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Training for Laparoscopic Surgery

HG Doctor
 

Introduction
Laparoscopic surgery has been the greatest
breakthrough of the last century for the general surgeons who were almost reduced to “Residual Surgeons”. Many general surgical procedures were being carried out by surgical specialists, interventional radiologists and endoscopists. Laparoscopic surgery opened a new vista for general surgeons and is now well established. Laparoscopic surgery has a great future as more and more surgical procedures are being performed by this technique.

Laparoscopic surgery is the performance of some general surgical procedures through key hole or ports with the help of specialized instruments and equipment. Illumination and magnification provided by this technology helps in better visualization and dissection of structures.

Laparoscopic versus Conventional Surgery
Laparoscopic surgery differs from conventional surgery in many ways. There is loss of tactile sensation as well as loss of depth penetration. The instruments are different in length and their usage. Considerable time is spent in setting up the equipment for laparoscopic surgery. Instruments in open surgery are reusable by autoclaving. Some of the instruments in laparoscopic surgery are reusable and a few are disposable. The instruments are expensive than for conventional surgery and also need to be replaced from time to time. Telescope, camera, light source and monitors have to be of good quality for optimum visualization and magnification. Hence financial considerations are important in initial investment and also reflect in the charges collected from patients.

Preamble
General surgeons obtain theoretical knowledge, clinical expertise and surgical proficiency during their undergraduate and postgraduate training in the medical colleges and hospitals. However Medical colleges and hospitals did not show much interest in establishing laparoscopic surgery in their institutions for a long time. Gynaecologists were already exposed to laparoscopy in a small way but the general surgeons were not except a few who performed diagnostic laparoscopies. This created a big lacuna in the training for laparoscopic surgery. Initially the surgeons who were interested in laparoscopic surgery went abroad and got trained by attending training centres and workshops. They purchased their own costly equipment and performed laparoscopic procedures, the most common being laparoscopic cholecystectomy which was then followed by many other procedures.

In the mean time the patients became aware of the advantages of laparoscopic surgery and demanded it. This put a lot of pressure on the surgeons to get trained and become proficient. Training centres were well established providing training on endotrainers and / or on animal models. The basic skills were mastered during these sessions and the surgeons trained themselves by longer periods of apprenticeship under experienced laparoscopic surgeons.

Current Status
Today a surgeon who is interested in performing laparoscopic surgery should take into consideration the following before he ventures into this field:

  1. He should be well versed with open surgery as laparoscopic surgery is nothing but transfer of conventional surgery into laparoscopic surgery. He has to orient himself with a two dimensional view of anatomy through the laparoscope.
  2. Equipment and instruments are expensive and need to be replaced from time to time. He must have access to them (either his own or at the institution) otherwise there is no use of undertaking the training.
  3. Alternatively two to four surgeons can pool in the resources and also work as a team to increase their experience, proficiency and expertise.
  4. The most common procedures performed are cholecystectomy, Appendicectomy, diagnostic laparoscopy and adhesiolysis. If the surgeon or group of surgeons is not likely to have these types of cases, it is not worth investing.
  5. The surgeon should get well trained at a recognized centre which will have facilities for didactic lectures, hands on training on endotrainers and preferably on animal models. The use of animal laboratory provides operative experience mimicking the actual clinical situation.
  6. The surgeon must obtain full knowledge of equipment and instruments. He must know how to use them as well as repair them.
  7. The surgeon should own an endotrainer to practice skills that will help hand eye co-ordination. Animal models are not easily accessible for repeated training.
  8. The surgeon should work with an experienced laparoscopic surgeon (a Perceptor) as an observer, second assistant, first assistant and then perform surgeries when being assisted.
  9. The surgeon should then perform laparoscopic surgery under supervision of the Perceptor.
  10. Initially all laparoscopic procedures should be recorded. They should be reviewed to realize the short comings and to improve the technique. Audit is an important learning tool.
  11. The surgeon should not feel shy or embarrassed to convert a laparoscopic procedure into an open procedure if the situation demands. Safety of the patient should be of paramount concern.
  12. The surgeon should not start a new laparoscopic procedure till he is well versed with one procedure.
  13. Laparoscopic surgery requires dedication, perseverance, patience and team work. Hence the surgeon should have a good and consistent team including Perceptor, Assistants, Nursing staff and Technicians.
  14. The surgeon should attend various seminars, workshops, lectures and operative sessions in Laparoscopic Surgery to update and to learn from the experience of others.

Levels of Training
For all practical purposes the following four levels of training are recommended.

Level 1
  Diagnostic laparoscopy
  Target biopsy
  Simple cyst aspiration
  Adhesiolysis of avascular adhesions
  Prerequisite for progression to level 2 training 20 cases at level 1 as an observer, assistant or main surgeon.
Level 2
  Adhesiolysis
  Laparoscopic cholecystectomy where there are no prognostic features to predict a difficult dissection
  Interval Appendicectomy
  Prerequisite for progression to level 3 training – 20 cases at level 2 as an observer, assistant or main surgeon.
Level 3
  All laparoscopic cholecystectomy
  All laparoscopic appendicectomy
  Diagnostic and other laparoscopic procedures in patients with previous laparotomy
Level 4
  Laparoscopic repair of hernia
  Laparoscopic vagotomy and seromyotomy
  Laparoscopic fundoplication
  Solid organ surgery
  Other advanced laparoscopic procedures

Future
It is possible that in future all medical colleges and hospital, as well as private hospitals routinely perform basic and advanced laparoscopic procedures and the laparoscopic surgery training centres may not be necessary. It is recommended that the guidelines mentioned above should be adhered to in the training.

Conclusion
Training techniques have to have objective evaluation, enhance minimal access skills and assess the further specific training requirements. Standardized drills are available which begin from the most basic localization and depth perception techniques and move on to more complex exercises that test the visual-spatial correlations. These basics and advanced drills are supervised by trained instructors and new ideals are introduced to the trainees at the appropriate times. This technique of drills and exercises is very common in many diverse fields viz. music and sports. The best analogy for surgical training is the flight simulator. It is expected that anyone completing the exercises satisfactorily will be thoroughly competent, reliable and safe practitioner of these skills.

Laparoscopic surgery is here to stay since it has many benefits and advantages to the patient. It should be considered as a ‘Landmark’ in the progress of general surgery and hence should be learnt and practised by all general surgeons. Presently it requires training at special training centres but gradually it will be absorbed as a part of general surgery training in the medical colleges and private hospital.

 

WORM TREATMENT

`An 8-week course of doxycycline is a safe and well-tolerated treatment for lymphatic filariasis with significant activity against adult worms and microfilaraemia'
Wuchereria bancrofti adult worms, which are a major cause of lymphatic filariasis, live symbiotically with Wolbachia species bacteria, and the bacteria are essential for worm development, embryogenesis, fertility, and viability. Therefore antibiotic treatment could prevent development of disease. Mark Taylor and colleagues did a randomised placebo-controlled trial to assess the effects of doxycycline treatment (200 mg per day for 8 weeks).

BMJ, 2005; 2067, 2116

Retd. Hon. Prof. of Surgery and Hon. Surgeon, Grant Medical College and JJ Group of Hospitals, and Senior Consultant Surgeon, Jain Clinic and Bhatia General Hospital, Mumbai. Course Director, ETHICON Institute of Surgical Education, Mumbai, New Delhi and Chennai.
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