- Email: [email protected]
A Novel Home Laparoscopic Simulator
ORIGINAL REPORTS
A Novel Home Laparoscopic Simulator Yahya Al-Abed, MD, MRCS, and David G. Cooper, MS, FRCS Department of Surgery, Norfolk and Norwich University Hospital, NHS Trust, Norwich, United Kingdom As laparoscopic surgery becomes increasingly accepted as the technique of choice for many procedures, changes in training structure and working practice limit opportunities for trainees to acquire these new skills. A solution to this problem is the development of simulators that help to develop and hone skills before exposure to the operating theater. Several excellent yet costly simulators exist that have been demonstrated to improve laparoscopic skills. Furthermore, several reports in the literature describe the development of “home simulators”; however, each of these has limitations. The development of a home laparoscopic simulator is reported here that is cheap and easy to build and incorporates an extra dimension of practical port insertion as well as a novel design for a mobile light and camera source. (J Surg 66:1-2. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: laparoscopic simulator, laparoscopic trainer COMPETENCY: Patient Care
INTRODUCTION During the past 20 years, laparoscopic surgery has become increasingly accepted as the technique of choice for many common procedures. As the list of operations deemed to benefit from the laparoscopic approach increases, established specialists must obtain the necessary techniques and skills to undertake them safely. In the United Kingdom, this change in emphasis has been mirrored by a reduction in exposure to surgery for trainees, because of the restructuring of training programs caused by Calmanisation and the European Working Time Directive.1,2 A solution to this problem exists in the form of “training rigs,” which can help trainee surgeons develop their basic skills in a safe environment before entering the operating theater; this practice, therefore, accelerates the learning process.3 Several commercially available laparoscopic trainers are available. These trainers are acquired largely by institutions because of their significant cost. A large part of this expense is related to sophisticated optical equipment or to virtual reality computer systems. Many “home-made” simulators have been reported in the literature.4-6 Although often both practical and cheap, these systems have variably depended on standard laparoscopic cameras and viewing stacks to use, and they have relied on static cameras and light sources (or natural light) or required
Correspondence: Inquiries to Yahya Al Abed, MD, MRCS, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY, UK, Fax: (⫹44 1 702 385833); e-mail: [email protected]
complicated machine components to construct. These factors render such systems impractical for home use, less realistic, or difficult to build. In addition, none of these simulators address the technique of port insertion, which is central to safe laparoscopic surgery. We set out to develop a cheap and easily reproducible home laparoscopic simulator that uses readily available materials and incorporates a mobile or static camera and light source for individual or dual use. In addition, the simulator would contain a replaceable abdominal wall for changeable port insertion.
MATERIALS AND METHODS The main body of the trainer is based on a plastic storage box of dimensions 45 ⫻ 35 ⫻ 15 cm. The removable lid has the central portion cut out, which leaves a reasonable frame to maintain rigidity and to form the aperture for the anterior abdominal wall. This frame is created by laminating 3 layers of foam flooring underlay and then stretching a pair of opened-up latex gloves across the inner surface. The gloves must be secured with screws, rubber washers, and bolts to prevent tearing (Fig. 1A). The latex gloves help to reproduce the strength and elasticity of the abdominal wall and the underlying peritoneum after insufflation. Standard disposable laparoscopic ports can then be used in varying positions and inserted by an open technique or under direct vision (Fig. 2A). The authors found these ports easy to obtain from a busy theater suite at no extra cost. This design reproduced the flexibility of the abdominal wall and port mobility accurately. To reproduce a mobile camera and light source, we adapted a flexible USB-powered Web cam, which was housed in a (2 ⫻ 17 cm) plastic ornamental pipe surrounded with a similar high-power flexible light source to which it was secured with clips (Fig. 1B). The unit was then inserted into the trainer through a hole made in 1 end 7.5 cm from the bottom. It was stabilized by passing it through another piece of latex secured to the end of the box. For individual use, the Web cam and light source could be removed from the plastic housing and clipped securely to the end of the box. The Web cam was then attached via a USB extension lead to a laptop computer, which doubled as the monitor (Fig. 2B). For optimal visualization, a 1.3-megapixel Web cam should be used running at 30 frames/second to achieve the best ratio of resolution to smooth animation. The light source should be a minimum of 1.25 W provided by a halogen bulb for adequate illumination. All components of the trainer were easily available from “do it yourself” and computer stores. The total cost of building the simulator was less than £40 Sterling. Laparoscopic instruments can, however, present another costly consideration. In our experience,
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/09/$30.00 doi:10.1016/j.jsurg.2008.08.002
1
institutions increasingly rely on disposable instruments. We found that a variety of graspers and scissors could be rapidly sourced from a busy laparoscopic unit, avoiding any additional cost.
