Concepts in advanced Laparoscopic training
1.Introduction
2.Guidelines in Basic laparoscopy
3.Guidelines in Advanced Laparoscopic Surgery
4.Skills Acquisition in Advanced Laparoscopic Operations
5.Training in Subspecialties
6.Skill Labs
7.Training in third world countries
8.Training in the west
9.why training by us?
10.How do we do it?
11.Assessment of the program
12.What is the future?
13.What has India done to standardize minimally invasive surgery?
INTRODUCTION
Laparoscopic operations are a primary component of general surgery. Training should be dedicated to the advancement of training in minimally invasive surgery to assure the safety ok such operations. The purpose of this program is impart safe basic and advanced laparoscopic skills to trainees and surgeons as well in minimally invasive surgery.
Opportunities to perform laparoscopic operations vary widely between the present surgical postgraduate training programs. The laparoscopic training program helps to bridge the gap for the general surgeon to become adept at laparoscopic surgery.
As utilization of minimal access procedures increases in the future, surgeons will more readily learn the skills necessary to safety accomplish these operations.
In that setting, the proposals below may no longer be necessary.
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GUIDELINES IN BASIC LAPAROSCOPY
Laparoscopic operations, as with all operations are appropriately learned in the broad context of surgical science and practice. Critical educational components include: pathology of disease, diagnosis, indications for surgery and contraindications, familiarity with alternative treatments, comprehensive principles if pre- and post- operative care and understanding of the prevention, diagnosis and treatment of complications. In addition, the relative advantages and disadvantages of both open and minimally invasive approaches must be known.
Lectures on handling of instruments are of paramount importance in the beginning. The choice of instruments over what is advertised by various industries helps one not to be taken for a ride.
A lecture by the laparoscopic anesthetist with view towards the importance of choosing the right patient is done to minimize the post op and intra operative disasters.
Stress is laid on the safety features of creating pneumo peritoneum, safe introduction of Veress needle versus Hassan method as well as the modified Hassan method that we use with low morbidity. Delegates should be guided through the importance of the various types of methods of initial creation pneumo with reference of the needle and the blind trochar and the importance of evidence based complications is stressed with each method. The importance of the primary trochar introduction is stressed with the dangers of the same.
Basic laparoscopic operations include laparoscopic cholecystectomy, laparoscopic appendectomy and diagnostic laparoscopy.
Stress is laid on the safe aspects of gall bladder dissection such as proximity to the Gall bladder, retro gall bladder dissection initially, creation of the window at the base, importance of dome down technique and the advantages of near dome down technique over the one described are all common surgery safe for the patient and the surgeon. Various kinds of knotting and endo looping are taught to make the delegates proficient in the technique of doing appendectomy and other types of relevant surgery.
Candidates should be guided through the basics of intra corporeal tying knots and basics of suturing including needle handling, various types of knotting techniques and indications for using each technique with reference to each particular operation and situation should be discussed with the candidates even in the basic course so that when the simple operation becomes more complicated, the surgeon would be able to adapt easily.
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GUIDELINES IN ADVANCED LAPAROSCOPIC SURGERY
All laparoscopic operations other than diagnostic gall bladder and appendix removals are defined as advanced. Prior to learning of performing advanced laparoscopic operations, the surgeon must be familiar with the experienced in basic laparoscopy.
The complicated of laparoscopy are well outlined and discussed in detail to avoid them to combat them as and when they arise. Each laparoscopic operation may not only involve the complication of any laparoscopy, but also that which is peculiar to that operation – such as ureteric injury in laparoscopic hysterectomy or damage to the common iliac vessels in a lap hernia repair, etc. the need to keep the track of the learning curve is stressed in each operation.
Stress is laid not only on training the surgeon in the art of advanced surgery, but also the nurses, technicians and of course the assistant surgeons. Advanced laparoscopy is the one in which the team consisting of the above members are dedicated and trained so that they move effortlessly as a tem during the routine surgery and more so when things need to be modified.
SKILLS ACQUISITION IN ADVANCED LAPAROSCOPIC OPERATIONS
Training to learn advanced laparoscopic operations begin with acquisition of skills is basic laparoscopy. There is a core group of technical skills common to all advanced laparoscopic operations. Such skills are best acquired in the operating room or alternatively, through skills laboratories involving surgical trainers, animal models, or other simulated operating conditions. Examples of such skills include
- 2 handed dissection technique
- Non dominant dexterity
- Extra & Intra corporeal knotting
- Intracorporeal suturing.
Mastery of these advanced laparoscopic skills by the surgeon is encouraged prior to initiating an experience performing advanced laparoscopic operations. Familiarity with the open operation will also facilitate mastery of the similar laparoscopic procedure using a minimally invasive access approach.
