Development of a Training Model for Laparoscopic Common Bile Duct Exploration
Identifieur interne : 002083 ( Pmc/Curation ); précédent : 002082; suivant : 002084Development of a Training Model for Laparoscopic Common Bile Duct Exploration
Auteurs : Alexis Sánchez ; Omaira Rodríguez ; Gustavo Benítez ; Renata Sánchez ; Liliana De La FuenteSource :
- JSLS : Journal of the Society of Laparoendoscopic Surgeons [ 1086-8089 ] ; 2010.
Abstract
A simple, low-cost model is described that allows for accurate reproduction of the main steps in performing laparoscopic common bile duct exploration.
Url:
DOI: 10.4293/108680810X12674612014464
PubMed: 20529526
PubMed Central: 3021306
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Development of a Training Model for Laparoscopic Common Bile Duct Exploration</title><author><name sortKey="Sanchez, Alexis" sort="Sanchez, Alexis" uniqKey="Sanchez A" first="Alexis" last="Sánchez">Alexis Sánchez</name></author><author><name sortKey="Rodriguez, Omaira" sort="Rodriguez, Omaira" uniqKey="Rodriguez O" first="Omaira" last="Rodríguez">Omaira Rodríguez</name></author><author><name sortKey="Benitez, Gustavo" sort="Benitez, Gustavo" uniqKey="Benitez G" first="Gustavo" last="Benítez">Gustavo Benítez</name></author><author><name sortKey="Sanchez, Renata" sort="Sanchez, Renata" uniqKey="Sanchez R" first="Renata" last="Sánchez">Renata Sánchez</name></author><author><name sortKey="De La Fuente, Liliana" sort="De La Fuente, Liliana" uniqKey="De La Fuente L" first="Liliana" last="De La Fuente">Liliana De La Fuente</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">20529526</idno><idno type="pmc">3021306</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021306</idno><idno type="RBID">PMC:3021306</idno><idno type="doi">10.4293/108680810X12674612014464</idno><date when="2010">2010</date><idno type="wicri:Area/Pmc/Corpus">002083</idno><idno type="wicri:Area/Pmc/Curation">002083</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Development of a Training Model for Laparoscopic Common Bile Duct Exploration</title><author><name sortKey="Sanchez, Alexis" sort="Sanchez, Alexis" uniqKey="Sanchez A" first="Alexis" last="Sánchez">Alexis Sánchez</name></author><author><name sortKey="Rodriguez, Omaira" sort="Rodriguez, Omaira" uniqKey="Rodriguez O" first="Omaira" last="Rodríguez">Omaira Rodríguez</name></author><author><name sortKey="Benitez, Gustavo" sort="Benitez, Gustavo" uniqKey="Benitez G" first="Gustavo" last="Benítez">Gustavo Benítez</name></author><author><name sortKey="Sanchez, Renata" sort="Sanchez, Renata" uniqKey="Sanchez R" first="Renata" last="Sánchez">Renata Sánchez</name></author><author><name sortKey="De La Fuente, Liliana" sort="De La Fuente, Liliana" uniqKey="De La Fuente L" first="Liliana" last="De La Fuente">Liliana De La Fuente</name></author></analytic><series><title level="j">JSLS : Journal of the Society of Laparoendoscopic Surgeons</title><idno type="ISSN">1086-8089</idno><idno type="eISSN">1938-3797</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>A simple, low-cost model is described that allows for accurate reproduction of the main steps in performing laparoscopic common bile duct exploration.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Peters, Jh" uniqKey="Peters J">JH Peters</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">JSLS</journal-id><journal-id journal-id-type="iso-abbrev">JSLS</journal-id><journal-id journal-id-type="hwp">jsls</journal-id><journal-id journal-id-type="pmc">jsls</journal-id><journal-id journal-id-type="publisher-id">JSLS</journal-id><journal-title-group><journal-title>JSLS : Journal of the Society of Laparoendoscopic Surgeons</journal-title></journal-title-group><issn pub-type="ppub">1086-8089</issn><issn pub-type="epub">1938-3797</issn><publisher><publisher-name>Society of Laparoendoscopic Surgeons</publisher-name><publisher-loc>Miami, FL</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">20529526</article-id><article-id pub-id-type="pmc">3021306</article-id><article-id pub-id-type="doi">10.4293/108680810X12674612014464</article-id><article-categories><subj-group subj-group-type="heading"><subject>Scientific Papers</subject></subj-group></article-categories><title-group><article-title>Development of a Training Model for Laparoscopic Common Bile Duct Exploration</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Sánchez</surname><given-names>Alexis</given-names></name><degrees>MD</degrees><aff>Central University of Venezuela, Surgery Department III, University Hospital of Caracas, Caracas, Venezuela.