|Year : 2016 | Volume
| Issue : 3 | Page : 214-219
Evaluation of hands-on seminar for reduced port surgery using fresh porcine cadaver model
Saseem Poudel1, Yo Kurashima1, Toshiaki Shichinohe1, Shuji Kitashiro2, Eiji Kanehira3, Satoshi Hirano1
1 Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
2 Department of Surgery, KKR Tonan Hospital, Sapporo; Reduced Port Surgery Forum, Saitama, Japan
3 Reduced Port Surgery Forum, Saitama; Department of Surgery, Medical Topia Soka Hospital, Saitama, Japan
|Date of Submission||23-Jul-2015|
|Date of Acceptance||26-Jul-2015|
|Date of Web Publication||3-Jun-2016|
Dr. Yo Kurashima
Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Kita 14 Nishi 5, Kita-ku, Sapporo
Source of Support: None, Conflict of Interest: None
Background: The use of various biological and non-biological simulators is playing an important role in training modern surgeons with laparoscopic skills. However, there have been few reports of the use of a fresh porcine cadaver model for training in laparoscopic surgical skills. The purpose of this study was to report on a surgical training seminar on reduced port surgery using a fresh cadaver porcine model and to assess its feasibility and efficacy. Materials and Methods: The hands-on seminar had 10 fresh porcine cadaver models and two dry boxes. Each table was provided with a unique access port and devices used in reduced port surgery. Each group of 2 surgeons spent 30 min at each station, performing different tasks assisted by the instructor. The questionnaire survey was done immediately after the seminar and 8 months after the seminar. Results: All the tasks were completed as planned. Both instructors and participants were highly satisfied with the seminar. There was a concern about the time allocated for the seminar. In the post-seminar survey, the participants felt that the number of reduced port surgeries performed by them had increased. Conclusion: The fresh cadaver porcine model requires no special animal facility and can be used for training in laparoscopic procedures.
Keywords: Cadaver porcine model training, laparoscopic training, reduced port surgery, surgical education
|How to cite this article:|
Poudel S, Kurashima Y, Shichinohe T, Kitashiro S, Kanehira E, Hirano S. Evaluation of hands-on seminar for reduced port surgery using fresh porcine cadaver model. J Min Access Surg 2016;12:214-9
|How to cite this URL:|
Poudel S, Kurashima Y, Shichinohe T, Kitashiro S, Kanehira E, Hirano S. Evaluation of hands-on seminar for reduced port surgery using fresh porcine cadaver model. J Min Access Surg [serial online] 2016 [cited 2019 Mar 24];12:214-9. Available from: http://www.journalofmas.com/text.asp?2016/12/3/214/183482
| ¤ Introduction|| |
From the 1990s, laparoscopic surgery started gaining in popularity for its minimally invasive approach and cosmetic benefit for the patients. For surgeons, a two-dimensional environment, longer instruments, fulcrum effect and decreased tactile response meant that completely new techniques were required to perform surgery using this method. The surgical curriculum evolved from only consisting of observational learning to actual surgical performances by surgeons-in-training. The ethical and safety issues of practicing on patients gave rise to learning outside operating rooms. Box trainers, porcine models, human cadavers and, more recently, virtual reality simulators have significantly assisted modern surgeons in completing the early phase of their learning curve outside the operation rooms., Studies have shown that training with simulators to achieve proficiency improves the performances of the surgeons in the operating room.,,
Along with this, surgeons had also started pushing themselves further trying to achieve the holy grail of scarless surgery by using a single site to introduce instruments and using instruments with smaller diameters, or using natural orifices as access points.,,,, “Reduced port surgery” is the term that was coined to include all these surgical techniques aiming to reduce trauma related to access in the surgical field. In the last few years, a huge array of access ports and devices for reduced port surgery have been developed. Japan has also seen an exponential rise in the number both of performing surgeons and types of operations performed using reduced port surgery techniques. However, we felt that there was a lack of training seminars to introduce devices and techniques of various reduced port surgery to the surgeons. The First Reduced Port Surgery Forum provided us with an ideal opportunity to host such a seminar.
The use of live porcine models is well documented in the literature, and has shown to have improved surgical performance. However, a huge effort is needed in order to hold a large-scale training seminar due to the need of animal lab and animal care facilities as well as anaesthesia. We thus decided to conduct our seminar using fresh porcine cadaver models.
