Training for Vascular Control and Reconstructive Parts of Laparoscopic Radical Prostatectomy

In spite of the increasing number of laparoscopic operations performed worldwide, the issue of how to teach and train laparoscopy has not been solved. In our opinion, today's residents should be exposed to standardized training programs in laparoscopy from the beginning of their residency so that they gain experience in laparoscopic surgery and open surgery both. Training by experienced laparoscopic surgeons will enable residents to deal with intraoperative complications laparoscopically without the need for conversion to open surgery. We believe that urologic surgeons who wish to practice laparo-scopic surgery and who have not been exposed to laparoscopic surgery should get their training in a laparoscopic center. Because of the long learning curve, especially for reconstructive laparoscopy, this training period should be at least several months before being able to practice reconstructive laparoscopy. For this purpose, the standardized Heilbronn laparoscopic training program is described.

Training Program

In a closed pelvic trainer, six different models were used to simulate and exercise reconstructive procedures. In step I, we used a two-row construction of four pins. In each row the middle pins had ring heads, the lateral pins had L-shaped hooks. This model allowed to practice hand-eye coordination under two-dimensional vision. In steps II and III, suturing and knotting activities were performed using a chicken leg to imitate human tissue (the different incisions and positions of the chicken leg allowed practice in changing angles of the needle, as needed in intracorporeal suturing). A bone and soft tissue model (chicken leg) was used in step IV; the bone part made it necessary to pass the needle above the bone through the soft tissue in the fashion that the needle was used to perform the stitch ligating the Dorsal-vein complex. In step V, we used a tubular structure (20 Chr. silicone catheter) to exercise interrupted sutures at the edges in 3, 5, 6, 7, 9, and 11 o'clock positions. In step VI, a urethrovesi-cal anastomosis was simulated in a porcine bladder model. The anastomosis was performed the same way as in our laparoscopic prostatectomy starting with the 6 o'clock stitch and continuing clockwise. The pelvic trainer was used in combination with a standard two-dimensional video technology. Suturing was performed with a needle holder and an endodissect using 3-0 Vicryl suture filaments (15 to 17cm). Only curved needles were used (RB needles) in our operating room for performing the ure-throvesical anastomosis.

We used a defined standard position of the instruments (distance between trocars 12 cm, intracorporeal instrument length 25 cm, angle between the instruments and the horizontal line 55 degrees, middle position of the object, middle camera position, diameter of 25 cm available for motion of the instruments, angle between the instruments <45 degrees) (77).

Definition of Task Goals

Expert laparoscopic surgeons in our hospital (defined as those who performed advanced laparoscopic procedures, i.e., pyeloplasty, radical prostatectomy, radical cystectomy, and retroperitoneal lymph node dissection), developed the various stages of the training program in order to define the expert level time for each stage. The average time of the results for each step were multiplied by the factor 2 and defined as task goals (double expert time) for the participants. Due to this, the time frames 3, 15, 15, 10, 20, and 30 minutes for step I, II, III, IV, V, and VI, respectively, have become the student's goal to reach before proceeding to the next stage.

Each training session time had to be recorded to calculate the needed time for reaching the expert level in each stage and for completing the entire program. As mentioned previously, the training program is planned to expose the participant gradually to more and more advanced tasks in laparoscopy. After reaching the expert skill level, which will be proved by a standardized test, they will be able to proceed to the next step until being able to participate in laparoscopic operations (Table 17).

Influence of the Program to Reconstructive Dexterity

A complete stitch contains two parts, the suturing part and the knotting part. Due to the two-dimension vision the inverted manipulation is the suturing part; especially the right positioning of the needle into the needle holder is a challenging procedure.

TABLE 17 ■ Model, Purpose of Each Step, and Required Time in Laparoscopic Training

Model

Purpose

Time (min)

Step I

Two-row pin construction

Hand-eye coordination under two-dimensional

3

vision passing a rubber band through the pins

Step II

Chicken leg: linear incision

Simple linear cutting, suturing, and knotting

15

Step III

Chicken leg: curved

Curved cutting, suturing (with changing angels

15

incision

of the needle) and knotting

Step IV

Chicken leg: dorsal-vein

complex-simulation

Suturing with a pronation movement of the needle

10

imitating the dorsal-vein complex stitch

Step V

Tubular structure

Circular suturing and knotting

20

Step VI

Porcine urethra

Urethrovesical anastomosis

30

Results of our study indicate that the especially challenging parts of reconstructive laparoscopy, such as intracorporeal suturing with the right angle of the needle in relation to the model and the needle holder, can be learned by using specially designed tasks.

Therefore, two parts of the program were examined more accurately concerning the influence of training to increase reconstructive capability.

Step IV (dorsal-vein complex simulation) and the 6 o'clock stitch (step V) were analyzed regarding the suturing and knotting parts. There was a significant decrease in total time required for a single stitch before and after the training. Training of reconstructive procedures decreased the total time by 55.7% for step IV (mean, 18 vs. 7.5 minutes) and by 52% for the 6 o'clock stitch (mean, 206 vs. 102.5 seconds). The mean time required for a single 6 o'clock stitch was 206 seconds before training and 102.5 seconds after training (p < 005). The same applied to the needed time to succeed step IV (before training 18 minutes and after finishing the program 7.5 minutes, p < 0.05).

The time for the suturing part (especially the ideal positioning of the needle) could be decreased in step IV by 72.2%, whereas the improvement of the knotting part was 34.3% (Fig. 1A and B). Accordingly, in the 6 o'clock stitch, the suturing part decreased by 66.3%, the knotting part only by 38.2% (78).

Our study (78) showed that, after passing the training program, all trainees decreased the time for succeeding each task compared to their baseline. Due to this, all participants were able to perform a safe urethrovesical anastomosis reproducible in less than 30 minutes at the end of the program. The mean time for reaching this level required 40 hours of practice. In this context, it might be interesting to note that the time for an urethrovesical anastomosis in the clinical setting (laparoscopic radical prostatectomy) ranges between 2 and 40 minutes.

Results of our study indicate that the especially challenging parts of reconstructive laparoscopy, such as intracorporeal suturing with the right angle of the needle in relation to the model and the needle holder, can be learned by using specially designed tasks.

This preclinical part of our training program is followed by clinical training in the operating rooms, including the first and second assistance and performing different parts of each laparoscopic procedure under supervision. This training runs at least three and up to 12 months.

FIGURE 1 ■ (A) Comparison of mean required time (separately for suturing and knotting) performing step IV (Dorsal-vein complex-simulation). Influence of training on suturing and knotting performance. (B) Comparison of mean required time (separately for suturing and knotting) performing the 6 o'clock stitch (step V). Influence of training on suturing and knotting performance.

FIGURE 1 ■ (A) Comparison of mean required time (separately for suturing and knotting) performing step IV (Dorsal-vein complex-simulation). Influence of training on suturing and knotting performance. (B) Comparison of mean required time (separately for suturing and knotting) performing the 6 o'clock stitch (step V). Influence of training on suturing and knotting performance.

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