</aff></contrib><contrib contrib-type="author"><name><surname>Rodríguez</surname><given-names>Omaira</given-names></name><degrees>MD</degrees><aff>Central University of Venezuela, Surgery Department III, University Hospital of Caracas, Caracas, Venezuela.</aff></contrib><contrib contrib-type="author"><name><surname>Benítez</surname><given-names>Gustavo</given-names></name><degrees>MD</degrees><aff>Central University of Venezuela, Surgery Department III, University Hospital of Caracas, Caracas, Venezuela.</aff></contrib><contrib contrib-type="author"><name><surname>Sánchez</surname><given-names>Renata</given-names></name><degrees>MD</degrees><aff>Central University of Venezuela, Surgery Department III, University Hospital of Caracas, Caracas, Venezuela.</aff></contrib><contrib contrib-type="author"><name><surname>De la Fuente</surname><given-names>Liliana</given-names></name><degrees>MD</degrees></contrib><aff>Central University of Venezuela, Surgery Department III, University Hospital of Caracas, Caracas, Venezuela.</aff></contrib-group><author-notes><fn fn-type="other"><p>This study was funded by the Scientific and Humanistic Development Center of the Central University of Venezuela.</p></fn><corresp>Address correspondence to: Alèxis Sanchez, MD, <addr-line>Avenida Principal de Santa Sofía, Torre Alfa, Piso 9, Consultório 9C, Santa Sofía, El Cafetal, Caracas, Miranda 1061, Venezuela</addr-line>. Telephone: <phone>058 414 3310944</phone>, Fax: <fax>058 212 9856257</fax>, E-mail: <email>dralexissanchez@hotmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jan-Mar</season><year>2010</year></pub-date><volume>14</volume><issue>1</issue><fpage>41</fpage><lpage>47</lpage><permissions><copyright-statement>© 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.</copyright-statement><copyright-year>2010</copyright-year><copyright-holder>Society of Laparoendoscopic Surgeons, Inc.</copyright-holder><license license-type="open-access"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link>), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.</license-p></license></permissions><self-uri xlink:title="pdf" xlink:type="simple" xlink:href="jsls-14-1-41.pdf"></self-uri><abstract abstract-type="precis"><p>A simple, low-cost model is described that allows for accurate reproduction of the main steps in performing laparoscopic common bile duct exploration.</p></abstract><abstract><sec><title>Background:</title><p>Training and experience of the surgical team are fundamental for the safety and success of complex surgical procedures, such as laparoscopic common bile duct exploration.</p></sec><sec><title>Methods:</title><p>We describe an inert, simple, very low-cost, and readily available training model. Created using a “black box” and basic medical and surgical material, it allows training in the fundamental steps necessary for laparoscopic biliary tract surgery, namely, (1) intraoperative cholangiography, (2) transcystic exploration, and (3) laparoscopic choledochotomy, and t-tube insertion.</p></sec><sec><title>Results:</title><p>The proposed model has allowed for the development of the skills necessary for partaking in said procedures, contributing to its development and diminishing surgery time as the trainee advances down the learning curve. Further studies are directed towards objectively determining the impact of the model on skill acquisition.</p></sec><sec><title>Conclusion:</title><p>The described model is simple and readily available allowing for accurate reproduction of the main steps and maneuvers that take place during laparoscopic common bile duct exploration, with the purpose of reducing failure and complications.</p></sec></abstract><kwd-group><kwd>Training</kwd><kwd>Common bile duct</kwd><kwd>Exploration</kwd><kwd>Choledocholithiasis</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>Laparoscopy has gained much acceptance during the past decade. Since the introduction of laparoscopic cholecystectomy and its well-known benefits of reduced pain, shorter hospitalization time, quick return to normal routine, and optimal esthetic results,<sup><xref ref-type="bibr" rid="B1">1</xref>–<xref ref-type="bibr" rid="B3">3</xref></sup> the number of procedures undertaken via minimally invasive surgery has been constantly increasing.</p><p>Mastering of laparoscopic cholecystectomy led laparoscopic biliary surgery to the next step, that is, laparoscopic common bile duct exploration. The feasibility and safety of this technique has been demonstrated by various authors,<sup><xref ref-type="bibr" rid="B4">4</xref>–<xref ref-type="bibr" rid="B15">15</xref></sup> with a success rate between 86% and 100%, morbidity around 7%, and mortality <1%.