DISCUSSION We feel our laparoscopic trainer is unique in providing a system that can be used easily by surgical trainees at home; it uses a mobile camera and light source to enhance realism and camera skills of the camera operator. In addition, it is easy to build and does not require any machined components. It incorporates a replaceable abdominal wall that can help develop port placing skills. Obviously, it depends on computer ownership; however, from our experience, almost 100% of our surgical trainees own a computer. As a higher surgical and basic surgical trainee, we have found it effective in improving a range of skills from simple camera manipulation and instrument management to more complicated dissection and suturing techniques. Indeed, the rig has proved popular with other trainee surgeons in our unit, some of whom have constructed their own version. Anecdotally, it has given them greater confidence when commencing
FIGURE 2. Insertion of port (A). The trochar is observed indenting the simulated peritoneum. Completed laparoscopic simulator (B).
the learning curve in laparoscopic surgery, specifically with regard to the introduction of ports.
REFERENCES 1. Kelty C, Duffy J, Cooper G. Out-of-hours work in cardio-
thoracic surgery: implications of the New Deal and Calman for training. Postgrad Med J. 1999;75:351-352. 2. Anwar M, Irfan S, Daly N. Amen F. EWTD has negative
impact on training for surgeons. BMJ. 2005;17:331:1476. 3. McCluney AL, Vassiliou MC, Kaneva PA, et al. FLS simu-
lator performance predicts intraoperative laparoscopic skill. Surg Endosc. 2007;21:1991-1995. 4. Mughal M. A cheap laparoscopic surgery trainer. Ann R Coll
Surg Engl. 1992;74:256-257. 5. Ricchiutii D, Arends Ralat D, Evancho-Chapman M, et al.
A simple cost-effective design for construction of a laparoscopic trainer. J Endourol. 2005;19:1000-1002. FIGURE 1. “Peritoneal” surface of abdominal wall simulated by the inner surface of the box cover (A). Web cam and lighting system (camera shown by the black arrow, light shown by the white arrow) (B). 2
6. Blacker AJR. How to build your own laparoscopic trainer. J
Endourol. 2005;19:748-751.
Journal of Surgical Education • Volume 66/Number 1 • January/February 2009
A Novel Home Laparoscopic Simulator Yahya Al-Abed, MD, MRCS, and David G. Cooper, MS, FRCS Department of Surgery, Norfolk and Norwich University Hospital, NHS Trust, Norwich, United Kingdom As laparoscopic surgery becomes increasingly accepted as the technique of choice for many procedures, changes in training structure and working practice limit opportunities for trainees to acquire these new skills. A solution to this problem is the development of simulators that help to develop and hone skills before exposure to the operating theater. Several excellent yet costly simulators exist that have been demonstrated to improve laparoscopic skills. Furthermore, several reports in the literature describe the development of “home simulators”; however, each of these has limitations. The development of a home laparoscopic simulator is reported here that is cheap and easy to build and incorporates an extra dimension of practical port insertion as well as a novel design for a mobile light and camera source. (J Surg 66:1-2. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: laparoscopic simulator, laparoscopic trainer COMPETENCY: Patient Care
INTRODUCTION During the past 20 years, laparoscopic surgery has become increasingly accepted as the technique of choice for many common procedures. As the list of operations deemed to benefit from the laparoscopic approach increases, established specialists must obtain the necessary techniques and skills to undertake them safely. In the United Kingdom, this change in emphasis has been mirrored by a reduction in exposure to surgery for trainees, because of the restructuring of training programs caused by Calmanisation and the European Working Time Directive.1,2 A solution to this problem exists in the form of “training rigs,” which can help trainee surgeons develop their basic skills in a safe environment before entering the operating theater; this practice, therefore, accelerates the learning process.3 Several commercially available laparoscopic trainers are available. These trainers are acquired largely by institutions because of their significant cost. A large part of this expense is related to sophisticated optical equipment or to virtual reality computer systems. Many “home-made” simulators have been reported in the literature.4-6 Although often both practical and cheap, these systems have variably depended on standard laparoscopic cameras and viewing stacks to use, and they have relied on static cameras and light sources (or natural light) or required
Correspondence: Inquiries to Yahya Al Abed, MD, MRCS, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY, UK, Fax: (⫹44 1 702 385833); e-mail: [email protected]
complicated machine components to construct. These factors render such systems impractical for home use, less realistic, or difficult to build. In addition, none of these simulators address the technique of port insertion, which is central to safe laparoscopic surgery. We set out to develop a cheap and easily reproducible home laparoscopic simulator that uses readily available materials and incorporates a mobile or static camera and light source for individual or dual use. In addition, the simulator would contain a replaceable abdominal wall for changeable port insertion.
