a skeptic environment. To these, we collectively want to express our gratitude for their hard work paving the road to contemporary MIS. Thank you!
References
1 1 Mishra, R.K. (2009). Chronological advances in minimal access surgery. In: Textbook of Practical Laparoscopic Surgery, 2e (ed. R.K. Mishra), 3–8. St. Louis, MI: Jaypee Brothers Medical Publishers.
2 2 Nezhat, C. (2011). Nezhat's History of Endoscopy: A Historical Analysis of Endoscopy's Ascension Since Antiquity. Tuttlingen, Germany: EndoPress.
3 3 Harrison, R.M. (1980). Historical development of laparoscopy in animals. In: Animal Laparoscopy (eds. R.M. Harrison and D.E. Wildt), 1–14. Baltimore: Williams & Wilkins.
4 4 Litynski, G.S. (1998). Kurt Semm and the fight against skepticism: endoscopic hemostasis, laparoscopic appendectomy, and Semm's impact on the "laparoscopic revolution". JSLS 2 (3): 309–313.
5 5 Bhattacharya, K. (2007). Kurt Semm: a laparoscopic crusader. J. Minim. Access Surg. 3 (1): 35–36.
6 6 Carter, J.E. (2006). Biography of Camran Nezhat, MD, FACOG. FACS. JSLS. 10 (2): 275–280.
7 7 Harrison, R.M. and Wildt, D.E. (1980). Animal Laparoscopy. Baltimore: Williams & Wilkins.
8 8 Johnson, G.F. and Twedt, D.C. (1977). Endoscopy and laparoscopy in the diagnosis and management of neoplasia in small animals. Vet. Clin. North Am. 7 (1): 77–92.
1 Surgeons' Skills Training
Boel A. Fransson, Chiya Chen and Claude A. Ragle
Adding Minimally Invasive Surgery to a Surgeon's Repertoire
Within the last decade, veterinary medicine has started to increasingly recognize the importance of skills development for surgeons who want to incorporate minimally invasive surgery (MIS) in their clinical practice.
Even for surgeons with considerable expertise in traditional open surgery, it often becomes readily apparent that some laparoscopic skills are distinctly different from those of open surgery. The challenges and differences include the use of long instruments, which magnifies any tremor and limits tactile sensation, often referred to as haptic feedback. When the instrument movement is limited by a portal into the body cavity, the surgeon needs to handle the resulting fulcrum effect and the loss of freedom to simply alter an approaching angle. But even more important, the normal binocular vision becomes monocular; as a result, the associated depth perception is lost. Other challenges include the loss of a readily accessible bird's eye view of the entire body cavity. The advantage of magnification may be perceived as offset by a reduced field of view, and any instrument activity outside the view becomes a liability.
Understandably, a surgery team with extensive experience of open procedures may initially be reluctant to take on some of the challenges of MIS. This may be especially conspicuous in small animal laparoscopy, in which the conventional surgical approach provides easy access to all intraabdominal organs. A budding small animal laparoscopic surgeon may meet resistance from referring veterinarians and even staff members when converting open procedures to laparoscopic because costs and surgery time, at least initially, tend to be higher. Educating the referral base, clients, and staff in the advantages of laparoscopy may alleviate but not completely remove the initial resistance.
The surgeon's transition from open to MIS surgery can be greatly facilitated by skills pretraining. The basic laparoscopic skills of ambidexterity, optimizing instrument interaction; observing cues for depth perception; and precise, deliberate movements need to be achieved early in the skills development for the benefit of patient safety and surgeon's confidence in the operating room (OR). Furthermore, for the surgeon interested in advancement from basic to advanced procedures, simulation pretraining becomes a necessity, especially if aspirations include MIS suturing.
Basic Laparoscopic Skills
The basic skills required for laparoscopic surgery include ambidexterity, hand–eye coordination, instrument targeting accuracy, and recognition of cues to provide a sense of depth [1, 2].
Although these skills are used, and therefore trained, in clinical practice, the surgeon should not rely on caseload for training, for reasons including patient safety and costs. The Institute of Medicine reported in “To Err Is Human” that approximately 100 000 humans die each year as a result of medical errors and that approximately 57% of these deaths are secondary to surgical mistakes [3]. More recent estimates suggest that these figures likely are severely underestimated [4]. The costs for medical errors in human medicine are staggering; up to $29 billion has been estimated [3]. Costs for learning in the OR are likewise steep; the additional costs have been estimated to $100 000 per resident in additional OR time alone [5].
Animal patient safety concerns and costs associated with errors and training time apply to veterinarians as well, albeit we do not have evidence of the exact costs. Veterinary training curricula are also faced with financial limitations, as well as increasing external and internal ethical concerns regarding the use of live animals for surgical training. Using cadavers for surgery training is also fraught with challenges because of problems with availability, storage, and limited usefulness because of decay. Finally, the tolerance for medical errors is declining, and the urgency to reduce errors made by inexperienced surgeons on actual patients has increased, in veterinary and human medicine alike [6]. For these reasons, both human and veterinary educators are being compelled to develop innovative teaching methods for surgical skill instruction.
Beside the ethical and cost issues, it is likely that a training program built solely on OR practice in live patients becomes limited, inefficient, and inconsistent. Conversely, a shift to simulation training outside the OR has been suggested to improve operative efficiency and quality [5]. For example, we have noticed in our work that even experienced veterinary laparoscopic surgeons tend to lag in efficient use of their nondominant hands, something easily rectified by simulation training [7]. In fact, the basic skills are most efficiently trained through simulation training [8]. This has been recognized for more than a decade among medical doctors. Since 2008, laparoscopic simulation training curricula have been a requirement for surgery residency programs in the United States [9]. Robust evidence has been presented to demonstrate that skills developed by simulation indeed transfer into improved OR performance [10–14]. Recently, a survey of ACVS residents demonstrated a widely held desire to include a MIS simulation training curriculum into the traditional surgical training programs [15].
Simulation Training Models
A number of simulation models have been presented and can currently be divided into three main categories: physical task trainers; virtual reality (VR); and hybrid, or augmented reality (AR), models combining VR with synthetic tissue models.
Another terminology for simulation is to denote how life‐like or “real” the model is perceived. Low fidelity tasks are often simple task trainers utilizing low cost materials. Cadaver training has been denoted to vary from medium fidelity to high [5], depending on species, surgery type practiced, and cadaver condition. Live animal models, if utilizing the patient species, is an example of a high fidelity model. Recently, higher fidelity synthetic models are being developed for small animal use [16], but they currently have limited availability. However, some models developed for use in human surgery may be of value also for veterinary training.
