Margaret Paz-Partlow

The use of a modular skills center for the maintenance of laparoscopic skills

AbstractBackground: A reliable method supplying graduated experience and practice is needed to develop and refine laparoscopic skills. The laparoscopic surgeon, like the microvascular surgeon, must have ongoing training to refine and maintain his or her skills. Methods: The authors describe a new modular training unit. The unit consists of a box with a built-in television camera, a light source, and a rotating platform. A videotape recorder with a timing device documents the actual “operating time” required for the various exercises. The first phase of training consists of a basic skills board. This initial phase enhances the use of dominant and nondominant hand motor activity. Results: The surgeon then progresses to lifelike models (biliary, suturing, hernia, gynecologic) to simulate the human operative setting. Ten surgeons spent 5 h each working with the module. The specific exercises were recorded and timed. Their progress is described. Conclusions: The modular laparoscopic skills center is an integral part of any laparoscopic educational program. It facilitates the acquisition and maintenance of laparoscopic skills.

Elective diagnostic laparoscopy

Laparoscopy developed as a science at the turn of the century, and many scientists assisted in the evolution of this technique. However, it was many years before the multiple trocar system was developed that allowed internal organs to be moved and biopsies to be obtained. This has led to the development of numerous indications for elective diagnostic laparoscopy. Adequate preparation and attention to instrumentation ensure the safety of this operation. Elective diagnostic laparoscopy is a useful adjunct to many other diagnostic modalities such as, for instance, the assessment of abdominal pain, abdominal masses, fever of unknown origin, and gastrointestinal bleeding. In many other circumstances, such as the assessment of oncology cases, this modality is superior to conventional radiology because biopsy specimens may be obtained. If the procedure is correctly performed, the diagnostic yield is extremely high and the morbidity and mortality are low. The role of this important technique should not be underestimated by todays practicing surgeon.

A new training device for laparoscopic cholecystectomy.

SummaryLaparoscopic cholecystectomy provides a new approach for gallbladder removal with which most general surgeons are not familiar. Requisites for the safe performance of this procedure are good hand-eye coordination, depth perception, and team cooperation. To aid with problems in depth perception and in the opposing movements caused by the lever principle, a training model was designed in which surgeons may execute a variety of exercises to enhance their motor skills and learn to work cooperatively with two other surgeons before operating on an experimental animal.

Mini-laparoscopy in blunt abdominal trauma

SummaryBlunt abdominal trauma in multiorgan injured or comatose patients always presents a problem. The aim is to assess, in the shortest period of time, which organ injury requires priority and whether intra-abdominal bleeding or perforation exists. Abdominal lavage proved to be too sensitive. Not every positive case needs exploration. Approximately 15%–20% of the cases explored because of positive lavage did not show a significant bleeding site that would require surgical treatment. The authors developed a mini-laparoscope that can be used at the bedside, in the emergency room, or in the intensive care unit. The procedure can be performed with intravenous sedation and local anesthesia. In 150 cases, no hemoperitoneum was found in 53% of these cases. Except for 1 (see text for details), none of these patients needed further exploration. In 21%, severe hemoperitoneum was discovered; these patients were transferred to the operating room, and this was confirmed by surgery. In 26%, a small amount of blood was found in the gutters. These patients were observed in the intensive care unit and an unnecessary exploration was avoided. Laparoscopy gives a wider range of decision making by observing the abdominal cavity. It can be completed in 10–20 min at the bedside. No serious complications were encountered. This procedure should be taught and practiced in trauma centers.

New ideas and improved instrumentation for laparoscopic cholecystectomy

SummaryA new cholangiograsper cannula was developed through which a Fr 4 or 5 ureteric cannula can be advanced into the incised cystic duct and held in a watertight position. This instrument facilitates intraoperative cholangiography. A plastic trocar stylet eliminates the metal shadow of the trocar during cholangiography. A new “laparocamera” is described where camera and telescope are built together in one unit decreasing the need for additional manipulation during the procedure. A camera holder driven by air helps the operator to keep his/her hands free. The need for a third assistant is avoided by inserting the camera into a (presterilized) holder, the position of which is controlled by press buttons.

