1 can not rely solely on the time on the stage learning laparoscopy usually have to master the use of instruments conditions can make their own simulator in fact is also simple an instant noodle carton pc camera laptop or desktop computer lights and two used pliers (laparoscopic special) and needle holder (laparoscopic special) can be borrowed offstage practice is mainly sensory and basic movements: separation, knotting and suturing techniques.
2 clamping rice grains practice: clip the loose rice grains into the locket after proficiency can use two pliers to pass the rice grains master the most basic senses laparoscopy is characterized by a flat display of three-dimensional space remember that there must be a sense of depth to practice to the eye to the heart to the hand in addition to the brain to have a scope of the patient’s overall view to be limited to the image in the monitor so as to quickly find the location of the mirror
3 Grape peeling exercise: put a few grapes in the exercise machine and use pliers and scissors to peel off the skin of the grapes completely to practice the feeling of the hand and the feedback from the equipment
4 knotting practice: take a short line with two pliers to tie the knot: double knot, surgical knot My personal feeling is that the best two pliers into a 90 degree angle, one pliers around the circle can use the other pliers to send the line knot up a little easier to fall
5 Suture practice: take a section of rabbit intestine or pig intestine, practice end-to-end anastomosis technique, experience the feeling of entering, pulling, holding and turning the needle.
The next step is the live animal test can choose piglets, in the surgical laboratory to contact the specific surgery remember to be sure to do the experimental object as a human being, must be successful, can fail to feel the problem, you can turn to the atlas of laparoscopic surgery, master the surgical steps and techniques, under the leadership of a senior physician, a simple surgery there is time to go out to meetings and exchanges to learn about the domestic and foreign masters of surgical operations, the best conditions to record It is also good to record the surgical videos and repeatedly study them. It is also good to explain and ask questions on the spot.
Methods of laparoscopic technique training
(i) Simulation training box operation skills training
The training helps the first-time laparoscopic surgeon to begin to adapt to the transition from stereoscopic vision under direct vision to planar vision with a monitor, to orient and coordinate, and to become familiar with various instrumentation techniques.
The difference between deep laparoscopic surgery and direct vision surgery is not only one of depth and magnitude, but also of visual orientation and coordination of movements. The beginner must be trained to adapt to this change. The images obtained by the laparoscopic camera and television surveillance system are equivalent to monocular vision and lack a sense of stereo, which makes them prone to errors when judging distance and proximity. The fisheye effect of the scope (the same object appears on the TV screen with the same geometry when the laparoscope is slightly deflected) requires gradual adaptation by the operator. Therefore, during training, it is important to grasp the smallness of the objects in the image and to estimate the distance between them and the laparoscopic mirror in relation to the smallness of the original entity to perform the instrumentation. The operator and assistant should consciously reinforce the sense of planar vision to judge the exact position of the instruments and organs by the shape and smallness of the surgical site organs and instruments after fluoroscopy, and the intensity of the image light to perform the operation.
Normal orientation and coordination are necessary for successful surgical operation. The operator determines the target orientation and distance based on the information obtained by vision and orientation, and the motor system coordinates the movements to perform the operation. This is a complete reflex that has been developed and taken for granted in everyday life and in direct vision surgery. In endoscopic operations, such as cystoscopic ureteral intubation, it is easy to adapt to the direction of the operator’s orientation and motor coordination because the direction of the scope is aligned with the direction of the operation. However, during televised laparoscopic surgery, the orientation and coordination developed from previous experience often leads to incorrect movements.
For example, when the operator is standing on the left side of a supine patient and the TV screen is placed at the end of the patient’s foot, the TV image shows the position of the seminal vesicles and the operator habitually extends the instruments in the direction of the TV screen and mistakenly believes that this is approaching the seminal vesicles, when in fact the instruments should be extended to the deep side to reach the seminal vesicles. This is a directional reflex formed in the past by direct vision surgery and intra-scope operation, which is suitable during TV laparoscopy. The operator should consciously determine the relative position of the instruments in his hands and the patient’s intra-abdominal organs when observing the TV image, make appropriate movements such as advancement, retraction, rotation or tilt, and master the amplitude in order to perform the exact treatment such as clamping, pulling, electrocuting, clamping and knotting at the surgical site. The operator and the assistant should determine the orientation of their instruments from the same television image according to their respective positions in order to cooperate with the operation. The position of the laparoscope should be changed as little as possible; a slight rotation may rotate or even invert the image, making orientation and coordination more difficult. Multiple practice in the training box or oxygen bag and mutual cooperation can make the orientation and coordination better adapted to the new situation, shorten the operation time and reduce trauma.
