri Skills Centre in Dundee for the ALSGBILaparoscopic Training Day. Delivered by anunrivalled faculty of laparoscopic surgeons

comprising of ALSGBI Council Members andexpert local faculty, the event, generouslysupported by Ethicon, was a huge success.Trainees worked in pairs undertaking a variety oflaparoscopic procedures and techniques onhuman cadavers for one half of the day andporcine models for the other half. With onetrainer per pair there was ample opportunity fordirect feedback. The Cushieri Skills Centreprovided cadavers embalmed using the Thielsoft-fix method which provided an excellentopportunity for practising dissection and tissueplane development. Participants ranged fromST3 through to ST8 and to accommodate variedtraining needs the programme was intentionallyflexible so as to allow participants to selectwhichever laparoscopic procedures they wishedto perform on the Thiel cadavers. These includedright hemicolectomy, left hemicolectomy, totalmesorectal excision, sleeve gastrectomy, jejo-

jejunostomy, gastro-jejunostomy, jejo-jejunostomydelete as repeated, gastriclymphadenectomy, hiatus hernia repair,fundoplication, cholecystectomy, CBDexploration, left and right hepatectomy andsplenectomy. Using novel porcine modelsdeveloped at the Cushieri Skills Centre,participants also had the opportunity to performsimulated laparoscopic ventral mesh rectopexy,trans-anal TME and laparoscopic parastomalhernia repair.

In February this year the ALSGBI alsoprovided support for the Association of Surgeonsin Training (ASiT) Core Laparoscopic Skills courseat the 2015 ASiT Conference in Glasgow. Thisone-day skills course is aimed at junior traineeswith basic laparoscopic skills experience.Interactive talks covered laparoscopic setup,patient positioning, instrumentation andergonomics with practical sessions using porcinemodels in which participants performed openHasson port insertion, laparoscopicappendicectomy and cholecystectomy inaddition to an introduction to laparoscopicsuturing. In addition to supporting thelaparoscopic pre-conference courses at the ASiTconferences over recent years, the ALSGBI alsoprovides a prize each year for the bestpresentation relating to minimal access surgery.Congratulations to Mr Joe Dixon, who wasawarded the 2015 ASiT/ALSGBI prize for his

presentation entitled “Laparoscopic versus OpenT4 Colonic Cancer Resection.”

From Autumn 2015 the ASGBI will launch theLapPass – the Laparoscopic Passport. The LapPassis a badge of proficiency in core laparoscopicskills and is available for core and specialtytrainees to undertake. Details are in MrSedmans’s article and on the ALSGBI website.

Finally, the 2015 ALSGBI ASM in Southport(26 and 27 November) provides a fantasticopportunity for trainees to present research and

audit projects with generous prizes for best DVD,oral and poster presentations. All oral presentedabstracts are published in a supplement to theSurgical Endoscopy Journal and with theALSGBI “Support a Trainee” scheme eachtrainee presenter will receive a bursary tocontribute towards travel expenses to attendthe conference. Again the ALSGBI LaparoscopicSurgery Training Day will take place on 25November at the MASTER Unit at BroadgreenHospital, Liverpool with a full day of wet-labtraining planned on whole porcine models withexpert faculty. Demand for places will be highso register early to avoid disappointment and Ilook forward to meeting more trainee membersin Southport for what promises to be afantastic meeting.

Mr Jonny Wild Trainee Representative on ALSGBI Council

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ALSGBI Trainees Group Update

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The 2nd DDF meeting was held inmid June at the ExCel centre inLondon. The DDF meeting is uniquein the UK as the only meeting thatbrings together professionals fromacross all disciplines. This allows theopportunity for interdisciplinary

debates and for better understandingdifferent aspects of GI diseasescompared to the usual surgical view.This was reflected in a diverse andinteresting program with somethingfor everyone.