Since many advanced laparoscopic skills by the surgeon is encouraged prior to initiating an experience performing advanced laparoscopic operations. Familiarity with the open operation will also facilitate mastery of the similar laparoscopic procedure using a minimally invasive access approach.
Since many advanced laparoscopic skills are common to all advanced laparoscopic operations, experience is a specific operation enhances the acquisition of skills necessary to perform others. Therefore it is the combined experience in advanced procedures that should be emphasized during training, rather than the mastery of any one individual procedure.
Post graduates will eventually learn all these in the operating room of the teaching hospitals. Until such time as complete integration is possible, these courses would be useful to incorporate the inanimate and animate exercises with lectures along with assisting in theatres sessions would help the surgeons to get an orientation of surgical skills in laparoscopy and thoracoscopy. The nurses are taught to take care of instruments and main camera unit, light sources and insufflators during and in between cases. The nurses are also taught skills in camera movements and extra corporeal knots that would facilitate the operations such as appendectomies and to minimize the bile leak from punctured gall bladders.
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TRAINING IN SUBSPECIALITIES
Laparoscopic cholecystectomy has given way to so many other operations in general surgery. Other specialties are trying to keep up with this change. At the present time the lap surgeons are part of the team along with concerned specialists in main hospitals dealing with minimally invasive surgery. For instance scrubbing with the urologist during a pyeloplasty or with the cardiac surgeon doing pericardectomy or PDA ligation has become a way of life for MIS surgeons.
So naturally there s a demand for training the specialists in other fields in MIS. This is carried out by combined hands on endoscopic workshops with the MIS surgeons and concerned specialists on the highly selected group. These groups of urologists or gynecologists or cardiac surgeons find the training satisfactory and rewarding.
There is also a subset of general and GI surgeons who after basic and advanced laparoscopic surgery who request for training in highly specialized areas.
There may be training for fundoplications or hernia repair or colectomies, etc. These groups can be managed in a day as they are experienced in advanced surgery.
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SKILL LABS
Operative surgery still remains manual craft. No amount of lecturing is going to help unless one has hands on program. The experienced open surgeon finds himself at a loss while handling the instruments to get a hand eye co-ordination and later on to get an accurate instrument targeting at MIS. Tying of knot and intra corporeal suturing is considered advanced in laparoscopy through this is basic in all types of open surgery. The creation of inanimate and animal training facilities by individual programs is encouraged to provide supplemental teaching of advanced laparoscopic surgical skills. Training centers will facilitate the acquisition of or access to advanced laparoscopic equipment and skills lab facilities. However we need to objectively watch these training centers to keep up with the basic assessments advancements and to certify the members in adequate program after training
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TRAINING IN THIRD WORLD COUNTRIES
The advantages of a minimal hospital stay and an early return to activity is attractive in the West and a necessity in the East. Unfortunately, MIS continues to be expensive due to the basic hardware and the consumables.
In the third world countries, we need to cut the cost down by using endo loop techniques by nurses, suturing and to cut down operating time to almost same as in open surgery to minimize the costs involved. The ordinary needles used to open surgery are the same at laparoscopy.
We also need to keep in mind that our surgeons from the government hospitals and mission's hospitals need this training at affordable rates. Such advances in surgery should be encouraged in all hospitals after proper training of personnel. At present one does not have to go the west to learn basic or advanced laparoscopy as we do have enough centers which train adequately
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TRAINING IN THE WEST
The hands on training programs in the West are fast becoming virtual with computers. Virtual imaging and teaching have the distinct advantages of using different levels of training such as level 1, level 2 etc as in electronic games. Also we can practice lap cholecystectomy on a normal liver, then a cirrhotic liver, etc. One can also change the setting of the game such as creation of cystic artery bleed. The main advantage of the virtual teaching is that the computer can grade you to different levels and you are able to compare yourself to the novice, average and the veteran surgeon.
Animals are done away with the keeps the public and animal rights groups at bay.
Disadvantage is one of the equipment. As one of the American surgeons told me what is the cost of one apparatus bought by the hospital to train the doctors in it compared to the litigation charges of the patient when things go wrong in theatre and patient sues.
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WHY TRAINING BY US?
First of all who should train? Basically a team that has done more should teach a team in training. Also the people who actually do the surgery such as the surgeons, assistants, nurses and technicians have to be down in the lab to help out the trainees and share the problems. One should be inclined to teach and impart one's knowledge and not leave the trainees with the junior most in the team who is incapable of sorting out the problems of the trainees.
We carried out the following operations:
I Diagnostic Laparoscopy – 30 July 90
I Lap Cholecystectomy – 13 Aug 91
Thor. Esophagectomy – 12 may 1992
I Lap. Assisted Colectomy – 28 Nov 1992
I Lap A P Resection – 26 June 1993
I Whipple's Procedure – 7 July 2002
We do more that 60 different types of laparoscopic and thoracoscopic procedures with the appropriate teams. Our team members come down and spend time in the lab with the trainees.
