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\"Cyberspace is composed of a multitude of different spaces, where users can represent themselves in many divergent ways. Why, in a video game, is it more acceptable to murder or maim than rape? After all, in each case, it is only pixels that are being assaulted. This book avoids wrestling with the common question of whether the virtual violation of real-world taboos is right or wrong, and instead provides a theoretical framework that helps us understand why such distinctions are typically made, and explores the psychological impact (rather than the morality) of violating offline taboos within cyberspace.The authors discuss such online areas as: \"Reality\" sites depicting taboo imagesSocial sites such as Chatroulette Online dating sitesVideo game content. This book evaluates the possibility for change afforded by cyberspace, and considers whether there are some interactions that should not be permissible even virtually. It also examines how we might be able to cope with the potential moral freedoms afforded by cyberspace, and who might be vulnerable to such freedoms of action and representation within this virtual space.This book is ideal for researchers and students of internet psychology, philosophy and social policy, as well as therapists, those interested in computer science, law, media and communication studies\"-- Provided by publisher.

BackgroundIn the current era, trainees frequently use unvetted online resources for their own education, including viewing surgical videos on YouTube. While operative videos are an important resource in surgical education, YouTube content is not selected or organized by quality but instead is ranked by popularity and other factors. This creates a potential for videos that feature poor technique or critical safety violations to become the most viewed for a given procedure.MethodsA YouTube search for “Laparoscopic cholecystectomy” was performed. Search results were screened to exclude animations and lectures; the top ten operative videos were evaluated. Three reviewers independently analyzed each of the 10 videos. Technical skill was rated using the GOALS score. Establishment of a critical view of safety (CVS) was scored according to CVS “doublet view” score, where a score of ≥5 points (out of 6) is considered satisfactory. Videos were also screened for safety concerns not listed by the previous tools.ResultsMedian competence score was 8 (±1.76) and difficulty was 2 (±1.8). GOALS score median was 18 (±3.4). Only one video achieved adequate critical view of safety; median CVS score was 2 (range 0–6). Five videos were noted to have other potentially dangerous safety violations, including placing hot ultrasonic shears on the duodenum, non-clipping of the cystic artery, blind dissection in the hepatocystic triangle, and damage to the liver capsule.ConclusionsTop ranked laparoscopic cholecystectomy videos on YouTube show suboptimal technique with half of videos demonstrating concerning maneuvers and only one in ten having an adequate critical view of safety. While observing operative videos can be an important learning tool, surgical educators should be aware of the low quality of popular videos on YouTube. Dissemination of high-quality content on video sharing platforms should be a priority for surgical societies.

Background Jejunostomy catheters for jejunal feeding are an effective method to improve nutritional status in malnourish patients. However, this procedure is commonly being performed using an open approach, which can be associated with more postoperative pain and prolonged recovery. The objective of this study was to assess the outcomes of patients who underwent placement of feeding jejunostomy using a laparoscopic approach. Methods A retrospective review was performed of patients who underwent laparoscopic jejunostomy tube placement between 1998 and 2014. Main outcome measures included indication for catheter placement, rate of conversion rate to open surgery, perioperative and late morbidity and in-hospital mortality. Results Two hundred and ninety-nine consecutive patients underwent laparoscopic jejunostomy during the study period. The mean age was 64 years, and 81 % of patients were male. The mean BMI was 26.2 kg/m 2 . The most common indications for catheter placement were resectable esophageal cancer (78 %), unresectable esophageal cancer (10 %) and gastric cancer (6 %). There were no conversions to open surgery. The 30-day complication rate was 4.0 % and included catheter dislodgement (1 %), intraperitoneal catheter displacement (0.7 %), catheter blockage (1 %) or breakage (0.3 %), site infection requiring catheter removal (0.7 %) and abdominal wall hematoma (0.3 %). The late complication rate was 8.7 % and included jejuno-cutaneous fistula (3.7 %), jejunostomy tube dislodgement (3.3 %), broken or clogged J-tube (1.3 %) and small bowel obstruction (0.3 %). The 30-day mortality was 0.3 % for a patient with stage IV esophageal cancer who died in the postoperative period secondary to respiratory failure. Conclusion In this large consecutive series of feeding jejunostomy, the laparoscopic approach is feasible and safe and associated with a low rate of small bowel obstruction and no intraabdominal catheter-related infection.

