| >CYBER-BASED
EDUCATION AND DISTANT LEARNING
TOP GUN LAPAROSCOPIC SUTURING PROGRAM Skill
Acquisition and Assessment for Laparoscopic Surgery
James
C. Rosser, MD; Ludie E. Rosser; Raghu S. Savalgi, MD, PhD, FRCS
Laparoscopic surgery affords opportunities for access and surgical manipulation that may replace traditional surgical approaches and permit new approaches previously impossible because of mechanical, anatomical, or physiologic considerations. Skills that permit competence and mastery in laparoscopic procedures are not directly derivative from skills used in open surgery. The effective acquisition of those skills by trainees is a matter of some importance to abbreviate the training period, minimize reliance on animal models, decrease operating room time, equip surgeons for independent operations, and reduce complications. Intracorporeal suturing is perhaps the most difficult of advanced laparoscopic skills and allows the surgeon to perform almost any maneuver through the laparoscope that can be achieved through an open incision. Suturing requires depth perception in the 2-dimensional image of the laparoscopy screen, accuracy with instruments beyond that necessary for dissection, and dexterity. In this study, dexterity drills, which correlate with incremental skill acquisition and the ability to perform intracorporeal suturing, were standardized. We
aimed to develop training methods with objective evaluation to enhance
laparoscopic surgical skills, provide training in laparoscopic suturing
techniques, and assess whether specific training exercises were helpful
in the attainment of intracorporeal suturing skills. PARTICIPANTS AND METHODS
All of the participants (i.e.,
board-certified or board-eligible surgeons) (N=150) in this study
attended a standardized training program that lasted for 3 days. The instructor-trainee ratio was 1:4. The data were collected by the instructors,
who ensured the quality of each drill or suturing performed. All instructors were involved in the development
of this course or had successfully completed the program. All exercises, including intracorporeal anastomosis,
were performed in a laparoscopic trainer (Surgi Trainer, US Surgical
Corporation, Norwalk, CT) (Figure 1) using a monitor (Trinitron
model No. PVM-1943MD, Sony, Tokyo, Japan), a telescope (3 chips, 0°,
10mm) (Stryker Endoscopy, Santa Clara, CA), and a medical video camera
(model No. 777, Stryker Endoscopy).
Use of the non-dominant hand was emphasized.
The participants performed 3 types of drills to improve their
dexterity, depth perception, instrument-targeting accuracy, visual
and spatial abilities, and hand-eye coordination.
These are generalized skill requirements not only for laparoscopic
surgery but also for other types of endoscopic surgical techniques.
The different steps in the drills also are relevant to laparoscopic
suturing. Intracorporeal suturing
requires motor and coordination function included in the 3 dexterity
drills. Therefore, repetitive
performance of the 3 drills may help laparoscopic intracorporeal suturing
directly or indirectly. Only
1 practice drill was allowed; thereafter, all the exercises were timed
in a standardized manner. The
participants performed the drills before the suturing exercises on
each day of the 3-day course. ROPE PASS DRILL This drill required ambidexterity,
depth perception, fine control of the instruments, and rhythmic, coordinated
movement. The 60x1/8 inch
rope was grasped with an endograsper with colored brands that were
1 inch long and 4 inches apart (Figure 2).