The purpose of this study was to report on a large-scale surgical training seminar on reduced port surgery done using the porcine cadaver model, and to assess its feasibility and efficacy.
| ¤ Materials and Methods|| |
This hands-on seminar was jointly organised by the Reduced Port Surgery Forum (Japan) and Department of Gastrointestinal Surgery II, Hokkaido University, during the 1st Reduced Port Surgery Forum in August 2012. The seminar was held in the Hokkaido University animal laboratory. The seminar was approved by the Ethical Committee of the Hokkaido University animal experiment centre. The participants were chosen from among applicants from different centres all over Japan. A questionnaire survey was performed immediately after the seminar and again 8 months after the seminar to assess the efficacy of the seminar.
The primary goal of the seminar was to give the participants an opportunity to try various access ports, platforms and devices that are used for reduced port surgery, and to get them used to the techniques and the concept of reduced port surgery. There were 24 participants from 17 institutions all over Japan. They were divided into 12 groups with 2 participants in each group. Twelve stations were set up with 10 fresh porcine cadaver models and two dry boxes. The porcine cadavers used for the seminar were sacrificed 3 h before the seminar. Each station had its individual unique access port and device used for reduced port surgery. All the companies involved in the production and sales of the access ports and devices used in reduced port surgery in Japan participated in this seminar by providing their access ports and devices for the seminar. In total, nine access ports/platforms, 3 needlescopic devices and two reduced port devices were provided for this seminar [Table 1]. Each station had one or more instructors who were experts in the use of the device at that station. In total there were 17 instructors, 1 advisor, 2 guest instructors, and 10 members as support staff. Each group spent 30 min at each station, performing various tasks. The tasks included laparoscopic knot-tying in the dry box, laparoscopic in vivo suture, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastrostomy (lymphadenectomy, resection and reconstruction), and laparoscopic colectomy using reduced port devices and procedures. The participants learned fundamental technical skills with the various access platforms and devices of reduced port surgery under the guidance of the instructors.
All the corporations involved in manufacturing and distribution of the instruments used for reduced port surgery in Japan were invited to participate in the seminar. The seminar did not advertise one product as being better than the other, but instead introduced the participants to all the products available in the market and gave them a chance to grow familiar through use with the concept of reduced port surgery and different devices used in this type of surgery. Participation fees collected from the participating corporations were used solely to cover the organisational expense of the seminar.
A questionnaire survey was done immediately after the seminar to assess the satisfaction among the participants and instructors. Another survey was done 8 months after the seminar to assess the effectiveness of the seminar.
The survey done immediately after the seminar consisted of two types of questions based on 5-point Likert-type scale. The first set consisted of questions whose answers would check the level of satisfaction on various aspects of the seminar, with 5 being the maximum possible score and 1 being the minimum. The second set of questions checked for the overall impression of the seminar, with the neutral score of 3 representing the best possible answer, and 1 and 5 being the two extremes. The participants were also provided with another set of questions which evaluated their perception of the usefulness of each segment of their training. This set of questions was also based on the 5-point Likert-type scale, with 5 being the maximum score and 1 being the minimum score.
The survey conducted among the participants 8 months after the training consisted of questions on the number of single port and reduced port surgeries performed by them and at their institute after their training. They were also asked questions regarding increase in single port surgery and reduced port surgery and about the devices they used.
| ¤ Result|| |
Twenty-four surgeons participated in the hands-on seminar. There were differences in the backgrounds of the participants [Table 2]. The median practising period for the surgeons was 12.5 years (4-29 years). The participants had performed a median of 227.5 (0-2650) laparoscopic surgeries and median of 22 (0-280) single port surgeries. Though the porcine abdominal wall gradually became rigid and needed higher pneumoperitonium pressure (20 mmHg) during the seminar, we were able to perform all the tasks as planned. The response rate of the questionnaire done immediately after the seminar was 100% (24/24) among participants and 94% (16/17) among instructors. The response rate fell to 54% (13/24) in the questionnaire survey done among participants 8 months after the seminar.
On the survey done immediately after the seminar, both the participants and instructors showed a high degree of satisfaction. The average scores of participants and instructors were above 3 in all of the questions asked [Table 3.1] and [Table 3.2]. At the end of the seminar, the participants strongly felt that their single port surgery will increase with an average score of 3.7 (±1.02) [Table 3.1]. The instructors strongly felt that the hands-on seminar was effective with an average score of 4.62 (±0.78) [Table 3.2].
The majority of participants [22/24 (92%)] and of instructors [12/16 (75%)] felt that the number of participants per group was highly appropriate. Similarly, 23/24 (96%) participants and 12/16 (75%) instructors felt that the number of instructors was highly appropriate. Regarding the fees of the seminar (20000 JPY = approx. 200 USD), 7/16 (44%) instructors felt that it was highly appropriate, while 8/16 (50%) instructors felt that it was either very cheap or cheap. Of the participants, 20/24 (83%) felt that the fee was highly appropriate.
