如何很快提高你的腹腔镜技能

Y.H. Sun et al. (eds.), The Training Courses of Urological Laparoscopy, 11
DOI 10.1007/978-1-4471-2723-9_2, © Springer-Verlag London 2012
Abstract An ideal learning curve ascends through laboratory training, attending
structured instructional courses, performing surgeries under supervision of a
quali fi ed mentor, followed by performance of cases which are properly selected.
Various pelvic trainers such as mechanical trainer, hybrid trainer, and virtual reality
trainer in the skills laboratory do help the novices to acquire the basic laparoscopic
skills and the video eye-hand coordination. Specialized models for individual procedures
(urethrovesical anastomosis, donor nephrectomy, pyeloplasty, etc.) can be
easily devised, and boost the trainee’s con fi dence and help in troubleshooting just
prior to the procedure. Mentoring is a key component of any laparoscopic training
program. A trainee can be mentored in ways of instructional courses, videotape,
mutual mentoring, supervised clinical training, telesurgical mentoring, and proper
case selection; nevertheless, the obstacles with mentoring lie in commitment from
both the trainee and the mentoring surgeon.
Keywords Laparoscopy • Learning curve • Mentor • Training
M. R. Desai , M.S., FRCS (Edin.), FRCS (England) (*)
Department of Urology ,
Muljibhai Patel Urological Hospital ,
Dr. Virendra Desai Road , Nadiad , Gujarat 387001 , India

A. P. Ganpule , M.S. (Gen. Surg.), DNB (Urology)
Department of Urology , Muljibhai Patel Urological Hospital ,
Dr. Virendra Desai Road , Nadiad , Gujarat 387001 , India
Chapter 2
How to Improve Your Laparoscopic
Skills Quickly
Mahesh R. Desai and Arvind Prakash Ganpule
12 M.R. Desai and A.P. Ganpule
2.1 Introduction
The model “see one, do one, and teach one” does not apply to laparoscopy because
of the spatial orientation which needs to be developed in a two-dimensional environment
and need for dissection with longer instruments. The inherent learning
curve that one has to overcome has been quite convincingly noted in a series wherein
there was a decrease in the complication rate from 13.3% to 3% after the fi rst 100
cases [ 1 ] .The need for overcoming this steep learning curve “quickly” warrants a
structured mentored approach for training in laparoscopy.
The training in laparoscopy, to blunt the learning curve, typically involves
graded learning curve. An ideal learning curve ascends through laboratory training,
attending structured instructional courses, performing surgeries under supervision
of a quali fi ed mentor, followed by performance of cases which are properly
selected.
The key question we will address in this chapter is how an uninitiated “novice”
can start doing laparoscopy quickly for urologic indications.
The pillars for proper laparoscopy training are:
(a) Skills laboratory training
(i) Pelvitrainer or box trainer training
(ii) Animal model skill acquisition
(b) Mentor supervised clinical training
(c) Case selection in initial cases
2.2 Skills Laboratory Training
Training in skills laboratory is an initial step in training in laparoscopy. The skills
laboratory (pelvitrainer and animal models) helps the individual to acquire the necessary
hand-eye coordination and adaptation to 3D vision. The various pelvitrainers
that are available are [ 2 ] :
2.2.1 Mechanical Trainers
On these models the trainees can learn adaptation to restrictive freedom of movement
and reduced haptic feedback. They also help in learning the nuances of
handling a laparoscope and trocar placement. Basic steps such as dissection, clipping,
and cutting can be practiced. These models are comparatively cheap
(Fig. 2.1 ).
2 How to Improve Your Laparoscopic Skills Quickly 13
2.2.2 Hybrid Trainers
They are similar to mechanical trainers except they receive inputs from a computer.
The trainer also gets a tactile feedback.
2.2.3 Virtual Reality
These have the capability to manipulate the images and receive a feedback. For
beginners the mechanical trainers are the best as they are cheap and can be easily
assembled. The trainers can be assembled with the following components, namely,
webcam, cardboard box, and desk lamp. The trainee can cut out a task for himself
and can score himself on a scorecard.
Standardized programs can be used to assess the baseline laparoscopic skills
and track the trainee’s progress. The McGill inanimate system for training and
Fig. 2.1 Skills laboratory training on pelvitrainer. ( a ) Simulator for laparoscopy. ( b ) Skills laboratory
exercises. ( c ) Knot tying skills on rubber pad
a c
b
14 M.R. Desai and A.P. Ganpule
evaluation of laparoscopic skills (MISTELS) [ 3 ] consists of peg transfer, pattern
cutting, ligating loops, and suturing with knots. All these can be performed on an
endotrainer box.