Building on the successfulinaugural DDF in Liverpool threeyears ago, the meeting entertainedaround 4000 delegates from thefive GI related societies - AUGIS,ACPGBI, BAPEN, BASL and BSG. Oneof the advantages of such a largemeeting is its ability to attractsenior medical and politicalspeakers and the plenary session

was evidence of this with Sir BruceKeogh, Medical Director of the NHSopening the DDF plenary sessionwith a talk on the future of theHealth Service. His message was thatinnovation is the future of the NHSand will require the implementation

of new technologies and informaticsif it is to survive in its current form.He pointed out that although therunning costs of the health serviceare high, much of that money isplowed back into the economythrough purchasing of UK productsand wages. The future of the tax-funded NHS depends heavily upon athriving economy as well. ProfessorMark Caulfield spoke on the 100,000Genome project and thedevelopment from this of targeteddesigner drugs to treat specificconditions. Professor Tim Hodgettsspoke on the future of trauma

surgery and how this onceCinderella specialty now pioneersmuch of our medical innovation,particularly in robotics and tele-medicine. Sir Mark Walport spokeon “Science, Government and TheNHS Shaping The NationwideScientific Agenda”. All in all anextremely thought provoking andfar reaching set of reviews for thenext decade of science, medicineand the NHS.

The following three days coveredthe breadth of gastrointestinalmedicine and surgery and therewere lots of debates and mixing ofthe societies’ programmes. TheAUGIS plenary session was followedby the BJS prize presentations andthe return of Professor OlivierScatton discussing the rise of

laparoscopic live donor livertransplantation. Challenging areasof treatment overlap including CBDstones, achalasia and GORDenjoyed lively cross specialtydebates exploring the roles ofnewer interventions and the choiceand sequence of procedures. DrJohn Hunter from Portland, Oregon,was a returning favourite and livelyspeaker.

A joint AUGIS and ACPGBIsession provided managementguidance, tips and tricks inemergency surgery for anastomoticleaks and iatrogenic perforations

and a talk on management ofBooerhaaves syndrome byProfessor Muntzer Mughal. A jointAUGIS and BSG session dealt withthe management of GI bleeds andan AUGIS and ACPGBI grand roundplenary session was appealing toALSGBI members including talks onlaparoscopic approaches toemergency surgery, imaging andaudit updates.

Obesity surgery featured heavilyat the DDF with BOMSS and AUGISsessions including grand rounds onhow to deal with commoncomplications of bariatricprocedures, surgery for metabolicdisorders, a choice of procedures forthe super obese and the politics andeconomics of bariatric surgery. Asession on ‘Severe Obesity from AllAngles’ was chaired by BOMSSPresident, Mr Roger Ackroyd andincluded talks on the psychology ofobesity, the role of the dietitian andthe role of the gastroenterologistwith Mr Sean Woodcock concludingthe session with an update on thestate of the bariatric surgery in theUK. Professor Francesco Rubinospoke on ‘Expansion of The Role ofThe Bariatric Surgeon’ and said: "Theage of metabolic surgery hasarrived." Professor Philip Jamesspoke on obesity prevention, sayingthat there has been a “repeatedfailure of health promotion as amainstay of policy with regard tofood and drink.”

The meeting was well receivedby all who attended and is due tobe repeated again in 2018.

Mr Ian BeckinghamAUGIS Representative

2nd Digestive Diseases Foundation (DDF) Meeting 22-25 June 2015, London

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The ALSGBI best abstract won the European Cup at theEuropean Association of Endoscopic Surgery (EAES)3-6 June 2015, Bucharest, Romania

Dr Jennifer Mason, a trainee from Yeovil Hospitalwho won the 2014 David Dunn Medal for the bestabstract at the ALSGBI Annual Scientific Meetingin November 2014 has won the European Cup atthe EAES Congress in Bucharest in June 2015. TheEAES selected the top presentation from 5national societies to be presented at the congressfor the European Cup, representing Spain,

Romania, Lithuania, Israel and the UK. TheEuropean Cup session was chaired by the threepresidents of the EAES (in the photos): current(Professor Mario Morino; Italy), coming (ProfessorEduardo Targarona; Spain), and past (ProfessorKarl-Hermann Fuchs; Germany).

