May 24, 1991 - Research Registrar. Malcolm W R Reed MD FRCS .... The box is simple, cheap and is of a type widely used in teaching workshops here and in ...
Annals of the Royal College of Surgeons of England (1992) vol. 74, 70-71
SURGICAL TECHNIQUES Sim u lated
laparoscopic cholecystectomy
All W Majeed
FRCS
Research Registrar
Malcolm W R Reed
MD FRCS
Lecturer in Surgery
Alan G Johnson MChir FRCS Professor of Surgery
Department of Surgery, University of Sheffield
Key words: Cholecystectomy; Laparoscopic
A new simulator specifically designed for practising techniques in laparoscopic cholecystectomy is described. The simulator is inexpensive and utilises pig galibladders. It allows a surgeon to practice without the need for assistance.
The technique of laparoscopic cholecystectomy is a recent innovation which has generated much interest among surgeons. The procedure requires the development of skills in laparoscopic surgery which will be unfamiliar to the majority of general surgeons. These skills can be acquired by the use of anaesthetised animals or animal tissues. The use of animals for training in surgical procedures is prohibited in the UK except as part of a research programme. Most surgeons will not have access to an animal laboratory and a simulator using animal tissues is the only alternative. We describe a simulator using pig gallbladders, as the size and anatomy of the cystic duct and gallbladder is similar to the human. This simulator was designed specifically for training in isolation and clipping of the cystic duct and dissection of the gallbladder from its bed.
The Laparoscopic Cholecystectomy Simulator may be obtained through: Mr Derek Boaler, Chief Technician, Medical Workshops, Royal Hallamshire Hospital, Sheffield S1O 2JF. Telephone: (0742) 766222 Ext 3137 Correspondence to: Mr A W Majeed, Department of Surgery, K Floor, Royal Hallamshire Hospital, Sheffield SlO 2JF
Materials and methods The Laparoscopic Cholecystectomy Simulator* is simple in design and construction. It comprises a square frame measuring 50 x 50 x 30 cm (Fig. 1). The upper part of the frame is covered by a sandwich of two black Perspex sheets. Holes are cut out of this composite sheet and thick rubber discs are inserted in the holes. The orientation of these holes is similar to those used in laparoscopic cholecystectomy. Small holes (a-d) are drilled in the centres of these discs to allow for the introduction of the laparoscope and operating instruments. The top part is constructed to allow it to be movable in the vertical axis. The bottom part comprises a stainless steel tray which is set on tracks and is therefore movable in two directions in the horizontal plane. A softboard sheet lies
*
Figure 1. The Laparoscopic Cholecystectomy Simulator
71 Simulated laparoscopic cholecystectomy in the region of the cystic duct and, when complete, clips can be applied and the duct divided. The gallbladder is then dissected off the liver bed using a bimanual technique.
in the tray and the specimen to be dissected is fixed to this sheet by long sturdy pins or large (14G) hypodermic needles. The construction of the frame thus allows the specimen to be positioned appropriately. The laparoscope is introduced through hole a or b (Fig. 1), depending on the orientation of the specimen, and fixed in place by a semi-rigid arm. This allows the surgeon to practise on the simulator without the need for assistance. A video camera is attached to the telescope and is connected to a monitor. A specimen of pig liver with an attached gallbladder is fixed on to the softboard. Pig gallbladders are ideal for training as the size and anatomy are similar to the human. The bottom tray can be repositioned to obtain an optimal view. It is then secured in place. Operating instruments are next introduced through portals c, d, e and f. Dissection is started
Laparoscopic techniques for cholecystectomy and other abdominal procedures are likely to become commonplace. Practise in these techniques is essential if complications are to be avoided (1). Indeed, it might be considered unethical to start practising these new techniques on patients without acquiring the necessary skills (2). Simulators have proved useful in the teaching of anastomoses and other operative techniques (3). The simulator we have described gives an accurate 'feel' for laparoscopic manipulation of instruments and an excellent training of eye-hand coordination using a video screen. Pig livers with attached gallbladders are easily obtained from the local abattoir at minimal cost. The use of a simulator such as that described here facilitates the acquisition of essential skills before application of this technique in patients.
References I Cuschieri A. The laparoscopic revolution-walk carefully before we run. J R Coll Surg Edinb 1989;34:295. 2 Berci G. Editorial comment. Outpatient laser laparoscopic cholecystectomy. Am J Surg 1990;160:488-9. 3 Hill J, Kiff ES. An abdominal wall jig for surgical craft workshops. Ann R Coll Surg Engl 1990;72:386-7.
Received 24 May 1991
Assessor's comment The benefits to the patient and health service are so dramatic that laparoscopic cholecystectomy has quickly become an operation which surgeons have had to learn. The problems encountered are new instruments, new technology and a different approach to the conventional cholecystectomy. This paper describes clearly a black box simulator which will enable surgeons to familiarise themselves with the new surgical instruments and help to develop the hand-eye coordination which is necessary when using the newer laparoscopic technique.
The box is simple, cheap and is of a type widely used in teaching workshops here and in the USA. This paper and the box is recommended to surgeons who intend undertaking laparoscopic cholecystectomy. BRIAN I REES FRCS Consultant Surgeon University Hospital of Wales Cardiff
