Integrated OR (The following text must be displayed alongside the image: © KARL STORZ – Endoskope, Germany)
Beyond facilitating the surgical procedure and improving efficiency, the integrated operating room facilitates live feeds to conference rooms and auditoriums for training and grand rounds. In addition, the integrated ORs have the potential to connect the surgeon for teaching and tele-monitoring at remote locations. The latter is discussed separately in Chap. 11, but briefly it involves remote coaching, whereby both the trainer and trainee are accessing live digital images of the operation, and the trainer can remotely coach surgeons through challenging parts of the surgery. However, technology needs to be matched at both sites to access the same quality of image with network cover of sufficient bandwidth to allow optimum audio and visual communication.
The primary focus of the OR team should always be patient safety and the effective performance of each procedure and these should also be the main objectives of both the trainer and trainee for a training case. However, training in the operating room should be conducted in an environment that is supportive to training and promote learning. Nevertheless, even with close supervision, inexperienced trainees will often take longer to perform a MAS procedure. This can create a conflict between the trainer, the trainee and the rest of the OR team. Dedicated operating training lists provide the best training environment in technically challenging surgery such as MAS. However, this warrants consideration of the financial pressures facing hospitals, with targets and the reduction of the training time (due to the adoption of European working time directive). Hence, these expectations and conflicts need to be addressed before, during and after the normal operating lists.
Before an operating list, the trainer needs to ensure the list is appropriately scheduled for training purposes and that the OR team are aware that some parts or the entire list will be used for training. Opportunity now exists, with the widespread use the WHO checklists, to address these issues and come to a common agreement and understanding for the whole team. During an operating list, the expectations and priorities of the trainee will need re-adjustment by the trainer if a case or cases have taken longer than expected. After completion of the case/ list, a sign out process can allow the team to draw together the useful learning points that make future training cases run smoothly.
Attributes of an ideal training environment are summarised in Table 1.1. These may vary from the trainer, trainee and OR staff’s point of view. The team brief is an ideal opportunity to discuss how the operating list should run for the mutual benefit of all and align all views of the entire team, in order to generate a safe environment for performance and training. Novices to MAS will be more susceptible to reduced performance in the presence of interference and the OR training environment should allow a trainee to focus on the task in hand with minimal interruptions.
Attributes of ideal training environment in the OR
1. Trainee-focused environment that supports learning
2. Unthreatening environment that allows the trainee and staff to ask questions and express opinion
3. Dedicated training list that allows time for training
4. Experienced professional staff who support training
5. Optimum selection of cases that suit the trainee’s level
6. Supportive trainer who is a role model
7. Committed trainee who can make progress
8. Calm, quiet environment in theatre with minimal interruptions (phones, conversations, music etc.)
9. OR equipped with technology that facilitates feedback; such as video recording and image capture
10. Setting that allows confidential feedback after the training session when required
Training Environment Outside the OR
A training environment outside the OR is designed to attain the attributes of ensuring a safe practice and optimum environment prior to undertaking surgery, usually through simulation techniques. One of the factors that underpin the success of a simulated training environment is the degree of realism where coaching is conducted. Technology is continually striving to provide an ever more realistic simulated environment for clinical training, which is resulting in very impressive systems. However, these systems are only available to a limited number of centres and thus to a limited number of learners. It will be necessary to be pragmatic about what facilities can be made available to the large numbers of surgical trainees who need to acquire MAS skills in a safe and effective manner. Very high fidelity learning environments will certainly have their place for the most advanced learners, multi-professional groups and perhaps for assessment and re-validation in the longer term. However, for the majority of learning episodes, it is unlikely to be possible to provide the highest level of realism.
When considering MAS, one could question the need for some elements that are included in a high fidelity simulated OR. For example, the room lights are often only used during the initial access and final closing aspect of a case. However, essential elements include:
Imaging equipment – actual laparoscope or static camera depends on the nature of the task. The more complex the task, the more advanced equipment are required for simulated training.