MATERIALS AND METHODS The main body of the trainer is based on a plastic storage box of dimensions 45 ⫻ 35 ⫻ 15 cm. The removable lid has the central portion cut out, which leaves a reasonable frame to maintain rigidity and to form the aperture for the anterior abdominal wall. This frame is created by laminating 3 layers of foam flooring underlay and then stretching a pair of opened-up latex gloves across the inner surface. The gloves must be secured with screws, rubber washers, and bolts to prevent tearing (Fig. 1A). The latex gloves help to reproduce the strength and elasticity of the abdominal wall and the underlying peritoneum after insufflation. Standard disposable laparoscopic ports can then be used in varying positions and inserted by an open technique or under direct vision (Fig. 2A). The authors found these ports easy to obtain from a busy theater suite at no extra cost. This design reproduced the flexibility of the abdominal wall and port mobility accurately. To reproduce a mobile camera and light source, we adapted a flexible USB-powered Web cam, which was housed in a (2 ⫻ 17 cm) plastic ornamental pipe surrounded with a similar high-power flexible light source to which it was secured with clips (Fig. 1B). The unit was then inserted into the trainer through a hole made in 1 end 7.5 cm from the bottom. It was stabilized by passing it through another piece of latex secured to the end of the box. For individual use, the Web cam and light source could be removed from the plastic housing and clipped securely to the end of the box. The Web cam was then attached via a USB extension lead to a laptop computer, which doubled as the monitor (Fig. 2B). For optimal visualization, a 1.3-megapixel Web cam should be used running at 30 frames/second to achieve the best ratio of resolution to smooth animation. The light source should be a minimum of 1.25 W provided by a halogen bulb for adequate illumination. All components of the trainer were easily available from “do it yourself” and computer stores. The total cost of building the simulator was less than £40 Sterling. Laparoscopic instruments can, however, present another costly consideration. In our experience,
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/09/$30.00 doi:10.1016/j.jsurg.2008.08.002
1
institutions increasingly rely on disposable instruments. We found that a variety of graspers and scissors could be rapidly sourced from a busy laparoscopic unit, avoiding any additional cost.
DISCUSSION We feel our laparoscopic trainer is unique in providing a system that can be used easily by surgical trainees at home; it uses a mobile camera and light source to enhance realism and camera skills of the camera operator. In addition, it is easy to build and does not require any machined components. It incorporates a replaceable abdominal wall that can help develop port placing skills. Obviously, it depends on computer ownership; however, from our experience, almost 100% of our surgical trainees own a computer. As a higher surgical and basic surgical trainee, we have found it effective in improving a range of skills from simple camera manipulation and instrument management to more complicated dissection and suturing techniques. Indeed, the rig has proved popular with other trainee surgeons in our unit, some of whom have constructed their own version. Anecdotally, it has given them greater confidence when commencing
FIGURE 2. Insertion of port (A). The trochar is observed indenting the simulated peritoneum. Completed laparoscopic simulator (B).
the learning curve in laparoscopic surgery, specifically with regard to the introduction of ports.
REFERENCES 1. Kelty C, Duffy J, Cooper G. Out-of-hours work in cardio-
thoracic surgery: implications of the New Deal and Calman for training. Postgrad Med J. 1999;75:351-352. 2. Anwar M, Irfan S, Daly N. Amen F. EWTD has negative
impact on training for surgeons. BMJ. 2005;17:331:1476. 3. McCluney AL, Vassiliou MC, Kaneva PA, et al. FLS simu-
lator performance predicts intraoperative laparoscopic skill. Surg Endosc. 2007;21:1991-1995. 4. Mughal M. A cheap laparoscopic surgery trainer. Ann R Coll
Surg Engl. 1992;74:256-257. 5. Ricchiutii D, Arends Ralat D, Evancho-Chapman M, et al.
A simple cost-effective design for construction of a laparoscopic trainer. J Endourol. 2005;19:1000-1002. FIGURE 1. “Peritoneal” surface of abdominal wall simulated by the inner surface of the box cover (A). Web cam and lighting system (camera shown by the black arrow, light shown by the white arrow) (B). 2
6. Blacker AJR. How to build your own laparoscopic trainer. J
Endourol. 2005;19:748-751.
Journal of Surgical Education • Volume 66/Number 1 • January/February 2009