title: Surgeons' perceptions of transanal endoscopic microsurgery using minilaparoscopic instruments in a simulator: the thinner the better.
abstract: BACKGROUND
  Several issues have limited the widespread adoption of transanal endoscopic microsurgery (TEM). The need for specialized equipment and the steep learning curve represent one of them. To operate on within a 4-cm diameter, rectoscope represents a major technical challenge. However, minilaparoscopic surgery has been introduced to reduce invasiveness and abdominal wall trauma. In TEM, instrument miniaturization may lead to technique optimization. We hypothesized that visualization and maneuverability during TEM performed with 3-mm minilaparoscopic instruments would be superior to TEM performed with conventional 5-mm instruments.
  
  
  METHODS
  Eighteen general and colorectal surgeons with experience with TEM under ten cases were recruited. Two tasks should be accomplished using the TEO(®)-Neoderma simulator. First, using conventional 5-mm TEO(®) curved-tip instruments, a "polypoid lesion" should be excised. Next, closure of the "rectal" defect should be undertaken. In the second part, the same participants repeated the same excision/closure tasks using 3-mm minilaparoscopic instruments. After tasks conclusion, participants fulfilled an evaluation questionnaire with seven questions regarding visualization and maneuverability when using 3-mm compared to 5-mm instruments.
  
  
  RESULTS
  For each one of the seven questions in the questionnaire, the score results were significantly higher for the 3-mm instruments indicating that performance with the 3-mm minilaparoscopic instruments in the TEO simulator was in all cases between "better than expected" and "much better than expected." Appropriateness of the diameter of the minilaparoscopic instruments was the best evaluated parameter. The question addressing the ease of performing the tasks in the simulator presented the lowest mean score.
  
  
  CONCLUSIONS
  The perceptions of participating surgeons indicated that there is better visualization and maneuverability during basic transanal endoscopic microsurgery tasks conducted in a simulator using 3-mm minilaparoscopic instruments when compared to conventional 5-mm instruments.
authors.affiliation: Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil, sergio.araujo@einstein.br.
authors.forename: Sergio Eduardo Alonso
authors.initials: SE
authors.lastname: Araujo
authors.forename: Carlos Ramon Silveira
authors.initials: CR
authors.lastname: Mendes
authors.forename: Gustavo Lopes
authors.initials: GL
authors.lastname: Carvalho
authors.forename: Marcos
authors.initials: M
authors.lastname: Lyra
mesh_terms: D001938:Brazil; D002983:Clinical Competence; D004502:Education, Medical, Continuing; D006801:Humans; D059032:Learning Curve; D012004:Rectal Neoplasms / Q000601:surgery*; D000066908:Simulation Training; D066231:Surgeons; D011795:Surveys and Questionnaires; D000067369:Transanal Endoscopic Microsurgery / Q000193:education / Q000295:instrumentation* / Q000379:methods