Dr Jennifer Mason presented her talk on“Factors predicting 30 days re-admission after

laparoscopic colorectal cancer surgery withinenhanced recovery”.

The meeting was well attended by over 1200surgeons from all over the world and we wouldlike to congratulate Jennifer for the achievement.

Mr Nader FrancisSouth & West Regional Representative

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“LapPass” The ALSGBI certificate of technical skillproficiency in laparoscopic surgery

Laparoscopic surgery is technically demanding and the skills required forproficiency are difficult to acquire. It is not for everyone. However, perhapsmore than for any other branch of surgery, simulator training lends itself topractising and perfecting laparoscopic technical skills. From Autumn 2015the ALSGBI will recognise those trainees who are able to demonstrateproficiency in a defined set of five laparoscopic tasks. These are not easy skillsto perfect and the possession of the passport will be a badge of proficiencywhich will be recognised nationwide and will mark out those who are seriouslaparoscopic surgeons. In turn, it would be anticipated that trainers willrecognise that those in possession of the LapPass will be suitable foraccelerated operative training.

The five skills are

1 Camera holding (which will be assessed intra-operatively) and fourtechnical tasks which will be demonstrated and assessed in training jigs.These skills are:

2 Grasping and manipulation3 Creation and accurate deployment of secure endo-loops

(e.g. Roeder knots)4 Cutting and dissection5 Intra-corporeal suturing

A Powerpoint show outlining these tasks and video demonstrations of eachthem is available on the ALSGBI website at www.alsgbi.org We are notassessing everything (e.g. access is not included) but only those skills we thinkare the most important and suitable for simulator training.

ACCEPTABLE JIGSA core principle in the rollout of the “LapPass” is that the training andassessment tools are widely available and that flexibility and innovation insetting these up are encouraged. Provided the assessor is confident thatthe jigs used accurately reflect the skill level required; a variety ofsimulators are acceptable. Paradoxically perhaps, the simpler the jig; themore widely available and the easier the assessment may be to conduct.Should high fidelity simulators be available these may be used; as will thecommercially available medium fidelity simulators with integral web camsand screens. However low tech solutions may be used such as simple closedboxes in theatre using the OR laparoscopes, stacks and clean instrumentsbetween, or at the end of, an operating list (fig. 1): or more simple still -open boxes or jigs with one eye blinded (to reduce the surgeons vision from3D to 2D) (fig. 2). Even smart phones mounted in cardboard boxes (fig 3)would be acceptable.

It is hoped that these assessments may be performed in a range ofsettings from skills labs to operating theatres and in coffee rooms betweencases. It is the trainees’ responsibility to set up the jigs and the assessor needonly be present for the performing of the tasks which, when successful, willtake only a few minutes each.

FIGURE 1Using the existing theatre equipment and a cardboard box at the end of a list.

continued overleaf

LapPass

I hereby certify that

has achieved technical skill proficiencyin Laparoscopic Surgery

Signed:

Mr Mark VipondPresident

Date:

GBI

10

FIGURE 2A three dimensional training jig can be made two dimensional by obscuringone eye. The Ned Kelly or Rooster Cogburn look!

FIGURE 3A cardboard box can be modified to accept a video smart phone andadditional light source. Trocars are not mandatory.

i-phone with zoom video facility in the front of a cardboard box.

Use your imagination and please send us photographs of your ideas. A prizewill be awarded to the most innovative solution described!

1 Camera Holding Skills A minimum of six cases with at least three different surgeons must beassessed and of these at least three should be with a 30o scope and all shouldbe with 2D imaging (for those fortunate enough to have 3D systemsavailable). Up to two cases ideally will involve intra-corporeal suturing (+ 1mark each if so).

Each case must be no shorter than 45 minutes in operative time and 30minutes of laparoscopy. Marks will be given for various elements of goodcamera work and the forms may be downloaded from the websitewww.alsgbi.org The best three 30o and the best three 0o cases will be used toobtain the requisite score.

Please visit the website www.alsgbi.org for explicit details of the skills requiredto be demonstrated.