Surgical instruments – depends on the task; the whole range of instruments are required for instance to teach an advanced laparoscopic procedure, while a limited number is required to teach certain tasks such as laparoscopic suturing.
Simulations: this can involve a box trainer, virtual reality (VR) simulator synthetic or real animal parts, or human cadaver.
Training Environment in the Dry Lab
An ideal training environment for dry lab training should have enough space to allow free movement of tutors and delegates, with sufficient lighting and equipment. One could also argue that the space should be designed with a flexible set up that supports seminars, hands-on skills with audio-visual facilities and video links to the OR.
The requirements for the laparoscopic work-stations depend on the nature of the tasks; full laparoscopic stacks are required for advanced MAS but a minimum of a camera, light source, scope and training box are sufficient for more basic tasks. The simulated tasks can vary from a box with synthetic organs to ex-vivo animal tissue or hybrid simulations. There is wide use of VR simulators in the training of basic laparoscopic tasks of core procedures, but VR simulators with good validity for advanced laparoscopic surgery do not currently exist . VR simulation still requires trainers to coach trainees on the simulated procedures and give constructive feedback .
There is a growing number of synthetic preparations, which often have a realistic anatomical appearances. The benefits of using these models include reproducibility, less requirement for specialist technical support and preparation, simple to store, low odour and are easy to dispose of. However, dissection of synthetic tissue is not as realistic and the material is either much stiffer or softer than that corresponding to the real task. Few of these models support the use of energised tissue dissection.
A compromise between synthetic models and live animal tissue is to create a hybrid of excised animal tissue mounted in specially designed frames. The aim is to fix the tissues in a position as close as possible to human anatomy [3–5]. The benefits are to improve the degree of realism and allow the use of tissue energisers. If ex-vivo animal organs are used, the environment should be designed such that surfaces are washable; adequate space and facilities to store and prepare and dispose of the materials is also necessary.
Wet Lab and Live Animal Lab
In the USA and some European countries, training using live animals is permitted. Whilst this approach provides realistic control of bleeding and tissue elasticity, there are many disadvantages: it is relatively expensive, due to the specialist facilities, staff and anaesthesia, and animal anatomy often differs significantly from humans, so the types of procedures that can be taught are limited. In addition to the growing ethical concerns, the use live animals for training is prohibited in the UK.
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Cadaveric Training: Fresh Frozen and Thiel Embalmed
Despite the demonstrable benefits of integrating cadaver dissection into a resident training program [6, 7], cadaver surgery is not yet utilised in most training programmes due to the financial constraints and limitation of supply . Cadaver training, however, can be justified and be cost-effective in advanced laparoscopic training, as there is no better alternative for high fidelity simulation.
Cadaver laboratories require very specialist skills among staff looking after the specimens and the environment. There are two cadaveric processing techniques: cryopreservation (fresh frozen) and embalming (Thiel method). The traditional formalin-fixed cadavers, are not suitable for simulated surgery.
There is some evidence to indicate that fresh frozen cadavers are more favourable for laparoscopic dissection compared to classical cadaver embalming . Traditionally formalin-fixed cadavers are less useful because the fixation causes tissue rigidity, loss of tissue texture, colour and consistency, limited preservation of surgical planes, and spaces, and difficulty in identifying small structures such as autonomic nerves . The embalmed bodies retain more of the elastic tissue structure, which is completely different from the traditional formalin-fixed cadavers. This results in well- preserved organs and tissues with regard to colour, consistency, flexibility and plasticity [11, 12].
The environment for fresh frozen and embalmed cadavers involves storage in licenced premises and must fulfill the regulations of the Human Tissue Act in the UK . This also involves proper care of donated cadavers for training, as well as security and confidentiality.
Cadavers are frozen within a week of procurement and then thawed at room temperature approximately 3 days prior to use for a training session. The cadaver room can be set up as an OR, with laparoscopic stacks, monitors and surgical instruments provided. Disposal of the cadaveric tissues must also be in line with national regulations or the Human Tissue Act.
Figure 1.2: Cadaver training model for laparoscopic surgery (with permission from the Vesalius Clinical Training Centre, Bristol)
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