BackgroundFacebook is a popular online social networking platform increasingly used for professional collaboration. Literature regarding use of Facebook for surgeon professional development and education is limited. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has established a Facebook group dedicated to discussion of surgery of the esophagus, stomach, and small intestine—the “SAGES Foregut Surgery Masters Program.” The aim of this study is to examine how this forum is used for professional development, education, and quality improvement.MethodsMember and post statistics were obtained from https://grytics.com, a Facebook group analytics service. All posts added to the Foregut forum since its creation in April 2015 through December 2016 were reviewed and categorized for content and topic. Posts were reviewed for potential identifiable protected health information.ResultsAs of December 2016, there were 649 total members in the group. There have been a total of 411 posts and 4116 comments with a median of 10.1 comments/post (range 0–72). Posts were categorized as operative technique (64%), patient management (52%), continuing education (10%), networking (10%), or other (6%). Video and/or photos were included in 53% of posts with 4% of posts depicting radiologic studies and 13% with intraoperative photos or videos. An additional 40 posts included links to other pages, such as YouTube, journal articles, or the SAGES website. One post (0.2%) contained identifiable protected health information and was deleted once recognized by the moderators of the group.ConclusionSocial media is a unique, real-time platform where surgeons can learn, discuss, and collaborate towards the goal of optimal treatment of surgical disease. Active online surgical communities such as the SAGES Foregut Surgery Masters Program have the potential to enhance communication between surgeons and are a potential innovative adjunct to traditional methods of continuing surgical education. Surgical societies should adopt and promote professional and responsible use of social media.

Background The relationship between volume and outcomes in bariatric surgery is well established in the literature. However, the analyses were performed primarily in the open surgery era and in the absence of national accreditation. The recent Metabolic Bariatric Surgery Accreditation and Quality Improvement Program proposed an annual threshold volume of 50 stapling cases. This study aimed to examine the effect of volume and accreditation on surgical outcomes for bariatric surgery in this laparoscopic era. Methods The Nationwide Inpatient Sample was used for analysis of the outcomes experienced by morbidly obese patients who underwent an elective laparoscopic stapling bariatric surgical procedure between 2006 and 2010. In this analysis, low-volume centers (LVC < 50 stapling cases/year) were compared with high-volume centers (HVC ≥ 50 stapling cases/year). Multivariate analysis was performed to examine risk-adjusted serious morbidity and in-hospital mortality between the LVCs and HVCs. Additionally, within the HVC group, risk-adjusted outcomes of accredited versus nonaccredited centers were examined. Results Between 2006 and 2010, 277,760 laparoscopic stapling bariatric procedures were performed, with 85 % of the cases managed at HVCs. The mean number of laparoscopic stapling cases managed per year was 17 ± 14 at LVCs and 144 ± 117 at HVCs. The in-hospital mortality was higher at LVCs (0.17 %) than at HVCs (0.07 %). Multivariate analysis showed that laparoscopic stapling procedures performed at LVCs had higher rates of mortality than those performed at HVCs [odds ratio (OR) 2.5; 95 % confidence interval (CI) 1.3–4.8; p  < 0.01] as well as higher rates of serious morbidity (OR 1.2; 95 % CI 1.1–1.4; p  < 0.01). The in-hospital mortality rate at nonaccredited HVCs was 0.22 % compared with 0.06 % at accredited HVCs. Multivariate analysis showed that nonaccredited centers had higher rates of mortality than accredited centers (OR 3.6; 95 % CI 1.5–8.3; p  < 0.01) but lower rates of serious morbidity (OR 0.8; 95 % CI 0.7–0.9; p  < 0.01). Conclusion In this era of laparoscopy, hospitals managing more than 50 laparoscopic stapling cases per year have improved outcomes. However, nonaccredited HVCs have outcomes similar to those of LVCs. Therefore, the impact of accreditation on outcomes may be greater than that of volume.

Background Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery. Design A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality. Results Among 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19–2.99), p  = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19–1.03), p  = 0.18; OR 1.55 CI (0.86–2.77), p  = 0.18). Laparoscopic cases averaged 27 min longer than open cases ( p  < 0.001). Conclusion Laparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.

Background Ileostomy reversals are commonly performed procedures after colon and rectal operations. Laparoscopic ileostomy reversal (LIR) with lysis of adhesions has potential benefits over conventional open surgery. The aim of this study was to compare outcomes of laparoscopic and open ileostomy reversal. Methods 133 consecutive patients undergoing ileostomy reversal at our institution between June 2009 and August 2013 were analyzed using a retrospective database. The group comprised 53 laparoscopic cases and 80 open cases, performed by four surgeons at a single center. The data were analyzed for patient demographics, operative characteristics, postoperative outcomes, and 30-day morbidity and mortality. Results The two groups had comparable mean age, gender distribution, ASA scores, and BMI. The laparoscopic group had a significantly longer duration of surgery compared to the open reversal group (109 versus 93 min, p  < 0.05). However, this group underwent more lysis of adhesions (60.4 % versus 26.3 %, p  < 0.01) as well as concurrent stoma site mesh reinforcement (32.1 % versus 6.3 %, p  < 0.01). In the laparoscopy group, 20.7 % of patients underwent intra-corporeal ileo-ileal anastomosis. There were no significant differences between the laparoscopic and open groups with regard to estimated blood loss (31 versus 40 ml, respectively) or mean length of stay (5.3 vs. 5.7 days, respectively). The rates of overall 30-day morbidity (16.9 % for laparoscopic vs. 21.3 % for open) as well as rates of specific complications were equivalent between groups. 30-day mortalities were not noted in either group. Conclusion LIR is safe and effective with low perioperative morbidity and mortality. The use of laparoscopy as an option in terms of concomitant hernia repair and lysis of adhesions may be considered in selected patients.