With regard to the total time allocated for the seminar, while 10/24 (42%) participants and 6/16 (37.5%) instructors felt that it was appropriate, 9/24 (37.5%) participants and 3/16 (19%) instructors felt that it was either short or too short. Meanwhile, 7/16 (44%) instructors felt that it was either long or too long. Of the participants, 7/24 (29%) could not perform all the tasks due to the lack of time.
In response to the questions about the specific tasks, the participants responded that the training in simpler tasks such as suturing and knot-tying was the most useful, with an average score of 4.08 (±0.76), compared to more complex tasks such as cholecystectomy (3.42 ± 1.5), gastrectomy (3.48 ± 0.93), colectomy (3.33 ± 0.94), appendectomy (3.29 ± 0.98), and in vivo suturing (3.12 ± 1.33) [Table 4]. The time allocation of only 30 min for each station for each group could be the main factor explaining this.
Impact after 8 months
The response rate from the survey done 8 months after the seminar was 54% (13/24). In that period the participants had performed a median of 10 (0-81) single port surgeries, and their institutions had performed a median of 30 (0-109) single port surgeries. Only 3/13 (23.1%) of the responders replied that the number of single port surgeries they performed increased and 3/13 (23.1%) of the responders had changed the platform or devices they had previously been using. Similarly, 8/13 (61.5%) of the responders replied that the number of reduced port surgeries they performed had increased [Table 5].
|Table 5: Survey after 8 months: How did the surgeries you perform change after the seminar?|
Click here to view
| ¤ Discussion|| |
Studies have proved that surgeons who undergo training and achieve proficiency using biological or non-biological simulators perform better in the operating room compared to surgeons who have only received conventional training in the operating room.,, However, the type of surgical training using simulators is still in its infancy in Japan.
While training involving dry boxes is relatively easier to perform with no constraint on where the training can be performed, it is only suitable for the training of basic laparoscopic skills such as suturing and handling of the instruments. In this seminar, our purpose was focused more on the training of advanced surgical skills, for which we felt that training using only the dry boxes was inadequate. While animal models play an important role in the field of surgical training, especially for training in advanced surgical procedures, factors such as the lack of an animal lab facility, need for an animal care facility, and the anaesthesia setup make it difficult for this type of training to be performed in any medical facility. These factors may have been limiting the development of animal lab for surgical training.
Our institution has been conducting small-scale training seminars using live porcine models for our residents for the past few years. With that experience, when we collaborated with the Reduced Port Surgery Forum to organise the large-scale hands-on seminar, we were able to determine the requirements for the anaesthesia of 10 porcine models. While a human cadaver solves the problem of anaesthesia, it is not always easy to secure the large required number of human cadavers for a seminar as seminars using human cadavers are not very common in Japan. Hence, we felt that the porcine cadaver model was our best option. Though at the time of the seminar there was a lack of literature with regard to the use of a fresh porcine cadaver model for surgical training, we felt that it would meet our primary goal of giving the participants the opportunity to try various access ports, platforms, and devices. Bordeianou et al. (2014) recently reported the use of a fresh cadaver porcine model for training in the transanal endoscopic microsurgery (TEM) procedure. To our knowledge this is the first report of the use of a fresh cadaver porcine model for training in laparoscopic procedures. Using a fresh porcine cadaver model has its own limitations. Being an animal model, a difference in anatomy exists. In addition, as we do not use anaesthesia, there are no respiratory movements. It is also impossible to recreate bleeding as in real operations or in live animal models. However, compared to cadavers, fresh cadaver models do have some oozing from the blood vessels. Our training did not involve simulation of bleeding or haemostasis technique, but involved the adaptation and overcoming of the loss of angulation that comes with single port surgery, and the use and adaptation of different devices available to perform different steps in the surgeries performed with conventional laparoscopy. A fresh porcine cadaver model provides that platform without the need of anaesthesia or an animal care facility.
The abdominal wall of the model becomes rigid with time. Except for the higher pneumoperitonium pressure (20 mmHg) found needed to counteract the rigidness of the abdominal wall, the seminar was conducted as planned and the participants were able to perform all the tasks without any difficulty. As indicated by the survey done among the participants and instructors, the participants and instructors were highly satisfied with the seminar.
We feel that training seminars using fresh porcine cadaver models have huge potential as an important tool in surgical education. As there is no need for an animal care facility to take care of the animals before the seminar or an anaesthesia facility during the seminar, a seminar using fresh porcine cadaver models can be conducted at any institution. This can increase the number of surgeons who can participate in these sorts of seminars and also pave the way for simulator-based training to be included in surgical residencies or fellowship courses.