MODEL REQUIREMENTS FOR THE TASKS2 Grasping and manipulationTask 2 requires three matchsticks mounted (a car sponge is a convenient wayof doing this but blu-tack or equivalent are alternatives). You will also needa few polo mints, a short length of cord or string and two laparoscopicgrasping forceps. This test is designed to assess bimanual dexterity in the 2dimensional environment. A practical tip is to palm the grasping forcepsrather than grasp them in the conventional manner as this allows a freerrange of movements, especially in pronation and supination.

Task 2. Grasping and manipulation with mints, cords and matchsticks.Target time to complete < 4 mins

3 Creation and accurate deployment of secure endo-loops (e.g. Roeder knots)

Task 3 involves creation and deployment of safe endoloops. You will need asurgical glove, lightly inflated, to the point that there are no folds in thefabric of the glove and with four hoops drawn around one of the fingers at1cm intervals. The glove will need to be fastened to the base of the boxtrainer. The endoloop needs to be created from a surgical thread no greaterthan “1” gauge and either monofiliament or braided suture may be usedprovided a suitable knot is applied (Roeder, Meltzer, etc … are all acceptableprovided they are properly and effectively tied). You will need a knot pusherof some description, a pair of laparoscopic scissors and a grasping forceps tocomplete this task. The glove should not visibly deflate within 1 minute ofamputating the finger tip. A practical tip is to use a braided thread of “0” or“2/0” gauge as these tend to give the best results.

Task 3. Creating and deploying endoloopsTarget time: Three loops tied and placed < 8 mins

11

4 Cutting and dissectionThe model for tasks 4 and 5 is ideally a car sponge which is clearly marked inindelible ink in accord with the instructions on the ALSGBI website. You willneed a grasping forceps and scissors and for the suturing exercise a pair ofneedle holders and suture thread sufficient for two knots.

A practical tip for the cutting exercise is to alternate the scissors betweenleft and right hands depending on the part of the circle being excised and toconcentrate as much (or more) on the direction of retraction afforded by thegraspers as you do on the scissors. “The graspers do the work and the scissorsget the glory”.

Task 4. Cutting an accurate disc. Target time: < 3 mins

5 Intra-corporeal suturingSuturing is the single hardest task to perfect. The exercise requires you tosecure two safe knots and to bring two parts of the tissue (1cm apart) intoapposition under mild tension. This exercise is best performed using adynamic camera and there are tricks a good cameraman can use to makesuturing easier (gentle dynamic zooming in and out) which are not possibleon fixed camera jigs.A short help video on the principles of suturing and knotting (includingendoloops) is available on the ALSGBI website.

Task 5. SuturingCreate two secured reef knots to ensure accurate apposition of tissue underslight tension. Target time: 2 sutures < 6 mins

ASSESSORS and ASSESSMENTAll consultant surgeons who normally conduct assessments and appraisalsfor the ISCP are suitable to act as assessors. It would make sense to asksomeone with a laparoscopic sub-speciality to perform the assessments inorder to ensure an optimum feedback and all active members of the ALSGBIwill be aware of these skills sets and be prepared to help.

We hope you will enjoy acquiring the LapPass. The tasks set arechallenging but the skills required are very much clinically relevant and formost people not intuitive. They will require practice, probably over manyhours at home or in the lab. They do not intend in any way to avoid the needfor courses but much like the Driving Test, lessons will help speedy acquisitionof the required proficiency and promote good habits; but on the day you stillhave to pass the Test itself with, or without, formal lessons. At the forthcoming ALSGBI meeting in Southport we shall have a trainingpantechnicon available to provide an opportunity for delegates to complete,be assessed and signed off for tasks 2 to 5 should they choose to do this.

The materials to help complete LapPass are on the website and includethe instructions for the tasks, the forms to be completed and generalguidance notes for assessors.

Mr Peter SedmanPresident Elect

Caption CompetitionHere is a snap of our President Elect, one can onlyimagine how he secured election to the post. Pleasecan you send us your versions of an appropriatecaption for the picture, your efforts will be rewardedby a bottle champagne.