Sleeve gastrectomy is emerging to be the procedure of choice in the management of severe obesity. The aim of this study was to analyze outcomes between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic adjustable gastric banding (LAGB). A retrospective matched cohort analysis was performed between 150 patients who underwent LSG versus 150 patients who underwent LAGB. The cohorts were matched for age, gender, body mass index (BMI), and preoperative comorbidities. Length of hospital stay (1.6 vs 1.1 days, P < 0.01) was longer in the LSG group. Perioperative complications were similar between groups (4.6% for LSG vs 2.0% for LAGB) but the late complication rate was significantly lower in the LSG group (1.3 vs 8.0%). The 30-day reoperation (0 vs 0.7%) and readmission (1.3 vs 1.3%) rates were similar between groups. There were no 90-day mortalities in the study. The mean reduction in BMI was significantly higher for LSG (-11.9 kg/m 2 for LSG vs -6.2 kg/m 2 for LAGB, P < 0.01) at 1-year follow-up. The number of medications used to control all comorbidities was significantly lower at follow-up compared with baseline for both groups. The mean reduction in the number medications used to control hypertension was greater in the LSG group (-1.00 ± 0.70 vs -0.35 ± 0.70 medications, P < 0.01). LSG has a perioperative safety profile comparable to that of LAGB but achieved significantly better weight loss and control of hypertension with a lower rate of late complications.

Rectal surgery continues to be an area of advancement for minimally invasive techniques. However, there is controversy regarding whether a robotic approach imparts any advantages over established laparoscopic procedures. The aim of this study was to analyze and compare outcomes of laparoscopic and robotic rectal resection operations. A single-institution retrospective review was performed identifying 83 consecutive patients undergoing low rectal resection requiring proximal diversion between 2009 and 2013. The cohort was comprised of 38 laparoscopic and 45 robotic cases. Data were analyzed for postoperative outcomes as well as 30-day morbidity and mortality. Male gender frequency, body mass index, and American Society of Anesthesiologists class were higher in the robotic group (71%, 28.6 kg/m 2 , and 2.6, respectively) compared with the laparoscopic group (42%, 23.7 kg/m 2 , and 2.2, respectively; P < 0.01). Length of stay was significantly longer for patients undergoing laparoscopic (7.5 days) compared with robotic procedures (5.7 days, P < 0.01). This difference was even greater when comparing patients who underwent a hybrid laparoscopic-assisted open total mesorectal excision (TME) with robotic TME (8.2 vs 5.7 days, respectively, P < 0.01). Conversion rate was 7.9 per cent for the laparoscopic group and zero per cent for the robotic ( P = 0.09). There were no mortalities in either group. A pure laparoscopic or robotic rectal surgery may be associated with a shorter hospital stay compared with a laparoscopic-assisted approach.

Purpose Although diseases of the lower gastrointestinal tract are common in patients with Parkinson’s disease, there is a paucity of data regarding postoperative outcomes after colorectal surgery. Methods The Nationwide Inpatient Sample database (2007–2011) was utilized to analyze outcomes in patients with Parkinson’s disease (PD) undergoing colorectal surgery. Main outcomes were risk-adjusted inpatient morbidity, mortality, hospital charge, and length of hospital stay. Results A total of 6490 patients were identified. Utilization of laparoscopic surgery in Parkinson’s patients has progressively increased in frequency over the latest 5 years analyzed. The most common diagnoses were colorectal malignancy (39 %) and intestinal obstruction (20 %). Right hemicolectomy (37 %) and sigmoidectomy (30 %) were the most common operations. Laparoscopy was used in 18 % of Parkinson’s patients and most commonly in the elective setting. 54.3 % of Parkinson’s patients had emergency surgery compared to 38.6 % in non-Parkinson’s. Overall morbidity and mortality were significantly lower after laparoscopic surgery compared to open (20 vs. 25 % and 2.1 vs. 6.6 %, respectively). Length of stay was significantly shorter (OR −1.86; p  < 0.01) for laparoscopic operations, but there were no significant differences in risk-adjusted outcomes between laparoscopic and open groups. Conclusion PD patients have high rates of morbidity and mortality after colorectal surgery; this may be because more than half of all patients in this population undergo emergent surgery. The laparoscopic approach appears to have short-term benefits in this patient population.