The rope was passed from one hand to the next in a maneuver
that maintained control of the instruments and managed the rope material
without tangling. The rope was initially coiled on a template
and lifted away serially, grasping the instruments with the non-dominant
hand and then dominant hand. Each
event is timed from the first grasp with the non-dominant hand until
the last grasp with the dominant hand. CUP DROP DRILL This drill requires the non-dominant
hand to transfer a smooth object to an aperture in a cylinder and
to drop the object from a height of 1 cm into the aperture (Figure
3). The event is timed from placing the grasper
in position. The drill requires
non-dominant dexterity, depth perception in a 2-dimensional field,
hand-eye coordination, and fine control of the instrument using a
rhythmic motion. TRIANGLE TRANSFER DRILL This exercise calls for engaging
a curved needle mounted on a grasper into a plastic loop at the apex
of a triangle. The loop is
seen only straight on, and its opening must be anticipated by depth
perception. With the needle in place, the triangle is transferred
across the field where the needle must be removed by abduction of
the elbow and flexion of the wrist (Figure 4). This series of movements closely correlate with those necessary
to establish initial penetration and recovery of the needle during
the tissue penetration phase of the intracorporeal suturing process. The drill also establishes ambidexterity, depth
perception, fine control of instruments, and coordinated, rhythmic
motion. Five triangles are
transferred in this timed event. INTRACORPOREAL SUTURING A silk suture on a curved needle
is used to approximate small intestine from pigs harvested at the
abattoir and stored frozen until thawing for use. An interrupted Lembert suture is placed, and an instrument tie is
performed. This skill calls
for depth perception in 2 dimensions, accurate instrument handling,
management of the materials, and ambidexterity.
The steps for the suture technique are as follows: Needle Positioning A 00-silk suture is grasped
2 to 3 cm from the SH needle with a needle-carrier in the non-dominant
hand. The suture and needle are advanced through
the port into the trainer. The
needle is suspended by the suture and is grasped at the juncture of
the proximal and middle third by a needle-carrier in the dominant
hand. The position of the needle is adjusted by pulling
on the suture. Tissue Penetration The
arm is abducted at the shoulder to place the needle perpendicular
to the tissue. The other hand
uses and empty needle-carrier to stabilize the tissue. Extension of the arm at the elbow causes lateral
displacement of the wrist, and the needle pierces the tissue. The wrist is rotated, and the tip of the needle
emerges from the tissue. The
needle tip is grasped with the carrier in the non-dominant and pulled
in rotation through the tissue, exaggerating the rotation with a dip
of the wrist to avoid traction on the tissue.
The needle-carrier in the dominant hand is used to stabilize
the tissue, and the thread is pulled through.
A short tail (i.e., 2-3 cm) is left at the needle entry site. Knotting The
needle is adjusted by gripping its tip, such that it is perpendicular
to the needle-carrier in the non-dominant hand. Traction on the suture is helpful. The swaged suture is placed to the left of
the needle-carrier in the dominant hand.
The non-dominant hand rotates with the needle clockwise for
2 more throws around the needle-carrier in the dominant hand. The tail of the suture is grasped with the
instrument in the dominant hand, and the knot is pulled tight by moving
the needle away and keeping the tail short.
The maneuver is repeated counterclockwise for 2 more throws,
and the sutures are cut. The
needle is withdrawn by grasping the suture tail and pulling the suture
and needle back through the port. STATISTICAL ANALYSIS The
time required to perform each dexterity drill or a single interrupted
stitch was documented in seconds. The participants in the initial courses performed 6 dexterity drills
of each type and 6 interrupted stitches. Subsequently, all the participants were made to perform 10 drills
of each type and 10 interrupted stitches.
The mean time in seconds required to perform a drill was correlated
(by multivariate analysis) with the mean time required to complete
a suturing exercise by the participants who performed 10 of each drill
and 10 of the suturing exercises.
Other participants who performed less than 10 drills and/or
suturing exercises were included for other analyses.
Including or excluding them did not make any difference in
the interpretation of the results reported in this article.
