After the introductory session, the actual laparoscopic training begins using inanimate models (e.g., bench models or training boxes). The inanimate models are totally risk-free, reproducible, readily available, inexpensive, offer unlimited practice, and basically require no intense supervision.4 The purposes of this training are: 1) To become comfortable working with both hands using laparoscopic instruments; 2) to become familiar with the video and laparoscopic equipment; and 3) to begin learning basic laparoscopic techniques.
The inanimate model is basically a clear (transparent) plastic box that may initially be used with direct visualization (without using a video camera) of instruments and models placed in the box (Figure 12.1).9 Trainees can experience various types of drills by simply changing the models in the see-through box, and can gradually acclimate themselves to instruments that are limited in their range of motion by the fixation of the cannula. At this phase of training, use of various types of unique instruments (with pistol-grip handles) is strongly encouraged. Techniques, such as cannula insertion, "running" (manipulating) the small bowel, cutting, suturing, dissecting, knot-tying, and applying endoscopic clips/staplers may be practiced under direct vision. To promote efficiency of these practices, many kinds of training "modules" have been proposed from academic centers, and some of them have been validated.4,9-11 Course tutors have to determine optimal combination of these modules according to trainees' basal (pretraining) skill levels and their demands.
Once the surgeon becomes comfortable performing these techniques under direct vision, the modules are placed in the laparoscopic training box, and the surgeon performs the same tasks under laparoscopic visualization with the video camera (Figure 12.2). This phase of training will require several hours of concentrated effort. The team must be capable of performing accurate and precise work in the inanimate model before graduating to the animal model. While the surgeon focuses on primary skills of surgery, the assistant surgeon should simultaneously practice similar skills on a separate trainer, or hold the video camera for the surgeon. The operating room nurses should use this time to familiarize themselves with equipment, assist the surgeon,
and learn the techniques so as to promote maximal efficiency in the operating environment.
Although training programs using inanimate models have become increasingly widespread, there remains one question raised by tutors and trainees: Can such programs provide residents with skills that are transferable to the operating room? Scott et al.4 randomized 27 junior (2PGY and 3PGY) residents into two groups: A group that received formal inanimate training and a control group. The training group practiced the video-trainer tasks as a group for 30 minutes daily for 10 days, whereas the control group received no formal training. All residents underwent a video-trainer test and validated global assessment of their ability to perform a laparoscopic cholecystectomy based on direct observation by blinded evaluators before and after the rotation. The trained group achieved significantly greater adjusted improvement in video-trainer scores and global assessments, compared with controls. They concluded that laparoscopic training on bench models improves video-eye-hand skills and translates into improved operative performance for junior surgery residents.
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