2.3 Homemade Endotrainer Box
Beatty et al. have described a laparoscopic trainer which can be assembled with a
meager cost of 50 GBP [ 4 ] . The assembly requires a computer with free USB port,
a webcamera, a clear translucent plastic box (30 × 20 cm in size), few reusable adhesives,
building brick, a 5-mm drill, and laparoscopic instruments. The advantages of
using a webcam are that it will act as a “cybercamera man” and has the ability to
zoom or defocus. The advantage of such webcam-based cheap trainers is that it can
be used by trainees and obviate the need to travel to centers having sophisticated
pelvitrainer. This will save time and money for the trainee.
The tasks that the trainee can perform are bead transfers, sewing beads on a
toothpick, and glove exercises such as cutting and suturing (interrupted and continuous
on a rubber mattress) (Fig. 2.1 ).
A variety of models for individual procedures have been described. A brief
outline of a few important ones is given. Most of these models can be easily prepared
and practiced just prior to the procedure. The trainee can practice on this
model just prior to the case which will boost his con fi dence and help in
troubleshooting.
2.3.1 Model for Urethrovesical Anastomosis
Two 10-cm segments of pigs’ intestine are used to create the model. One segment
of the pig’s intestine is placed over a syringe and secured to the syringe with 2-0
silk. This represented the bladder portion. The urethral portion is created by placing
the other segment of pig intestine over a 15-ml centrifuge tube; this represents the
bladder. The whole assembly is kept in a box trainer. Once the anastomosis is completed
by the trainee, it can be tested by injecting water with a syringe. A Petri dish
below the neoanastomosis quanti fi ed the leakage. A study by Boon et al. on this
model suggested that test of performance time and postoperative leakage accurately
re fl ected the experience of the surgeon [ 5 ] . Similarly, Laguna et al. [ 6 ] have shown
the construct validity of chicken model in simulation of laparoscopic radical prostatectomy
suture. In this study, after partially emptying the abdominal cavity of a
cadaveric chicken, the esophagus was intubated with 18 Fr catheter, and the model
was placed in a laparoscopic pelvitrainer. The urethrovesical anastomosis can be
practiced on this model (Fig. 2.2 ).
2 How to Improve Your Laparoscopic Skills Quickly 15
2.3.2 Donor Nephrectomy
In a training model by Cavallari et al., the workers performed hand-assisted donor
nephrectomy (HALDN) in 10 pigs [ 7 ] . They concluded that in vivo training models
make it possible to reproduce the positions and operative dif fi culties encountered in
clinical practice. They conclude that this model is a high- fi delity model training
procedure that was useful and convenient to achieve skills for HALDN.
2.3.2.1 Laparoscopic Pyeloplasty
Ramchandran and coworkers [ 8 ] have devised a model from crop and esophagus of
a chicken cadaver (Fig. 2.3 ). The assembly was placed in a laparoscopic training
box. An assessment was done as regards the time required to complete the anastomosis
and quality of anastomosis. All the trainees could complete the anastomosis,
and there was a signi fi cant improvement after the 4th attempt.
Fig. 2.2 Urethrovesical anastomosis on cadaveric chicken model
16 M.R. Desai and A.P. Ganpule
McDougall [ 9 ] described a porcine model for training in laparoscopic pyeloplasty.
In this model a secondary ureteropelvic junction obstruction was created after
ligating the ureter, and after 6 weeks, the enlarged pelvis was suitable for training.
2.4 Mentoring
Mentoring is a key component of any laparoscopic training program. There have
been extensive data regarding the usefulness of such training in developing laparoscopic
skills. The obstacles with mentoring include commitment from both the trainee
and the mentoring surgeon. A trainee can be mentored in the following ways:
2.4.1 Didactic Lectures and Instructional Courses
After attaining basic laparoscopy skills, a brief mentor program simultaneously is
advocated to successfully launch the laparoscopic ef fi ciency. There are mini fellowships
or a dedicated 2-year endourology or Society of Urologic Oncology fellowship
program. The didactic lectures and courses help the trainee to have one-on-one
interaction with the trainers and learn the theoretical aspect of the disease and treatment
before its application.
2.4.2 Videotape Mentoring
Nakada et al. [ 10 ] described the concept of videotape mentoring in teaching advanced
laparoscopic techniques. This group of workers demonstrated that videotape critiquing
and analysis were bene fi cial. The uninitiated may bene fi t by repeatedly viewing
Esophagus Crop
Fig. 2.3 Chicken crop model
for learning pyeloplasty
2 How to Improve Your Laparoscopic Skills Quickly 17
the videotapes of operations performed by him or one of his colleagues. A further
step in this direction would be reviewing videos of initial cases by the trainee himself.
The trainee can identify the pitfalls and the troubleshooting in the cases and
improve on them.
