Fig. 4.1
A summary of training evolution during a trainees career to becoming a trainer expert. Green shading denotes time spent both outside and inside the operating room in training activities. As an individual’s career progresses the focus and duration of training activities will reflect the needs and responsibilities of that individual
The training of basic laparoscopic skills can be divided into inside the operating room (OR) or outside the OR. Both arenas offer unique opportunities for learning and acquiring skills.
As a surgeon’s career progresses from a novice trainee to an expert training will most likely happen in conjunction both outside and inside the OR. Skills gained outside the OR can then be used inside the OR to build their skill level. Throughout the training period, a trainee’s progress should be reviewed regularly and goals refined according to his or her needs.
Training Laparoscopic Skills Outside the OR
The rapid expansion of the world-wide-web and speedy dissemination of information has enabled sharing of knowledge in an accessible and intuitive manner. The relative shortening of trainee working hours has also led to an expansion of training opportunities outside the OR. Training literature is available through relevant websites and video-upload sites have an ever-increasing number of surgical training videos that can be used by the trainer [5] and trainee. Caution by trainers has to be given to the quality and methods taught in these videos, but this represents an exciting change to training methods in recent times.
Governing Body Accredited Training Programs
Accredited training programs for trainees are available in many countries. These courses follow the curriculum closely and represent an efficient way to attain basic skills outside of the OR [6, 7]. The Fundamentals to Laparoscopic Surgery course (FLS) is one example of this. It is a comprehensive web-based education module that includes a hands-on skills training component and assessment tool designed to teach the physiology, fundamental knowledge, and technical skills required in basic laparoscopic surgery. The goal is to provide surgical residents, fellows and practicing physicians an opportunity to learn the fundamentals of laparoscopic surgery in a consistent, scientifically accepted format; and to test cognitive, surgical decision-making, and technical skills, all with the goal of improving the quality of patient care. The FLS program content has been endorsed by the American College of Surgeons (ACS) and is a joint educational offering of SAGES and ACS [8] (Table 4.1).
Table 4.1
Skills fundamental to laparoscopic surgery (FLS)
Depth perception using monocular optical system |
Operating through a trocar (lever effect, decreased degrees of freedom) |
Operating with long instruments with dampened force feedback |
Use of non-dominant hand |
Use of angled laparoscope |
Transferring objects between long instruments placed through fixed access points in body wall (trocars) |
Precise cutting with both hands using laparoscopic instruments, placed through trocars, using monocular optical system |
Use of ligating loops to control hollow tubular structures |
Cannulation Suturing and knot tying with intracorporeal and extracorporeal techniques using laparoscopic instruments |
Training Ergonomics
The increased technological complexity and sometimes poorly adapted equipment have led to increased complaints of surgeon fatigue and discomfort during laparoscopic surgery. Teaching the trainee to understanding ergonomics cannot only enhance learning but also reduce physical strain and fatigue..
The importance of ergonomics in the setting of laparoscopy cannot be over-emphasized. Studies have shown that correct ergonomics can reduce key skill acquisition time [9].
Surgeon’s Position
A surgeon can perform laparoscopic surgery in a number of positions but two main ones exist; between the legs and at the side of the patient. The trainee will find one more ergonomic depending on the procedure. It is usually the surgeon’s preference or habit of getting adjusted to a particular position. Subsequent technical steps will vary according to the chosen position. Adopting one or the other position is often necessary to obtain optimal triangulation .
Operating Table Height
The height of operating table should be adjusted between 64 and 77 cm above floor level, depending on the height of the operating surgeon, since the discomfort and operative difficulty are lowest when instruments are positioned at elbow height [10].
Monitor Position
Neck strain can occur with an inadequately positioned monitor. The image should be 25° below the horizontal plane of the eye. It has also been shown that laparoscopic task efficiency can be enhanced if the image is placed near the operative field, adjacent to the hands, because the resultant “gazedown” view aligns the surgeon’s visual and motor axes [10]. A second monitor may be needed for procedures that require position changes or to allow the assistants to see without undue neck strain [11].
Training Situational Awareness (SA)
This subject is fully covered in the Chap. 13 (Human Factors). Surgery, one of the most complicated, time-critical and high-pressure medical practices, demands acute SA. Traditionally, the surgical staff were responsible for monitoring different activities within an operating room. However there are now multiple OR data sources in an operating room and monitoring and analyzing all the data streams arriving from sensors, services and devices can be challenging. Situation awareness simply means understanding the current situation; this requires active involvement and planning.
SA can be trained using a variety of different methods that can be broadly split into theoretical training and virtual reality training. Theoretical training would be a method of discussion with the trainer regarding key points to convey to the trainee. Virtual reality training would employ the use of training simulators in order to assess SA. Tracking has been shown to be an effective tool (whether eye or instrument) to assess SA.
Training Laparoscopic Skills Inside the OR (Transferring Skills to the Patient)
Most surgical regulatory bodies will have a curriculum that trainees will have to adhere to. This will outline the skills to be attained by the end of a placement and/or year and the number of cases to be completed at various levels of involvement. Trainers should consult with the trainee to help fix realistic goals and also explain what is expected of them as mentors. Inside the OR training will involve equipment learning, troubleshooting and technical skills attainment. A trainer’s method of teaching inside the OR will vary, but should directly relate to the goals set. An evaluation of tasks and skills performed inside the OR should regularly take place, which then provides the focus for learning activities outside the OR. In this way a reciprocal relationship is set-up.
Training Safe Access Techniques
When teaching trainees this most elemental step in laparoscopic surgery it is worth bearing in mind that almost fifty percent of all laparoscopic related major complications occur due to placement of trocars and iatrogenic injury to intra-corporeal structures. The majority of injuries are associated with blind placement of the first trocar or Veress needle, most often but not always at the umbilicus [12, 13].
In addition to the numerous examples of trocar technology available now to the surgeon it is worth remembering that often the most basic teaching methods may yield appropriate and safe results. For instance, the resting of the trocar inserting hand index finger onto the barrel of the trocar during insertion allows for improved control and decreased likelihood that the trocar will enter to an increased depth causing injury. Also, it is important to emphasis that an open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, and much safer compared to the use of Veress Needle [13].
Access is associated with injuries to the gastrointestinal tract and major blood vessels, and at least 50 % of these major complications occur prior to commencement of the intended surgery. Increased morbidity and mortality result when laparoscopists do not recognize injuries early and/or do not address them quickly. The next step after entry of any trocar into the abdomen is a visual check with the laparoscope to assess any injury to abdominal wall vasculature (bleeding from the internal entry point of the port) and intra-abdominal organ damage. Any such damage should be dealt with immediately and its occurrence clearly indicated in the operation note. The same applies to checking for bleeding during withdrawal of trocars at the end of surgery.
In general, there is no uniform consensus about port placements for laparoscopic procedures. The placement of ports is currently dictated by the type of operation being performed and the surgeons’ preference, based on individual experience. For optimal ergonomics and visualization during laparoscopy, trocars are usually placed in a triangular fashion, termed triangulation [14, 15]. The operative field should be fifteen to twenty centimetres from the optical trocar. In general, the remaining trocars (usually two) are placed in the same fifteen to twenty centimetre arc five to seven centimetres either side of the optical trocar. If necessary, retracting ports can be placed in the same arc but more laterally so as to prevent instrument ‘fencing’ [10].
Grasping
When using graspers it is foremost important to realize there is a lack of visual or haptic feedback. Subsequently, a concentrated increased amount of force maybe applied to delicate structures. Appropriate graspers must be applied for the task in-hand e.g., atraumatic bowel graspers for handling of bowel.
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