Please don’t learn laparoscopy on your patient
The advent of laparoscopic techniques has led to a new paradigm in surgical skill training. Recently launched many Hands-on courses are now enabling young surgeons and gynaecologists to practice laparoscopic techniques on synthetic, porcine or more recently virtual-reality models. The aim has been to ensure trainees are armed with basic laparoscopic skills, such as hand-eye coordination and depth perception prior to entering the operating room. The success of these initial laparoscopic courses led to the development of similar courses for the advanced laparoscopic skills required for gastric and colonic and gynecological minimal access surgery. A cursory review of the literature reveals a number of publications on the use of simulation for training in technical skills, not only for surgery and gynaecology but for all types of interventional techniques like endoscopy and urology. This is further fuelled by the production and marketing of new synthetic and virtual models at almost every surgical conference one attends.
The common question asked by all surgeons is, ‘Which model should we use?’ Of course, this is dependent on the facilities and resources available at each laparoscopic training centre. It is thus encouraging to see the approach of trainer to design a laparoscopic training course with human cadavers as the training modality. The human cadaver is anatomically identical to the patient in the operating room, and has been regularly used to teach medical students basic anatomy.
The availability of such a model should enable surgeons to practice their skills before performing live cases. This is not a unique approach, and indeed has been pursued across the globe. However, it is not appropriate, nor realistic, for all simulation types to attempt to achieve the exact fidelity of our patients in the operating room. Training in surgery is beginning to evolve into a stepwise, curricular approach that is not organ- or procedure-specific.
Proficiency in tasks such as laparoscopic suturing or division of a vessel. The constituent parts can then be combined with anatomical knowledge to enable completion of a specific procedure. Traditionally, all skills and tasks were learnt on the patient. Within this hierarchical, stepwise model of training, each simulation type can be evaluated in terms of its efficacy in transferring the skills to the trainee. For example, basic psychomotor skills can be learnt with a simple, cheap version of a video-box trainer. Higher level skills such as dissection and use of high-energy instruments will necessitate the use of more realistic tissues, which can be achieved on porcine or human cadaveric models. Recent advances in virtual reality
simulation are also beginning to produce realistic simulations of complete procedures, for example,
laparoscopic cholecystectomy.
It may not be possible to strive toward realistic imitation of the anesthetized patient at every
stage in the training curriculum. The human cadaveric or animal model is cheap and easy to obtain and should be utilized by surgeons once they have achieved mastery of skills with inexpensive synthetic
models on the laparoscopic box simulator. In other countries where human cadaveric models are in restricted supply, live or dead animal, synthetic, semi synthetic or virtual reality simulation should be utilized. Though the tools may vary, the important aspect is to ensure that the early part of the surgeon’s learning curve is no longer achieved at the expense of our patients. Please don’t learn laparoscopy on your patient!
July 23rd, 2008 at 2:52 pm
You are right. Either people are doing too much or too less without learning laparoscopy.