Our lab is not supported by one particular company which would result in the interests of that company, but is supported by a host of companies which bring their best and the latest equipment to the trainees to practice on.
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HOW DO WE DO IT?
We have Basic laparoscopic program called HELP (Hand on Endoscopic and Laparoscopic Program) for 3 days. This is to train surgeons who have no knowledge of prior laparoscopy and they are trained in lap cholecystectomies, appendectomies and diagnostic laparoscopies. We feel that tying and intra corporeal suturing is basic in laparoscopy and hence this is incorporated in all our basic and advanced teaching programs. Advanced program consists of splenectomies fundoplications, suturing gastrojejunostomies, adrenalectomies, coelctomies etc.
The advanced programs differs depending on the attending group such as urologist would undergo training in lap varicocelectomies, total cystectomies, bladder sutures, pyeloplastics, nephrectomies, etc. The advanced programs differs depending on the attending group such as urologists would undergo training in lap varicocelectomies, total cystectomies, bladder sutures, pyeloplastics, nephrectomies, etc. Gynecologists would undergo training in tubectomies, turbo tubal anastomosis, bladder suturing, hysterectomies, endo looping, etc.
Cardiac surgeons would concentrate on thoracoscopy, esophageal, lung, cardiac surgery including internal mammary artery harvesting.
Stress is laid on the indications of laparoscopic surgery and also contraindications to avoid the needless complications.
Our pattern of instruction is as follows:
- LECTURES
- ENDOTRAINERS
- SIMULATED MODELS
- ASSISTING
- PROCTORS
We do have a teaching session varying form 3-5 days once or twice a month at Kovai Medical Center and Hospital, Coimbatore. Details are available on we page www.lapsurgeon.org.
We have different groups of sessions based on the following specialty surgeons.
- General Surgeons
- GI Surgeons
- Gynecologists
- Pediatric Surgeons
- Urologists
- Thoraric Surgeons
- Spinal Surgeons
There is also subnet in each group who want to do one day program. This may consist of advanced laparoscopic surgeons who wish to undertake only one further surgery or technique such as suturing or hernia surgery or fundoplications or only gastrectomies, etc. we have this group for a day with intense videos, and simulators.
We have a support group of further education discussions and support by way of email groups dedicated to those who attend the program
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ASSESSMENT OF THE PROGRAM
Assessment of the program is done by a scoring system at the end of the program where we are able to diagnose our deficiencies and improve on them. The program is supported by more than 5 companies working together so the delegates are able to see the best in each company product. Basis by no particular company is avoided and the program is completely academic and not industry driven. We also have an email group where we are able to discuss various problems and trouble shooting between groups of like minded people and this helps sharing of knowledge in the long term.
We are also able to discuss complications by rerunning the tapes and offer advice on how to avoid disasters. We have so far trained more that 350 surgeons from all over India, UK, Germany, Bulgaria, Middle East and Malaysia. We are able to keep in touch with most of them closely.
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WHAT IS THE FUTURE?
The future in the west appears to be the virtual laboratory and in the East with the inclusion of laparoscopy in teaching hospital, training centers will and should stop over a course of time. However, MIS has opened the plethora of training and this is likely to continue in other aspects such as
- Virtual Surgery.
- Tele Surgery.
- Robotic Surgery.
While the open surgery is called the first generation surgery, and the minimally invasive surgery is known as second generation surgery. It is already being superseded by the third generation surgery – the robotic surgery! Robotic surgery involves:
- Master and Slave Robots
- No tremors by the surgeon are transmitted to the patient
- No Shoulder / Arm Strain which is an advantage
- Movements like wrist
- Repeated Sequences are easy to make.
- Remote Surgery is easy and basic to all robots
- Sutured anastamosis is made easier by the robotic surgery.
The cost of the robot is Rs 5, 00, 00,000 in Indian money. It can be shared by many departments. It appear out the reach of the average Indian Hospital, but the prices have to come down with more usage of the robots in the West and when more advanced models flood and market
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WHAT HAS INDIA DONE TO STANDARDIZE MINIMALLY INVASIVE SURGERY?
The former President of India His Excellency K Narayanan formed a Core Committee of experts from all over India to formulate the Guidelines for Minimally Invasive Surgery. This committee under the leadership of Dr Pradeep Chowbey the former President of IAGES had over a period of about two years operations by the minimally invasive route such as creation of pneumoperitonuem, Cholecystectomy. Malignancy, training centers, etc. These are brought out in a book and are now available for the surgeons and hospitals to use. This book outlines the important steps in each operation to adopt based on evidence based surgery and may act as a useful guide to the practicing laparoscopic surgeon.
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