Entries have to be sent to Mrs Jenny Treglohanjtreglohan@alsgbi.org by 1 December 2015

“LapPass” The ALSGBI certificate of technical skillproficiency in laparoscopic surgery

12 COURSES

ALSGBI Industry Partners' Course InformationElemental Healthcare LtdElemental Healthcare Ltd offer informative workshops on the latest innovation in Endoscopic Fluorescence Imaging – PINPOINT. For more information contact:-Kendra Chase | M: +44 (0)7789 880 211 | E: kendra@elementalhealthcare.co.uk | Melanie Goodall | T: 0844 412 0020 | E: melanie@elementalhealthcare.co.uk

Colorectal Workshops: Evaluating Anastomotic Perfusion Using Infra-red FluorescenceThese colorectal workshops are held in collaboration with HTC, NIHR, Leeds Teaching Hospitals and Professor David Jayne, demonstrating intra-operative real-time perfusion assessment. The workshopsinclude live operating; a technology overview as well as reviewing research and literature.

To register as a delegate please contact: Dr Neville Young, Programme Manager, ColorectalTherapies Healthcare Technology Cooperative, Level 7, Clinical Sciences Building, St. James’University Hospital, Leeds, LS9 7TF. T: 0113 206 5256 E: mednyo@leeds.ac.uk

OlympusContact: Mrs Tracy Bray, General Manager - Events, Olympus | Direct Line: +44 (0)1702 616333 | Email: info@olympus.co.uk | Web: www.olympus.co.ukFurther details of these events and our European courses are available on our website or will be in due course.

Date Course Venue

22–24 September 2015 Surgical Energy Masterclass for Theatre Practitioners KeyMed House, Southend

28–29 September 2015 Laparoscopic Colorectal Cadaveric Workshop Christie Hospital, Manchester

1–2 October 2015 Advanced Laparoscopic Hiatal Course Royal Infirmary, Edinburgh

12–13 October 2015 Total Laparoscopic Hysterectomy, Derby – 2 day Delta Centre, Royal Derby Hospital

24–27 November 2015 Frontiers in Intestinal and Colorectal Disease St Marks Hospital, London

26–27 November 2015 Laparoscopic Colorectal Surgery Cadaver Course University of Glasgow, Glasgow

7 December 2015 Total Laparoscopic Hysterectomy, Derby – 1 day Delta Centre, Royal Derby Hospital

6–8 January 2016 Glasgow Cadaveric Advanced Gynaecology Laparoscopy Course Southern General, Glasgow

Karl Storz Endoscopy (UK) LtdKARL STORZ Endoscopy (UK) Ltd is now in the 8th year of offering customer-focused training courses in Proctology. For more information, contact:-Gary Calvert | M: +44 (0)7812 973603 | E: gcalvert@karlstorz-uk.com or Charles Goudie | M: +44 (0)7976 202090 | E: cgoudie@karlstorz-uk.com

Autumn Workshop 2015 The LIMIT Centre, Leeds

Winter Workshop 2015 The LIMIT Centre, Leeds

Spring Workshop 2016 The LIMIT Centre, Leeds

Summer Workshop 2016 The LIMIT Centre, Leeds

4.7% in a recent NHS study(2).

A subsequent cost effectiveness analysis conservatively established that these clinical benefits provided an average cost reduction of £95 per patient, after the cost of the HumiGard product. With such a simple change in surgery providing such significant clinical and economic benefits, why wouldn’tyou use it? Please contact your local Fisher & Paykel Healthcare representative for more details on +44 1628 626 136

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1. Kurz, A., Sessler, D.I. & Lenhart, R. 1996. Perioperative normothermia to reduce the incidence of surgical wound-infection and shorten hospitalization. New England Journal of Medicine, 334:1209-1215.

