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Tananchai Lucktong, a laparoscopic trainee in the department of surgery at the
University, stands before a flesh-toned mannequin made of foam rubber in the
shape of a human torso.
Special lengthened surgical instruments traverse the abdominal wall and allow
the organs within the mannequin to be manipulated. Lucktong handles them
gently, simulating operative techniques. On a small television screen in front
of him, a foam rubber version of the human digestive tract sits inside the foam
model.
Lucktong watches the business ends of his instruments nudge simulated organs.
As his scalpel's high-frequency ultrasonic vibrations cut through the mock
tissue, a wisp of smoke appears.
"It's not completely realistic. It doesn't bleed," Lucktong said. "But it does
provide an opportunity to practice with instruments in the positions they would
normally be in if you were in surgery."
The mannequin that Lucktong is operating on is called a trainer, part of
Carolina's Laparoscopic Institute of North Carolina (LINC), a
multimillion-dollar collaboration with surgical instrument manufacturer Ethicon
Endo-Surgery. LINC's mission is to help surgeons become acquainted with the new
techniques and skills of minimal access surgery - which doctors view as the
future of surgery.
Laparoscopic surgery is better for the patient, but generally more difficult
for the surgeon. The surgeon makes a few small incisions, an inch long or less,
and inserts specially designed surgical tools through them. Because the
incisions are much smaller than in conventional "open" surgery, the patient
experiences less pain, less trauma to the abdominal wall, quicker recovery and
a shorter hospital stay, and he or she can return to work sooner, said Mark
Koruda, professor and chief of the gastrointestinal surgery section at
Carolina.
Gallbladder removal, for instance, can involve three or four days in the
hospital if performed by "open" surgical techniques. But when the gallbladder
is removed laparoscopically, the patient can leave the hospital the same day.
Most gallbladder operations at the University are performed laparoscopically,
and many other procedures use a minimally invasive approach.
But the small incisions make the surgeons develop new techniques to perform
these operations. Laparoscopic surgeons must insert a small video camera
through another small port in order to visualize the operative field. The
television image is two-dimensional, making it more difficult for the surgeon
to judge depth. "It's like shooting baskets with one eye closed," Lucktong
said.
And there are other physical and mechanical constraints that make laparoscopic
surgery trickier, Lucktong added.
"Because you're operating at a distance, using long instruments, you can't feel
the tissue as well. There's less tactile feedback. And the motion of your
instruments is limited by fixation to the abdominal wall."
That's why it's important for surgeons to train at LINC before going into the
operating room, Koruda said. Before LINC opened about two years ago, surgeons
basically received on-the-job training, he said. Their only exposure to these
instruments and techniques was exclusively in the operating room while
operating on their patients.
"If we waited to train in the operating room, there wouldn't be enough cases to
master these rudimentary skills," he said. "But these are skills that are very
amenable to learning in a lab, because you don't need a patient to practice
using the instruments and the camera."
Just like a good pilot needs to spend time in the flight trainer, Koruda said,
surgeons who practice their skills at LINC are better prepared when they get to
the operating room.
Surgeons at any skill level can practice at LINC. While looking at a
laparoscopic grasper on a television monitor, the surgeon-in-training can
practice grabbing black-eyed peas and dropping them in a cup. At laparoscopy
meetings surgeons sometimes compete to see who can get the most peas in the cup
in a minute.
Lucktong makes it look easy. "You learn to respond to different cues to judge
depth," he said.
One of the most basic and important surgical skills is tying knots, Lucktong
said. But tying knots laparoscopically takes practice. Computers at LINC have
video clips on CD-ROM that demonstrate step-by-step how to do it. Behind the
computers is a row of boxes called pelvic trainers equipped to let the surgeon
follow along with the video or practice independently.
Surgeons can also watch videos of various surgeries to review how they are done
before going into the operating room. It's all part of LINC's mission to get
surgeons better acquainted with the techniques before operating. A
better-trained surgeon means quicker operations with far fewer complications.
Those techniques will be increasingly useful as more and more surgeries are
done laparoscopically, using minimally invasive surgical techniques.
"As the technology improves with time, minimally invasive surgeries like
laparoscopy will be applied to some extent in virtually every operation,"
Koruda said.
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