As discussed earlier, there are some minor differences from real surgeries or training seminars using live animals, but it should not hamper training in laparoscopic skills.
There were concerns about the total time allocated at each station. Although the allotted time may have been adequate for the participants to be able to satisfactorily acquire simple skills such as suturing in the dry box, it may have been the factor that resulted in lower scores for the complex tasks. The main aim of this seminar was to teach the participants the basic skills of reduced port surgery, thus giving them an opportunity to try different access ports, platforms and devices. By collecting all the access ports, platforms and devices sold in Japan at the time of the seminar and using them to teach the participants the basic skills of reduced port surgery, with which most of the participants were highly satisfied, we feel that we were able to fulfill the main aim of our seminar.
With regard to the impact of the seminar for the participants from different backgrounds, it was difficult to numerically prove if the number of reduced port surgeries actually increased. There were several participants who only started doing single port and reduced port surgeries after attending the seminar, and 8 out of 13 (61.5%) of the responders in the post-seminar survey indicated that the number of reduced port surgeries performed by them had increased. Even if the majority of the participants could not advance promptly to single port surgery, they had been introduced to the concept of reduced port surgery, and they started thinking about and practising reduction of the number and diameter of the ports they used. In that respect, we feel that our seminar has been successful in introducing the concept of reduced port surgery.
Our seminar was the first of our efforts using the fresh porcine cadaver model and was mainly engaged in introducing the participants to the concept and basic skills of reduced port surgery. The main drawback of our seminar was that we did not focus on the teaching of specific skills. Neither did we evaluate how much the participants had learnt from the seminar. As we have successfully shown that the fresh porcine cadaver model can be used in training surgeons in advanced laparoscopic surgery techniques, we feel that our next step should be to use these models to teach specific skills with more specific purposes, giving ample time for the participants to acquire the skills, and establish appropriate measures to evaluate the impact of training.
| ¤ Conclusion|| |
The fresh porcine cadaver model was used successfully in training for reduced port surgery. It requires no special animal facility, and it demonstrated great potential for surgical training.
We would like to thank all the instructors and staff from the Department of Gastrointestinal Surgery II, Hokkaido University, and KKR Tonan Hospital who helped in organising this hands-on seminar.
Financial Support and Sponsorship
Conflicts of Interest
The authors do not have any conflicting financial relationship with the corporations that participated in this seminar.
| ¤ References|| |
Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004;91:1549-58.
Majeed AW, Reed MW, Johnson AG. Simulated laparoscopic cholecystectomy. Ann R Coll Surg Engl 1992;74:70-1.
Kirwan WO, Kaar TK, Waldron R. Starting laparoscopic cholecystectomy--the pig as a training model. Ir J Med Sci 1991;160:243-6.
Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am J Surg 2010;199:115-20.
Sturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ. A systematic review of skills transfer after surgical simulation training. Ann Surg 2008;248:166-79.
Zendejas B, Brydges R, Hamstra SJ, Cook DA. State of the evidence on simulation-based training for laparoscopic surgery: A systematic review. Ann Surg 2013;257:586-93.
Wheeless CR Jr. A rapid, inexpensive and effective method of surgical sterilization by laparoscopy. J Reprod Med 1969;3:65-9.
Pelosi MA, Pelosi MA 3rd
. Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med 1992;37:588-94.
Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.
Gagner M, Garcia-Ruiz A. Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc 1998;8:171-9.
Autorino R, Yakoubi R, White WM, Gettman M, De Sio M, Quattrone C, et al
. Natural orifice transluminal endoscopic surgery (NOTES): Where are we going? A bibliometric assessment. BJU Int 2013;111:11-6.
Curcillo PG, Wu AS, Podolsky ER, King SA, Reduced port surgery: Developing a safe pathway to single port access surgery. Chirurg 2011;82:391-7.
Nunobe S, Hiki N, Tanimura S, Nohara K, Sano T, Yamaguchi T. The clinical safety of performing laparoscopic gastrectomy for gastric cancer by trainees after sufficient experience in assisting. World J Surg 2013;37: 424-9.
Cruz JA, Passerotti CC, Frati RM, Reis ST, Okano MT, Gouveia EM, et al
. Surgical performance during laparoscopic radical nephrectomy is improved with training in a porcine model. J Endourol 2012;26: 278-82.
Bordeianou L, Sylla P, Kinnier CV, Rattner D. Perineal sigmoidopexy utilizing transanal endoscopic microsurgery (TEM) to treat full thickness rectal prolapse: A feasibility trial in porcine and human cadaver models. Surg Endosc 2015;29:686-91.
[Table 1], [Table 2], [Table 3.1], [Table 3.2], [Table 4], [Table 5]