2. N. Noor, D. Reynecke, J. Hendricks, R. Motson, T. Arulampalam. 2015. Use of warmed humidified insufflation carbon dioxide to reduce surgical site infections in laparoscopic colorectal surgery: a cohort study. (Abstract no. DDF15-1605 ) Presented at the 2nd Digestive Disorders Federation meeting, 22 -25 June, London. World leaders in the humidification of medical gases

www.fphcare.co.uk/surgical

A reduction in SSIs of 12.1% to 4.7% A cost reduction of £95 per patient

A minor change benefits

in surgery delivering significant clinical and cost

The CO2 used for insufflation in traditional laparoscopy and the ambient air which the surgical wound is exposed to during open surgery is vastly different to normal physiological conditions. The result of the exposure causes cellular desiccation and evaporative cooling, with the initial insult leading to a number of post-operative complications. Clinical trial data has shown that by providing warm, humidified CO2 during laparoscopic colorectal surgery, postoperative hypothermia can be reduced(1). This is suggested to be one of the key mechanisms contributing to a significant reduction in Surgical Site Infection incidence from 12% to

Maintenance of operative normothermia

Transanal TME Courses supported by Karl Storz Endoscopy (UK) LtdThese 2-day interactive workshops are aimed at colorectal surgeons experienced in minimal invasiveTME as well as transanal surgery, in particular TEM and/or TAMIS.

7-8 October ICENI Centre, Colchester

1-2 December ICENI Centre, Colchester

The above courses are facilitated at the Evelyn Surgical Training Centre, Cambridge. To register asa delegate on a TaTME Course, please contact Daisy Martlew, ICENI Centre, Colchester.

Daisy Martlew, ICENI Centre Co-ordinator | E: daisy.martlew@anglia.ac.ukColchester Hospital, Turner Road, Colchester, Essex CO4 5JL

Transanal Endoscopic Operations (TEO®) Courses supported by Karl Storz Endoscopy (UK) LtdThese one day events incorporate live surgery, procedural presentations and hands-on simulatortraining and are aimed at consultants wishing to undertake TEO® in their hospitals

17 November Queen’s Medical Centre, Nottingham

Courses are available via the Duke’s Club Website, www.thedukesclub.org.uk for Trainees

To register your interest as a delegate on a TEO® Course, please contact Dan Danby, KARL STORZCourse Administrator, specifying which course you are interested in and we will be in touch.

Dan Danby, Course Administrator, KARL STORZ Endoscopy (UK) Ltd | E: ddanby@karlstorz-uk.comT: +44 (0)1753 503500 | F: +44 (0)1753 578124 | 415 Perth Avenue, Slough, Berkshire SL1 4TQ

13

East & Far EastReport on David Dunn Travelling Fellowship 2013

Having started as aConsultant Surgeonat BroomfieldHospital in February2012 I have beenkeen to developadvanced minimalaccess techniques foroesophago-gastricresections. As such Iwas fortunate to visit

the units of Professor Ichiro Uyama at FujithaHealth University, Japan and Professor Palaniveluat GEM Hospital, Coimbatore, India as part of theDavid Dunn Travelling Fellowship.

JapanFirst stop in Japan was at National Cancer Centre(NCC), Tokyo. This institute is a solemn institutionat the centre of numerous clinical trials for gastriccancer. Vast majority of the surgery is open.During this week, I attended three gastrectomies,one open & shut case (peritoneal metastasis) and

one oesophagectomy. I was introduced toProfessors Katai, Fukagawa & Morita and able toattend their Friday morning MDT (conducted inEnglish). I intended to make most of my Japan railcard and travel on the famed Shinkansens (highspeed trains) aided by very useful advice fromProfessor Morita for my travels to North Japan.

I travelled to Fujita University in the secondweek, spending 2 weeks with Professor Uyama’sunit. His contemporaries at the NCC regardProfessor Uyama as the ‘Emperor’ of laparoscopicgastrectomies.