Electronic imaging in endoscopy

SummaryEndoscopy evolved from a hollow tube view of visually restricted areas into an expansive, distal representation of the anatomy. Rod lens telescopes, improved coherent imaging bundles, superior light sources, and other optical advances enhanced endoscopic observations. Yet complicated endoscopic procedures remained visible to the endoscopist alone, relegating assistance and consultation toverbal description of sophisticatedvisual observation. Instrumentational advances alone did not promote three crucial elements:participation, cooperation and documentation. The importance of these elements has increased with the need for coordinated assistance in complex operative endoscopic manipulations, as well as in a visual record for improved documentation and consultation. New imaging technologies are supplanting the unwieldy, often daunting equipment once required for photodocumentation. The charged couple device (CCD) 2/3 and 1/2 in. “chip” video camera miniaturization provides nearly weightless TV coobservation. Distal chip placement has created the “video endoscope”. Combined with the 8 mm tape format, the chip has created a lightweight, single unit camera, monitor, and recorder. A recent advantage, magnetic disc recording, permits still video storage of up to 25 images. An electronic printer produces a hard color copy (4×5), which is inserted in the chart before the patient leaves the endoscopy room. The cost of the equipment can be shared in multidisciplinary institutions.

Ancillary Instruments for the Video Microlaryngoscope

Two years of experience with the video microlaryngoscope has identified the need for ancillary instrumentation to take full advantage of the systems potential. The authors developed the following additions to video microlaryngoscopy: 1) a hinged mirror that may be articulated from its pistol grip handle: 2) a 4-mm 30° or 70° angled telescope for examination of subglottic areas not accessible by mirror examination; and 3) angulated laryngeal instrumentation that permits operation on previously obscured anterior anatomy. The authors also find that the video microlaryngoscopes distal view eliminates interference with visualization caused by the syringe during vocal cord injection.

Percutaneous endoscopic laser lithotripsy of retained stones in the left hepatic duct

SummaryA 35-year-old woman with a retained stone in a branch of the left hepatic duct was referred to us. The stone was discovered on the postoperative T-tube cholangiogram. A flexible ureteroscope was introduced into the duct, under fluoroscopic and direct endoscopic vision and the pulsed dye laser was used successfully to disintegrate the calculus. The postoperative course was uneventful. We suggest that in certain selected cases, the pulsed dye laser might be useful in disintegrating stones sited in difficult positions.

The rotary gallstone lithotrite to aid gallbladder extraction in laparoscopic cholecystectomy

SummaryDuring laparoscopic cholecystectomy, a large stone burden may cause difficulty when extracting the gallbladder through the abdominal wall. Currently, the alternatives available to the surgeon include increasing the incision, removing stones singly, or utilizing complex fragmentation techniques like the pulsed dye laser [1]. We have employed an electromechanical rotary gallstone lithotrite (RGL) to fragment stones to an aspiratable size.Initially, cholesterol spheres were pulverized in a latex balloon to demonstrate the efficacy of the device. Then, human gallstones were placed in the balloon and reduced to fragments less than or equal to 1 mm from initial sizes of 4–24 mm.Human stones were then inserted in ex vivo porcine gallbladders in a controlled experiment and treated with the device. Ten out of 12 tests were completed within 30 s; one test required 49 s and one 105 s to achieve complete fragmentation. Blinded histological evaluation demonstrated that tissue abrasion caused by use of the device would not interfere with the diagnosis of unsuspected malignancy. Clinical trials have now commenced under the auspices of the hospital ethical committee.

The impact of electronic imaging in intraoperative biliary endoscopy (choledochoscopy)

SummaryIn the last decade, choledochoscopy has become an essential tool for biliary surgery. It is widely accepted, but it is not employed by every surgeon who performs choledocholithotomies. The reason is the limited experience of surgeons performing 30–40 cholecystectomies per year. A survey of 150 hospitals clearly showed that common bile duct exploration is performed in 10%–15% of these cases. General surgeons are not endoscopists. A new video choledochoscope that displays the image in a large format via the TV monitor was developed, which can be viewed with both eyes and an assistants help; this expedites and coordinates the procedure. The entire process is videotaped and can be used for further analysis and during consultation. It has become the method of choice for teaching. Most importantly, the learning curve of general surgeons has become significantly shorter. The procedure is taught and the surgeon can learn it easily. Its use will contribute to a decrease in the incidence of retained stones and will improve patient care.