Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Wrong e-mail address for Christian Larsen
- Jeanett Østergaard (15 May 2009)
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Major advance or the beginning of a slippery slope?
- Richard G Fiddian-Green (16 May 2009)
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Relationship to age?
- Joan McClusky (18 May 2009)
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Cadaver based laparoscopic training: A realistic alternative to virtual reality
- Peter S Kang, Austin G Acheson, and Alan F Horgan. (6 June 2009)
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Issues in Laparoscopic surgery training
- Mr Amir Nisar (27 July 2009)
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Jeanett Østergaard, Medical Doctor Gynaecological department Juliane Marie Centret, Rigshospitalet, Copenhagen, Denmark
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I'm writing on behalf of my colleague Christian Rifbjerg Larsen, who is currently on vacation. You have put his e-mail address down wrongly. It is crl@dadlnet.dk and NOT as you wrote crl@dadlner.dk. With regards, Dr. Jeanett Østergaard, Rigshospitalet, Copenhagen, Denmark Competing interests: None declared |
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Richard G Fiddian-Green, FRCS, FACS None
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Simulator training would seem, from these data (1), to be a very good way of training gynaecological registrars to do a laparoscopic salpingectomy. Whilst this might reduce the time taken to acquire basic laparoscopic skills does it lead to a higher or lower standard of care? The two goals, raising the median standard of surgical care and raising the highest standard of care, might not be compatible, the former detracting from the latter especially in the case of the goal of performing the more complex operations with zero percent mortality and morbidity. Cabinet ministers and managers, conscious of doctors' wages being the highest cost item in healthcare, might be encouraged by these data to exploit simulator training to reduce the time it takes to train gynaecologists and even to delegate minor operations to technicians. Extending surgical care for minor high volume operations to technicans or incompletely trained gynaecologists might also be used to reduce the costs of a formal medical education and gynaecological training especially in lesser developed countries. This is a seriously flawed goal. Ritual circumcision in South Africa generates a stream of sometimes very serious complications and even deaths each year. To address this problem "traditional surgeons and nurses registered with the health department were trained over five days on ten modules including safe circumcision, infection control, anatomy, post-operative care, detection and early management of complications and sexual health education. .. From 192 initiates physically examined at the 14th day after circumcision by a trained clinical nurse high rates of complications were found: 40 (20.8%) had mild delayed wound healing, 31 (16.2%) had a mild wound infection, 22 (10.5%) mild pain and 20 (10.4%) had insufficient skin removed (2). The infection rate is the concern for it can on occasion lead to necrosis of all the penile skin, as I once saw. Infection is a function of several variables, other than aseptic technique, notably the degree of trauma and haematoma formation caused. Training a surgeon to be able to perform even minor operations without causing unnecessary trauma and haematoma would take, I suspect, much more than simulator training to avoid with any regularity. Perioperative management is another variable especially important in resolving complications should they develop. Loss of all the penile skin would, for example, be easily avoided if there were proper postoperative care. That includes the attentions of a fully trained gynaecologist/surgeon. Whilst cosmetically appealing I have serious concerns about laparoscopic surgery in general for, as observed in the case of colon surgery (3), the open standards with which they have been compared leave much to be desired and might not be attainable ever again if open surgical skills decline pari passu with the increase in laparoscopic surgery. The goal of zero mortality and zero complications, which in many centers has very nearly been achieved with open surgery even in the case of highly complex operations on patients with co-morbidities, is compromised by the "I-think-we-will-get-away-with-it" approach to surgery. This would appear to be par-for-the-course in laparoscopic surgery [I think I can get on the green from behind this tree despite the lousy lie] given the steady stream of trocar injuries and the rise in hepatic duct injuries. The exposure and tactile feedback needed to achieve the highest standards of care are simply not possible with laparoscopic surgery. 1. Christian R Larsen, Jette L Soerensen, Teodor P Grantcharov, Torur Dalsgaard, Lars Schouenborg, Christian Ottosen, Torben V Schroeder, Bent S Ottesen. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009;338:b1802. 2. Karl Peltzer, Ayanda Nqeketo, George Petros, and Xola Kanta. Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluation. BMC Public Health. 2008; 8: 64. 3. R.Fiddian-Green. Open versus laparoscopy-assisted colectomy. The Lancet, Volume 361, Issue 9351, Pages 74-74 (22 April 2003). Competing interests: None declared |
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Joan McClusky, Medical writer New York, NY 10003
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This is a fascinating study. Over 10 years ago, there were some mentions of what were then called "nintendo surgeons"--young surgeons who had grown up playing computer games and were found to learn and ably perform laparoscopic procedures much more quickly than older surgeons, despite the latter generally having a much more extensive background in open procedures. The surgeons in this study were mostly of an age where they could have grown up playing computer games. It would be interesting to see if such a background made a difference in learning and performance, and also whether simulator training might be beneficial for older surgeons who did not play such games while growing up. Competing interests: None declared |
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Peter S Kang, Laparoscopic Colorectal Fellow Nottingham University Hospitals NHS Trust. NG7 2UH, Austin G Acheson, and Alan F Horgan.