The atmosphere and hierarchical nature atFujita was a total polar opposite to that I saw atthe NCC. There appeared to be a lot of banterbetween colleagues and also between differentlevels of hierarchy. Despite all this, it was obviousthat Professor Uyama was highly revered by thewhole department. The department seemed to bea buzz with activity, excitement and pride. In thenext two weeks, I observed 5 total & 3 sub-totalgastrecomies (all laparoscopic) and one robotictotal gastrectomy. Professor Uyama hasdeveloped a great laparoscopic technique for bothD2 dissection as well as a linear stapledoesophago-jejunal anastomosis. The technique isvery standardised; a junior registrar would be

performing a total gastrectomy. The Professor wasapproachable, open to questions and very willingto teach and discuss. He took time to go throughthe differences in the port placements betweenlaparoscopic and robotic gastrecomies. He even

hosted dinner after a marathon 7hr roboticgastrectomy and before leaving in the early hoursof the following morning to travel to the USA.

I found the attitude and approach of theJapanese surgeons unique & interesting. They areskilful, patient, systematic and meticulous. There isnever a race against time and yet they have anuncanny ability to combine humility withconfidence. They are very dogmatic, yet at the sametime pragmatic. Despite their regimented approach,there always seems to be room for innovation. Thetwo Japanese words that describe their attributesare ‘kata’ and ‘gambatte’. The former means‘method’ and the later means ‘fight on’.

IndiaMy next leg of the fellowship took me toCoimbatore in Southern India where I visitedProfessor Palanivelu at GEM Hospital. He is one ofthe most renowned laparoscopic surgeons inIndia. He attracts politicians and celebrities to his

hospital. During my visit, one of the state’s cabinetministers had a laparoscopic cholecystectomy.

GEM hospital is set up to do minimal accessoperations for every conceivable GI pathology. Forthe length of my visit of 2 weeks, there wasn’t asingle open operation.

Details of each operation are religiouslyrecorded into a database. Every operation isrecorded and edited pretty much straight after bythe fully staffed on site audio-visual department.Not surprisingly, Professor Palanivelu has published

widely. He started to perform totally MinimalAccess Oesophagectomy in 1997, almost 2 decadesago and published a series 130 cases in 2006. Athoracoscopic approach is now the establishedstandard technique in their unit. They haven’t hadto open a chest for a number of years. So much sothat the hospital doesn’t even keep a rib retractor!

The technique of resection has changed overthe years. A 3-stage Mc Keown type resection wascommon in the past. With increasing incidence oflower oesophageal & OG junction tumours, 2-stage Ivor-Lewis resection with intra-thoracicanastomosis is now the commonest operation.Thoracoscopic part of the operation was initiallyperformed in the prone position. Now it is donein a left lateral semi-prone position. ProfessorPalanivelu performs a linear stapled or hand sewn

oesophago-gastric anastomosis. He prefers thelatter and does it with PDS suture. The posteriorlayer is interrupted and the anterior layer is closedwith a continuous suture.

I had the opportunity to have a number ofdiscussions with Professor Palanivelu. While GEMhospital attracts a number of rich and famouspatients, the vast majority of the patients stillcome from the neighbouring villages. ProfessorPalanivelu developed the minimal accesstechnique, after failing to convince the farmersand manual labourers to have laparotomy &thoracotomy for oesophagectomies. Lack of socialsupport system means that these patients needto return to their jobs at the earliest, with minimalloss of function. Hailing from India, I totallyunderstand this issue.

‘Necessity, mother of innovation’ has been theprinciple of so many things that come of out India.

I have had the most amazing experience visitingthe busiest hospitals in Japan & India headed byworld-renowned surgeons. I am ever so grateful toALSGBI for awarding this coveted fellowship to meand Ethicon for sponsoring this fellowship.

Legend for the photos: All the photos are selfexplanatory apart from the Photo no. 4:Brihadeeswarar Temple, 66m tall, completed in1010 AD.

Mr N V Jayanthi

14

PINPOINT Endoscopic Fluorescence Imaging provides illuminationbeyond the limits of the human eye, confidently visualising andassessing tissue perfusion in real-time and improving patient outcomes.

In combination with high-definition white-light video, fluorescenceimaging provides the ability to visualise blood flow in vessels, tissuesand organs throughout the body.