An unpaired Student t test was used to compare the time
required to perform the first vs. the 10th drill or suturing
exercise. All data are given
as the mean=SEM. --------------------RESULTS--------------------
DEXTERITY DRILLS The time required to perform a single drill was as follows: rope pass drill, 65.26=00.67 seconds (n=12+6); cup drop drill, 91.9+=00.9+ seconds (n=1232) and triangle transfer drill, 47.82=00.88 seconds (n=1232). The time required to perform successive drills shown in Figure 5 through Figure 7. All the participants improved in successive drills, and there was a significant difference (P<.001) between the time required for the first and the 10th drills for all 3 types of drills (Figures 5-7). INTRACORPOREAL SUTURING Ninety-six participants attempted a single interrupted stitch at the beginning of the course. Seventy-nine participants (82%) took either longer than 5 minutes or could not complete a knot in 10 minutes. Fifty-five participants (57%) required longer than 5 minutes to complete a stitch. Twenty-four participants (25%) were incapable of completing a stitch within 10 minutes, and the time they required for a single interrupted stitch was recorded as 600 seconds. The time required for the entire group (n=96) to perform a single stitch before receiving any instruction was 376.30=18.33 seconds. In reality, this value could be still higher, as 24 of the participants (25%) would have taken more than 600 seconds to complete a stitch. It was impractical to continue the exercise for longer than 10 minutes because of the limitation of time. Soon after receiving instructions about the technique of suturing, the time required declined significantly (P<.001) (Figure 8) and continued to decline. The time required to perform a single interrupted stitch during the course after the instructions was 150.75=2.95 seconds. All participants were required to perform a 2-layered, 8-cm anastomisis as a clinically relevant exercise at the end of the course. The time required to perform this exercise was 108.57=2.02 minutes (range, 47-180 minutes). The mean values for the drills and for the single interrupted stitch
of all the participants who performed 10 drills and 10 single interrupted
stitches were tested for correlation. There was a significant correlation between the time required for
the single interrupted stitch and the times recorded for all 3 drills: rope pass drill, r=0.62; triangle transfer
drill, r=0.57; and cup drop drill, r=0.+6 (n=89 and
P<.001 for all 3 drills).
These observations suggest that each drill may help to improve
the skills required for laparoscopic suturing.
The age of the participants (42.21±1.15
years) did not correlate with the mean time required to perform a
single interrupted stitch. ------------------------COMMENT------------------------ The mechanical skills needed for successful laparoscopic surgery
are fundamentally different from those required for open surgery. Laparoscopic surgery relies on a 2-dimensional
image, minimal tactile feedback, and reliance on instruments operated
at a distance. Open surgery
relies heavily on hand-eye coordination with depth perception, palpation,
and reliance on simple instruments used by the surgeon who is physically
in the operative field. The
public1 and profession2 in concert call for
objective evidence that surgeons, regardless of their previous accomplishments,
have acquired the needed skills for new procedures.
When surgeons are equipped with the proper skills, they are
more confident and more likely to apply newer techniques.3 The use of gradual drills and exercises is common in fields as diverse as music and sports.4 However, perhaps the best analogy for surgical training is flight training. It is expected that anyone completing the exercises will be a thoroughly competent, reliable, and safe practitioner of these skills. This study describes 3 drills that demand the following skills that are relevant to successful laparoscopic surgery: ambidexterity, depth perception, handling materials, manipulating instruments, and using movements that are fluid and rhythmic. At the outset, the correlative laparoscopic skill of suturing could not be accomplished in less than 5 minutes by more than half the trainees. However, steady acquisition and facility with the drills was associated with steady acquisition of the skill of suturing. It is unclear whether drills and exercises can be used in isolation
to credential surgeons. The
evaluation of skill in general is subject to debate.5.6 Some students show no relationship between an
objective assessment of skills and applied clinical skill.7 The use of drills should be restricted to self-paced skills acquisition
in analogous activities relevant to the surgical skills in question.
Ultimately, one can only be credentialed based on actual clinical
performance. The drills are designed to prepare surgeons who probably have no
greater innate dexterity than other physicians.8 Surgical proficiency is not in all likelihood
a manifestation of innately superior psychomotor skills.9 Rather, surgical proficiency is a manifestation
of considerable attention to technique and good training. Conventional surgical training techniques are
not necessarily applicable to laparoscopic surgery. Laparoscopic surgical training is more reasonably
begun from an analogous experience, such as drills, to prepare for
the real time pace of the operating room.
The experience in flight simulation10 as an educational
tool should be taken to heart. Surgical
tasks that are inefficient, impractical, slow, costly, or dangerous
when taught in the operating room should be learned during an analogous
experience before coming to the operating room. -----------------------REFERENCES----------------------
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