2.4.3 Mutual Mentoring
This concept was brought out by Jones and Sullivan [ 11 ] . These two authors simultaneously
were fellowship trained and performed procedures jointly. The advantage
of this procedure as noted by them includes expert camera assistance, a “second
opinion” during surgery. This approach bene fi ts two novices at the same time. This
approach has the potential to bene fi t both the parties although it may be geographically
restrictive and time-consuming.
2.4.4 Mentored Supervised Clinical Training
This generally is the training in the last stage. The mentored supervised clinical
training is also preferably structured. In the initial stage the trainees act as camera
driver. This helps in understanding the laparoscopic anatomy and the ergonomics of
laparoscopic instrument use. The next step would be performing simple operations
such as renal cyst marsupialization, laparoscopic ureterolithotomy, or laparoscopic
orchidopexy. All these procedures should be performed under the mentorship of an
experienced laparoscopic surgeon.
The mentor should have a keen sense of responsibility and patience for teaching.
The mentor gives guidance regarding the anatomic landmarks such as the psoas
muscle, aorta and the inferior vena cava, the renal vein, adrenal gland, and the vessels
[ 12, 13 ] . In pelvic surgeries he also guides regarding the dissection of the space
of Retzius.
The mentor can also guide the trainee regarding the tricks of applying a variety
of clips and the troubleshooting guidelines in the event of a problem. Such training
programs have been developed to develop skills in laparoscopic pyeloplasty and
laparoscopic adrenalectomy. The mentored training should be structured for each
procedure. The procedure should be divided in steps, and the mentor should take
over the case if he feels the case is not progressing or the trainee is not able to handle
it. The example of how a procedure for the purpose of mentoring can be divided
according to steps is given below:
Laparoscopic Pyeloplasty
1. Trocar placement and dissection of the retroperitoneal space
2. Gerota’s fascia incision and mobilization of dilated renal pelvis and upper
ureter
18 M.R. Desai and A.P. Ganpule
3. Trimming of renal pelvis and ureter
4. Corner stitch and excising the stenotic segment with the redundant pelvis
5. Stent insertion and anterior ureteropelvic anastomosis
Laparoscopic Nephrectomy
1. Trocar placement and re fl ection of the colon
2. Dissection and lifting of the ureterogonadal packet
3. Identi fi cation and dissection of the vessels
4. Securing the vessels
5. Dissection of the upper pole
6. Retrieval of the specimen by entrapment in the bag
2.4.5 Telepresence Mentoring
Telesurgical mentoring is an evolving offshoot of telemedicine. This concept involves
an experienced surgeon assisting or directing another less experienced surgeon who
is operating at a distance [ 14 ] . Setup includes real-time transmission of audio and
operative images to a central “telesurgical mentor” assisted by 2-way intraoperative
interaction. The mentor can guide and teach practicing surgeons new operative techniques
utilizing dedicated computer-based image and audio transfer system. This is
believed to enhance surgeon’s education and decrease the likelihood of complications
due to inexperience with new surgical techniques. The goal of this application of
telemedicine is to improve surgical education and training for complex laparoscopic
urological procedures, with an ultimate aim to improve health-care delivery by widespread
availability of urologic surgical expertise. Eventually, surgical telementoring
could assist in the provision of surgical training to trainee surgeons with limited experience.
It allows novice surgeons with limited formal advanced laparoscopic urologic
training to bene fi t from expert intraoperative advice, simultaneously allaying performance
anxiety arising from constant presence of expert surgeon in the vicinity. At the
same time, it appears to assist in independent decision making, increasing con fi dence
of operating surgeon, expert help being available as and when needed.
Disadvantages are: requirement of constant involvement of instructor surgeon, and
secondly, the telementoring of surgical procedures is currently achieved via a wired
infrastructure that usually requires sophisticated videoconference systems along with
trained and dedicated IT personnel for troubleshooting and maintenance.
2.4.6 Case Selection
Proper case selection is “key” to success of a laparoscopic surgeon in the initial part
of the learning curve (Fig. 2.4 ). In the initial cases, one should do an axial imaging
prior to the procedure; this helps to assess the vascular anatomy as well as helps the
2 How to Improve Your Laparoscopic Skills Quickly 19
surgeon to predict the possible dif fi culties he is likely to face during the course of
the operation. An improper selection of the case in the initial cases will not only
undermine the con fi dence of the surgeon but will also slow the learning process.
For example, the best case to start with for a nephrectomy would be a thin patient
with no adhesions and a single vessel on CT angiography (Fig. 2.5 ). Although the
right side is slightly easier for dissection than the left side, one has to be careful
about the vena cava and the short adrenal vein. A thin patient is always desirable
than an obese patient from point of view of the morbidity and ease of the procedure.
The case selection should be as shown in Figs. 2.4 and 2.6 .