• SIMULTANEOUS IMAGING Fluorescence and white light• HIGH DEFINITION IMAGING Superior resolution (1080p full HD)• ONE BUTTON TRANSITION Superb usability

PINPOINT Endoscopic Fluorescence ImagingBrighter than any other

PINPOINT offers brilliant, high-definition, white-light video with theadded advantage of SPY Fluorescence imaging technology, whichhas been demonstrated as beneficial in a variety of surgicalapplications, including:

Reducing Anastomotic Leak RateColon ResectionPINPOINT assesses tissue perfusion and assists surgeons in makinginformed decisions which positively affect outcomes. Studies showthat only 1.4% of lower anterior resections resulted in an anastomoticleak rate when PINPOINT was used (reduced from 12.6%).¹

Laparoscopic CholecystectomyAvoid Common Bile Duct InjuryIdentifying vital biliary anatomy, especially in difficult cases, is easierwith PINPOINT. The system also enables to you confirm the integrityof the cystic duct and artery at the completion of surgery.

Find out more, view PINPOINT in action and download some of the clinical studies atwww.elementalhealthcare.co.uk/news

1. Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, et al. Perfusion assessment inlaparoscopic left sided/anterior resection (PILLAR)

II: A multi-institutional study. Ann Surg. Sep 2014Detection of sentinel lymph nodes in minimally evasive surgery using ICG and near-infrared fluorescenceimaging for uterine and cervical malignancies, Jewell et al. Feb 2014

15

Teleflex turns its attentionto Percutaneous Surgery

Teleflex Incorporated, a leading global provider of medical devices forcritical care, urology and surgery, acquired the assets of Mini-LapTechnologies, Inc., a leading developer of next-generation minimallyinvasive surgical instruments, in December of 2014. The transactionprovides Teleflex a platform technology, additional marketed productsthat address various segments of the surgery market, as well aspipeline products.

MiniLap® instruments, with their slim 2.3 mm shaft diameters forthe graspers and 2.4 mm shaft diameters for the MiniPolar probes,can be percutaneously inserted into the abdomen using an integratedneedle tip. The grasper jaws or probe can then be deployed to graspor coagulate tissue. The patented deployment design allows grasperjaws to open up to 12.5 mm to grasp difficult structures, likedistended gall bladders.

MiniLap® instruments were conceived by a surgeon who soughtways to manipulate and hold surgical mesh directly through theabdominal wall, to enable successful tacking techniques. The simpleconcept of ‘manipulation’ quickly proved of value, and due to theunique features of the device, surgeons from multiple specialtiesbegan to adopt its use as a percutaneous complement in multi-portlaparoscopy.

The MiniLap® Percutaneous Surgical System includes fourMiniLap® Graspers (Alligator, Clutch, Babcock, Bowel) and fourMiniPolar™ Electrosurgical Probes (Curved Spatula, Straight Spatula,Conical, Hook).

The MiniLap® System complements Teleflex’s diversified range ofWeck® brand surgical instruments, which include Weck Hem-o-lokpolymer locking clips and the Weck Vista® Access portfolio, whichprovides confidence, clarity and control during general and advancedlaparoscopic procedures. For closure, surgeons can rely on theinnovative design of the Weck EFx® Endo Fascial Closure System,which provides reproducible fascial closure in varying body types witha controlled suture delivery.

About Teleflex IncorporatedTeleflex is a leading global provider of specialty medical devices for arange of procedures in critical care, urology and surgery. Our missionis to provide solutions that enable healthcare providers to improveoutcomes and enhance patient and provider safety. Headquarteredin Wayne, PA, Teleflex employs approximately 12,200 people andserves healthcare providers worldwide. Additional information aboutTeleflex can be obtained from the company's website at teleflex.com.

Teleflex, MiniLap®, MiniPolar™, Weck®, Weck Vista® and Weck EFx®are trademarks or registered (in the U.S. and/or other countries)trademarks of Teleflex Incorporated or its affiliates. ©2015 TeleflexIncorporated. All rights reserved.

Not all products are available in all regions, contact your RegionalSales Representative for local information.

Ian MellorsProduct Manager Teleflex UK+44 (0)7739 628969ian.mellors@teleflex.com

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