</p><p>Training of the surgical team and the availability of appropriate surgical material are fundamental factors in achieving satisfactory results.<sup><xref ref-type="bibr" rid="B15">15</xref>,<xref ref-type="bibr" rid="B16">16</xref></sup></p><p>Traditionally, the learning of new surgical techniques has been achieved through observation and realization under the supervision of experienced surgeons. However, this type of training is costly for the institutions, besides having obvious medical and legal implications.<sup><xref ref-type="bibr" rid="B16">16</xref>–<xref ref-type="bibr" rid="B18">18</xref></sup></p><p>Training using animal models is an excellent alternative that has been used for training in several procedures such as cholecystectomy,<sup><xref ref-type="bibr" rid="B20">20</xref></sup> hepatectomy,<sup><xref ref-type="bibr" rid="B21">21</xref></sup> and treatment of portal hypertension,<sup><xref ref-type="bibr" rid="B22">22</xref></sup> amongst others. The use of porcine organs ex vivo has also been described.<sup><xref ref-type="bibr" rid="B23">23</xref></sup></p><p>The porcine model for exploration of the biliary tract was first described by Cameron et al<sup><xref ref-type="bibr" rid="B24">24</xref></sup> in 1994 and later by Watson et al.<sup><xref ref-type="bibr" rid="B25">25</xref></sup> More recently in Latin America, Pejkol et al<sup><xref ref-type="bibr" rid="B26">26</xref></sup> described a similar model and studied its impact on the training of surgical residents.</p><p>The problem with animal models lies in the cost, particularly in the case of the biliary tract, because it requires a previous intervention for the ligature of the biliary tract, and keeping the animal in captivity for at least a week to achieve an appropriate dilation of the choledochus to allow for instrumentation.</p><p>The experience in Venezuela with this type of surgery is limited. We have described our first experience in the technique at the University Hospital of Caracas<sup><xref ref-type="bibr" rid="B15">15</xref></sup>; we consider it to be a complex technique where training of the surgical team is of the essence.</p><p>Due to what has been described within the laparoscopic surgery workshop, the objective of which is to school general surgery residents in laparoscopic surgery, we have suggested the development of an inert model that would be a readily available and low-cost tool for training in the instrumentation of the biliary tract, which we will now describe.</p></sec><sec><title>MODEL DESCRIPTION</title><p>The materials required for the construction of this model are a black box that is normally used for practicing laparoscopic techniques, available in the majority of centers, and easily obtainable medical surgical materials as are as follows (<bold><xref ref-type="fig" rid="F1">Figure 1</xref></bold>):
<list list-type="simple"><list-item><p>1. Latex vesical catheters</p></list-item><list-item><p>2. Silastic vesical catheters</p></list-item><list-item><p>3. Polyglactin 910 sutures (Vicryl) or polyester (Ethibond) due to its easy management</p></list-item><list-item><p>4. t-tube (Kehr).</p></list-item></list></p><fig id="F1" position="float"><label>Figure 1.</label><caption><p>Material used for the elaboration of the training model.</p></caption><graphic xlink:href="jsls-14-1-41-g01"></graphic></fig><p>Laparoscopic instruments for this practice must include basic dissection and prehension instruments along with 2 laparoscopic needle holders. Additional requirements include a helicoidal basket or Dormia basket for practicing calculi extraction.</p><p>In our described model, we aspire to reproduce the fundamental steps of laparoscopic biliary tract surgeries, such as:
<list list-type="simple"><list-item><p>1. Intraoperative cholangiography</p></list-item><list-item><p>2. Transcystic biliary tract exploration</p></list-item><list-item><p>3. Laparoscopic choledochotomy and t-tube insertion.</p></list-item></list></p></sec><sec><title>INTRAOPERATIVE CHOLANGIOGRAPHY</title><p>Intraoperative cholangiography constitutes the initial step in the laparoscopic instrumentation of the biliary tract. For practicing this step, we used a portion of a vesical catheter joined perpendicularly to another, thus simulating the manner in which the cystic duct joins the main biliary tract (<bold><xref ref-type="fig" rid="F2">Figure 2</xref></bold>).</p><fig id="F2" position="float"><label>Figure 2.</label><caption><p>Intraoperative cholangiography (IOC) model.</p></caption><graphic xlink:href="jsls-14-1-41-g02"></graphic></fig><p>This model allows the surgeon to simulate the necessary movements and steps, ie, the partial section of the cystic duct for later insertion and progress of the cholangiography catheter towards the biliary tract, as is performed during live surgery.</p></sec><sec><title>TRANSCYSTIC EXPLORATION</title><p>For the construction of this model, we require a Silastic vesical catheter that has been modified using a stylet to simulate the cystic duct and the main biliary tract.</p><p>The use of a transparent catheter allows the surgeon to practice the capture of fictitious calculi in a 2-dimensional plane, as would be done in live surgical exploration guided by fluoroscopy, thus allowing familiarization with the helicoidal baskets or Dormia baskets, instruments that are not usually handled by the surgeon (<bold><xref ref-type="fig" rid="F3">Figure 3</xref></bold>).</p><fig id="F3" position="float"><label>Figure 3.</label><caption><p>Transcystic duct exploration model.</p></caption><graphic xlink:href="jsls-14-1-41-g03"></graphic></fig></sec><sec><title>LAPAROSCOPIC CHOLEDOCHOTOMY AND T-TUBE INSERTION</title><p>The mastering of this technique is indispensable, because transcystic exploration is not always successful. There are well-defined indications for this approach, which are (1) >10 calculi in the biliary tract, (2) calculi >1cm in size, (3) presence of intrahepatic calculi, and (4) a friable cystic duct.<sup><xref ref-type="bibr" rid="B27">27</xref></sup></p><p>In this case, we simulate the biliary tract by using a transparent hose upon which we perform a cut, simulating a longitudinal choledochotomy, through which the surgeon proceeds to insert and manipulate the helicoidal basket for practicing capturing and extracting calculi.<sup><xref ref-type="bibr" rid="B24">24</xref></sup></p><p>In this model, the surgeon will also have the opportunity to practice 2 of the more difficult steps of laparoscopic common bile duct exploration, that is, placement of the t-tube and handling the suturing and intracorporeal laparoscopic knotting for closure of the choledochotomy (<bold><xref ref-type="fig" rid="F4">Figure 4</xref></bold>).</p><fig id="F4" position="float"><label>Figure 4.</label><caption><p>Laparoscopic choledochotomy model.</p></caption><graphic xlink:href="jsls-14-1-41-g04"></graphic></fig></sec><sec sec-type="results"><title>RESULTS</title><p>The proposed model allows for the practice of the aforementioned fundamental steps of laparoscopic biliary tract surgery.</p><p>The likeness of the simulated model technique and the actual live surgery are clearly visible, thus permitting improvement in the surgical team's performance of the steps requiring special skills, which are as follows:
<list list-type="simple"><list-item><p>1. Introduction and progression of the cholangiography catheter within the cystic duct (<bold><xref ref-type="fig" rid="F5">Figure 5</xref></bold>).</p></list-item><list-item><p>2. Insertion of the Dormia basket through the cystic duct and its progression towards the choledochus, a moment of special concern because inadequate handling could cause lesions of the main biliary tract (<bold><xref ref-type="fig" rid="F6">Figure 6</xref></bold>).</p></list-item><list-item><p>3. Handling of helicoidal and Dormia baskets for the capture and extraction of calculi, maneuvers to which the surgeon is not accustomed and are directly related to the success of the procedure and complications, such as trapping of the basket (<bold><xref ref-type="fig" rid="F7">Figure 7</xref></bold>).</p></list-item><list-item><p>4. Placement of the t-tube, considered by some to be one of the most grueling steps of the surgery (<bold><xref ref-type="fig" rid="F8">Figure 8</xref></bold>).</p></list-item><list-item><p>5. Mastering suturing and intracorporeal knotting is a fundamental factor when advanced laparoscopic surgery is undertaken and is necessary in this particular case for the closure of the choledochotomy over the Kehr tube (<bold><xref ref-type="fig" rid="F9">Figure 9</xref></bold>).</p></list-item><list-item><p>6. Handling of 30 degrees by the assistant, taking into account that the adequate exposure and visualization of the surgical field is fundamental for avoiding failure and complications.</p></list-item></list></p><fig id="F5" position="float"><label>Figure 5.</label><caption><p>Intraoperative cholangiography. In vivo surgery and model view.