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Dear Sir We read with interest the study by Larsen et al (1), which proposes the use of virtual reality simulation in laparoscopic surgery training. Whilst we accept the advantages of virtual reality simulation training for surgical training (1), a more realistic team training experience can be achieved by use of fresh frozen cadavers. We report our experience using fresh frozen cadavers in laparoscopic colorectal training for the National Training Programme (NTP). The storage and use of cadavers for the purposes of laparoscopic training, is authorised under The Human Tissue Act 2004 Part 1 schedule 1 (2). The Human Tissue Act 2004 repeals and replaces the Human Tissue Act 1961, the Anatomy Act 1984 and the Human Organ Transplants Act 1989. Two specialist colorectal centres’ currently use fresh frozen cadavers for laparoscopic colorectal training for the NTP, Newcastle Surgical Training Centre, Freeman Hospital, and Nottingham University Hospitals. The cadavers are fresh frozen and thawed prior to use. Our experience shows that fresh cadavers provide a realistic operative experience for trainees and the team. • There is perfect reproduction of Laparoscopic anatomical landmarks • Tissue flexibility and consistency is realistic • Tactile feedback from tissue handling • Ability use gravity and retraction to make simulation more realistic • Operative technical steps identical to live surgery Kneebone et al (3,4) suggest that simulation based training occurring outside the clinical setting risks isolating the trainer, from the team, and creates an oversimplification of a complex reality. Laparoscopic training using the fresh cadaver, allows all members of the team, the surgeon, the assistant, and theatre nurse, to participate in the training experience together, which simulates the live setting with greater accuracy than virtual reality. In addition the team will gain experience of actual operation room set up, actual instruments used, patient positioning and safety, which is not replicated with virtual reality simulation alone. We accept that virtual reality simulation has role in the future training of surgeons as an adjunct to clinical experience (4). We propose that fresh cadaver based training provides a more realistic training experience for all members of the team, although we recognise it is expensive and requires specialist facilities. References 1. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T , Schouenborg L, Ottosen C, Schroeder TV, Ottesen BS. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009;338:b1802. 2. Human Tissue Authority. Human Tissue Act 2004. Available at: http://www.hta.gov.uk/about_hta/human_tissue_act.cfm. 3. Kneebone RL, Nestel D, Vincent C, Darzi A. Complexity, risk and simulation in learning procedural skills. Medical Education 2007; 41(8):808-14. 4. Kneebone R, Aggarwal R. Surgical training using simulation. BMJ2009;338:b1001 Competing interests: None declared |
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Mr Amir Nisar, Consultant surgeon and Minimal Invasive surgery trainer Maidstone Hospital, Kent, England, UK
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I congratulate the authors on excellent work on simulators. There is no doubt that we need good laparoscopic training models for the surgeons in training. Further complex and advanced models are required for experienced surgeons who wish to take on more challenging and complex operations. I have just one comment on your study are that in the simulator trained group the surgeons performed some exercises to improve their eye hand coordination where as the other group did nothing in this respect. Probably a better model would have been to compare simulator trained group with a box trainer/ animal tissue group or other methods of training. I have been a trainer and instructor in Laparoscopic surgery for more than fifteen years. I have visited many centers to train and help the surgeons establish new Laparoscopic procedures in their units. My personal experience shows that in teaching new procedures every tool helps. Simulators are very useful and the new simulators are much more effective than the 1st generation simulators. However there are three problems with the simulators; 1. These are expansive. 2. Simulation has significant limitations and they lack variation despite many recent advances. 3. Trainees find these simulators boring and do not use these regularly even if the availability was not an issue. My personal opinion is that the box trainer with plastic or animal tissue model is far superior and effective due to the reasons mentioned above. An even better model is Cadaveric model. I am the course director of the pioneering Laparoscopic / Thoracosopic Cadaveric minimal invasive Oesophagectomy in United Kingdom. This course incorporates upper GI and Colorectal disciplines. Our expert faculty and participants on these courses have found this model extremely useful for the following reasons; 1. It is realistic in terms of depth perception and organ recognition. 2. The movements and technique required is a very similar (if not identical) to actual operation. 3. This offers additional benefit to the surgeons to revise human anatomy. 4. The combination of Cadaveric model with Laparoscopic feel for depth perception and tissue and plane recognition is invaluable. These Cadaveric models are far superior to any other available and we hail this as the "missing link" bridging "THE GAP" between training and actual surgery in theatre on patients. We believe that after simulator training the participants should be trained on animal models and box trainers, followed by cadaveric models (in selected procedures) before taking on complex operations on actual patients in the hospitals. This will reduce errors and improve results with shorter operating time and less operative complications. Competing interests: None declared |
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