2.5 Concluding Remarks
While the Halstedian model of unregulated apprenticeship served trainee surgeon
well a century years, the surgical technology of the twenty- fi rst century has increased
demands on surgical education. Minimally invasive surgery has radically changed
the 3-dimensional visualization and tactile feedback of open surgery. Laparoscopy
has further challenged the trainee surgeon by creating a 2-dimensional working
environment and reduced tactile sensation.
Being prepared to perform an operation no longer simply means reading the
appropriate pages of surgical atlas. Before entering the operating room, the basic
skills for minimally invasive procedure such as urological laparoscopy must be
developed. This would result in marked improvement of level of care and reduced
medicolegal cost. Despite extensive amount of data from the urological literature,
the ideal training program in urological laparoscopy remains to be determined
objectively. As of today, there is no single-structured and dedicated program for
laparoscopic skills training. In view of differing heath-care policies globally, at the
moment, the program is fractured. There is a consensus as to what an ideal program
should be. It would consist of a combination of inanimate models, animal labs, and
clinical exposure under a mentor through fellowship program.
Learning curve – step ladder pattern for nephrectomy
Simple
nephrectomy
Pyonephrosis
Nephrectomy in
kyphoscoliosis
ADPKD
TB Kidney
XGPN
Obese patient
Thin patient
Fig. 2.4 Learning curve in
laparoscopy
20 M.R. Desai and A.P. Ganpule
The ideal training modality requires acquiring basic laparoscopic skills in a dry
and wet skills laboratory, simultaneously also acquiring the laparoscopic skills under
the guidance of a mentor and then fi nally doing the procedures independently.
As surgeons, we have a passion for what we do, and we do it to make it the best.
To quote Alvin Tof fl er, “the illiterate of the 21st century will not be those who cannot
read and write, but those who cannot learn, unlearn, and relearn.” Surgical education
requires this same passion and desire for excellence.
a
b
BMI–23 kg/m2
No perinephric stranding
Single artery and vein
Small non functioning kidney
Fig. 2.5 Case selection
2 How to Improve Your Laparoscopic Skills Quickly 21
References
1. Fahlenkamp D, Rassweiler J, Fornara P, et al. Complications of laparoscopic procedure in
urology; experience with 2407 procedures at 4 German centers. J Urol. 1999;162:765–71.
2. Autorino R, Haber GP, Stein RJ, et al. Laparoscopic training in urology critical analysis of
current evidence. J Endourol. 2010;24:1377–90.
3. Dausters B, Steinberg AP, Vassiliou M. Validity of the MISTELS simulator for laproscopy
training in urology. J Endourol. 2005;19:541–5.
4. Beatty JD. How to build an inexpensive laparoscopic webcam based trainer. BJUI.
2005;96:679–82.
5. Boon JR, Salas N, Avila D. Construct validity of the pig intestine model in the simulation of
laparoscopic urerhrovesical anastomosis: tools for objective evaluation. J Endourol.
2008;22:2173–716.
6. Laguna PA, Alacazar AA, Mochtar CA, et al. Construct validity of chicken model in simulation
of laparoscopic radical prostatectomy suture. J Endourol. 2006;20:69–71.
7. Cavallari G, Tsivian M, Bertelli R, et al. A new swine training model of hand assisted donor
nephrectomy. Transplant Proc. 2008;40:2035–7.
8. Ramachandran A, Kurien A, Patil P, et al. A novel training model for laparoscopic pyeloplasty
using chicken crop. J Endourol. 2008;22:725–8.
9. McDougall EM, Elashry OM, Clayman RV. Laproscopic pyeloplasty in the animal mode.
JSLS. 1997;1:113–8.
10. Nakada SY, Hedican SP, Bishoff JT, et al. Expert videotape analysis and critiquing bene fi t
laparoscopic skills training of urologists. JSLS. 2004;8:183–6.
11. Jones A, Eden C, Sullivan ME. Mutual mentoring in laparoscopic urology-a natural progression
from laparoscopic fellowship. Ann R Coll Surg Engl. 2007;89:422–5.
12. Zhang Xu, Zhang GX, Wang B-J, et al. A multimodality training program for laparoscopic
pyeloplasty. J Endourol. 2009;23:307–11.
13. Zhang Xu, Wang B-J, Ma X, et al. Laparoscopic adrenalectomy for beginners without open
counterpart experience, initial results under staged training. Urology. 2009;73:1061–5.
14. Lee BR, Bishoff JT, Janetschek G, et al. A novel method of surgical instruction: international
telementoring. World J Urol. 1998;16:367–70.
Learning curve – the step ladder
Donor nephrectomy
Simple nephrectomy
Use camera port through umbilicus
LESS procedures in porcine models
Assisting experts in cases
Instructional course
Fig. 2.6 How should one
start doing laparoscopy?

看起来很吃力。

努力学习，争取早日看懂并理解透.......{:soso_e113:}

很遗憾  看不懂啊  不过  仍然感谢