</p></caption><graphic xlink:href="jsls-14-1-41-g05"></graphic></fig><fig id="F6" position="float"><label>Figure 6.</label><caption><p>Laparoscopic transcystic duct exploration. In vivo surgery and model view.</p></caption><graphic xlink:href="jsls-14-1-41-g06"></graphic></fig><fig id="F7" position="float"><label>Figure 7.</label><caption><p>Laparoscopic choledochotomy and common bile duct exploration with basket.</p></caption><graphic xlink:href="jsls-14-1-41-g07"></graphic></fig><fig id="F8" position="float"><label>Figure 8.</label><caption><p>T-tube placement.</p></caption><graphic xlink:href="jsls-14-1-41-g08"></graphic></fig><fig id="F9" position="float"><label>Figure 9.</label><caption><p>Choledochotomy closure over t-tube.</p></caption><graphic xlink:href="jsls-14-1-41-g09"></graphic></fig><p>Practice using this model has produced better training of the surgical team, which has led to increased effectiveness, diminished surgical time and conversion rate. However, an objective analysis of the impact of this simulator in the learning process is not the purpose of this article. For that end, a prospective controlled study is currently underway.</p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The use of inert training models aimed at lowering the learning curve and even with the purpose of evaluating skills has been described and studied in centers around the globe for many years.<sup><xref ref-type="bibr" rid="B28">28</xref>–<xref ref-type="bibr" rid="B30">30</xref></sup></p><p>Performing advanced laparoscopic surgery requires the acquisition of particular skills within the surgical team, because this kind of approach requires overcoming difficulties that lie with this technique, such as (1) 2-dimensional vision with loss of depth perception, (2) diminished range of movement of instruments compared with those performed freely by the wrists and elbows during open surgery, (3) diminished tactile perception, and (4) the disparity between visual and proprioceptive feedback brought on by hand movements leading to a contrary effect on the opposing end of the instrument, known as the <italic>fulcrum</italic> effect.<sup><xref ref-type="bibr" rid="B19">19</xref>,<xref ref-type="bibr" rid="B31">31</xref></sup></p><p>Animal models have been traditionally used for practicing this type of surgery<sup><xref ref-type="bibr" rid="B24">24</xref>–<xref ref-type="bibr" rid="B26">26</xref></sup>; however, in the case of the biliary tract, it becomes exceedingly costly because a prior intervention is required and the animal must be kept in captivity for at least a week. The model proposed by Windsor, who used a saphenous magna vein and tributaries to simulate the biliary tract, is hindered by the limited availability of said biological material.<sup><xref ref-type="bibr" rid="B32">32</xref></sup></p><p>The model we propose is simple, low-cost, and readily available, allowing the surgeon to simulate the fundamental steps of surgeries like intraoperative cholangiography, transcystic exploration, and laparoscopic choledochotomy. Performing these steps gives us the chance to practice the necessary skills that will facilitate the adequate accomplishment of this surgery, which is considered very demanding from a technical point of view.<sup><xref ref-type="bibr" rid="B27">27</xref></sup></p><p>It is well known that performing simpler surgeries allows for the practice and development of determined skills that help in developing towards more complex procedures. It is a learning process known as transfer of training.<sup><xref ref-type="bibr" rid="B33">33</xref></sup> Several studies<sup><xref ref-type="bibr" rid="B33">33</xref>,<xref ref-type="bibr" rid="B34">34</xref></sup> have demonstrated that after practicing on inert models like the one proposed, and mastering certain steps ex vivo, adequate training transfer occurs within the operating room, thus reducing failure and complications as well as advancing the learning curve.</p><p>Technical advances alongside the development of virtual reality models and specific simulators for high-end procedures<sup><xref ref-type="bibr" rid="B35">35</xref>,<xref ref-type="bibr" rid="B36">36</xref></sup> could lead to great improvements in laparoscopic surgery training. However, these tend to be of great cost and difficult attainability within our centers.</p></sec><sec sec-type="conclusions"><title>CONCLUSION</title><p>The model proposed is simple, very low-cost, and readily available. 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