1 Eye-hand coordination training
Place a drawing with 16 letters and numbers and 16 small cardboards with corresponding letters and numbers on the bottom board inside the training box. The staff should look at the monitor screen, listen to the instruction and use their right hand and left hand to hold the grasping forceps to point to the corresponding direction; and use their left hand and right hand to change the position of each small cardboard at will.
Beans training In the training box on the bottom of a handful of soybeans and a narrow-mouth bottle, respectively, with the left and right hand grasping pliers to move the beans one by one into the narrow-mouth bottle. The relative position of the beans and the narrow-mouth bottle can be adjusted to further train accurate positioning skills.
2 Two-handed cooperation training (handing line training)
Place a suture of about 50cm on the bottom board of the training box, hold the grasping forceps with both hands, one hand holds one end of the suture and passes it to the other grasping forceps, gradually passing it from one end of the suture to the end.
3 Basic surgical operation training
(1) Paper-cutting training
Place a square piece of paper on the bottom board of the training box, and cut it according to the pre-drawn simple figure with the grasping forceps in the left hand and the scissors in the right hand.
(2) Clamping training
Titanium clips and silver clips are often used in laparoscopic surgery to clamp tissues or to stop bleeding, and the clamps are trained in the concealed box.
(3) Suturing and knotting training
A rectangular piece of film with a hollow central oval is placed on the bottom plate of the training box and a simple pair of sutures is placed and knotted. When tying the knot, ask another person to act as an assistant to help fix the knot and cut the end of the thread.
Once the simple butt suture is mastered, the continuous suture can be further practiced, again with the helper. In addition to training with film gauze, isolated animal organs, intestinal tubes, blood vessels, etc. can also be used for training.
(B) Animal experimental training
After the training box has mastered the basic operation skills of various laparoscopic surgeries, animal surgery experiments can be performed, the main purpose of which is to familiarize with the establishment of the pneumoperitoneum, the separation and ligation of tissues, suturing, hemostasis and other basic skills; to familiarize with the use of various special instruments in vivo, as well as the in vivo surgery of various organs; and to further strengthen the operational cooperation between the surgeon and the assistant.
Generally, the animals used are pigs or dogs. Anesthesia is first administered intraperitoneally using 3% sodium pentobarbital at 30 mg/kg body weight, followed by skin preparation, establishment of intravenous access and inhalation anesthesia by tracheal intubation by the anesthesiologist, followed by body fixation.
Usually the supine position was adopted.
The pneumoperitoneum is established by practicing the puncture method and the incision method, respectively.
After the pneumoperitoneum is established, the first step is to train in the identification of the orientation of the abdominal organs. Confirmation of the laparoscopic position of the internal organs on the monitor is an important step in performing the procedure. This is not difficult for physicians who are already skilled in anatomy and surgical procedures, but the images obtained through the television surveillance system are equivalent to monocular vision and lack a sense of three-dimensionality, which makes them prone to errors when judging distance and proximity, and this still requires some adaptation training in practice. During the entire laparoscopic procedure, it is essential that the assistant holding the scope ensure that the surgical field of view is correctly oriented, as otherwise it will lead to incorrect judgments by the surgeon. Next, practice puncturing other trocars with the assistance of laparoscopic guidance.
Practice laparoscopic ureterotomy suturing laparoscopic nephrectomy laparoscopic partial cystectomy as needed. Hemostatic techniques are to be the focus of training and various methods of hemostasis may be practiced in the final stages of surgery with intentional injury to the vessels.
(iii) Clinical learning
After passing the above training in the simulation training box as well as animal experiments, the trainees are basically familiar with the various instruments of laparoscopic surgery and have mastered the basic operational skills of laparoscopic surgery. The next step is the clinical study phase. The trainees will be given a tour of various urologic laparoscopic procedures and will be familiarized with the special approaches to common urologic laparoscopic procedures, etc. The trainee will then go on stage to hold the scope for an experienced laparoscopic surgeon and gradually transition to being able to work smoothly with the procedure and begin to perform relatively simple laparoscopic procedures, such as laparoscopic spermatic vein ligation, under the supervision of a supervising surgeon.