The use of a modular skills center for the maintenance of laparoscopic skills.

BACKGROUND: A reliable method supplying graduated experience and practice is needed to develop and refine laparoscopic skills. The laparoscopic surgeon, like the microvascular surgeon, must have ongoing training to refine and maintain his or her skills. METHODS: The authors describe a new modular training unit. The unit consists of a box with a built-in television camera, a light source, and a rotating platform. A videotape recorder with a timing device documents the actual "operating time" required for the various exercises. The first phase of training consists of a basic skills board. This initial phase enhances the use of dominant and nondominant hand motor activity. RESULTS: The surgeon then progresses to lifelike models (biliary, suturing, hernia, gynecologic) to simulate the human operative setting. Ten surgeons spent 5 h each working with the module. The specific exercises were recorded and timed. Their progress is described. CONCLUSIONS: The modular laparoscopic skills center is an integral part of any laparoscopic educational program. It facilitates the acquisition and maintenance of laparoscopic skills.

Safety evaluation of laparoscopically applied clips.

We have evaluated in vitro, the security of laparoscopically applied clips, through two commercially available clip appliers: the Endo Clip II (US Surgical) and the Ligaclip (Ethicon). The clip performance was tested with respect to dislodgment and leakage. Dislodgment was attempted both transversely and at 45 degrees with respect to the main axis of the tubular structures tested. The mean maximum force (N = 24) necessary to dislodge a clip applied to silicone tubing (2.1, 2.4, 3.2 mm o.d.) and porcine vascular tissue was measured. The maximum force needed to transversely dislodge a clip applied to silicone tubing, ranged from 262 +/- 9 g (2.1 mm) to 315 +/- 11 g (3.2 mm) for the Endo Clip II applier, while the values for the Ligaclip were 220 +/- 28 g (2.1 mm) and 273 +/- 11 g (3.2 mm), respectively. To achieve dislodgment at 45 degrees pull, corresponding forces of 294 +/- 8 g (2.1 mm) and 369 +/- 14 g (3.2 mm) for the Endo Clip II, and 254 +/- 14 g (2.1 mm) and 297 +/- 13 g (3.2 mm) for the Ligaclip (N = 24) were required. Transverse dislodgment forces, for clips applied to tissue, were 556 +/- 146 g for the Endo Clip II and 356 +/- 170 for the Ligaclip (N = 6). Leakage tests were also performed under pulsatile blood circulation at mean pressure of approximately 800 mm Hg. No tested clips applied to either silicone tubing or tissue allowed for any blood leakage. The dislodgment test showed that the Endo Clip II exhibits superior performance compared to the Ligaclip, based on the fact that it requires more force for transverse and semiaxial dislodgment. In the leakage test, both clip appliers performed equivalently.

The use of models in laparoscopic education.

From earliest times, visual aids - from crude diagrams to complex, beautiful wax anatomical models - have been created to enhance the surgical learning process. Surgical educators realized early that suitable models could be used to develop the needed technical expertise essential to the safe performance of surgery. Practice on models also assisted in developing surgical judgment.

The laparoscopic hernia trainer. The role of a life-like trainer in laparoendoscopic education.

The safe and effective performance of laparoscopic inguinal hernia repair requires a working knowledge of pre-peritoneal anatomy. Most surgeons are unfamiliar with the retro-peritoneal view of the groin. A model has been developed which allows surgeons to learn pre-peritoneal anatomy, to practice laparoscopic inguinal herniorrhaphy and to assess their repairs. This model is a valuable laparoendoscopic educational tool.

Biliary lithotripsy as an adjunct to laparoscopic common bile duct stone extraction.

We investigated various energy sources and delivery systems suitable for fragmentation of common duct calculi by a laparoscopic technique. We evaluated electrohydraulic lithotripsy (EHL) using 1.9-Fr probe delivering 80 W and laser lithotripsy using a 200-micron(s) fiber delivering 30-70 mJ/pulse at 5-20 Hz. In vitro biliary stone fragmentation analysis suggested that the laser lithotripsy produced a more controllable fragmentation than EHL. Initial attempts to employ EHL techniques in animal models resulted in common bile duct injury or inadequate fragmentation of stones. In contrast, biliary lithotripsy was accomplished in pigs using the pulsed-dye laser at 10 Hz and 60 mJ/pulse. Histologic evaluation revealed no evidence of ductal injury related to laser stone fragmentation. Subsequently, laser common duct lithotripsy was used in two human subjects. One patient had a 1.8-cm impacted ampullary stone and one patient had a 3-cm intrahepatic stone. In both cases, the stones were removed laparoscopically after laser fragmentation. Our experience suggests that the laser lithotripsy may facilitate laparoscopic common duct stone extraction procedures.

Problem-solving in laparoscopic surgery.

The advent of the laparoscopic revolution and the wider applicability of laparoscopic procedures has caused surgeons to re-think the dynamics of intraoperative problem-solving. Problems of body habitus, previous surgery, exposure, bleeding, and anesthesia, as well as the problem cholangiogram, require new and innovative approaches, a practical approach to each of these common laparoscopic problems is presented.

Laparoscopic choledochoscopy and extraction of common bile duct stones.

Various strategies have been proposed for the treatment of common bile duct stones encountered during laparoscopic cholecystectomy (LC). Eighty-three patients who had choledocholithiasis discovered during or just prior to LC are included in this study. These patients were treated by various modalities including preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic choledochotomy, transcystic duct-common bile duct (TCD-CBD) exploration, and conventional "open" common duct exploration. Sixty-six patients were successfully treated with TCD-CBD exploration. They were discharged on average 2.6 days postoperatively and were able to return to normal physical activities within 7 days of discharge. There was minimal morbidity and no mortality. The technique of TCD-CBD exploration is described in detail. The role of laparoscopic choledochotomy and endoscopic sphincterotomy for management of common duct stones in patients undergoing laparoscopic cholecystectomy appears limited.

Endoscopy of the lacrimal outflow system.

Management of obstructions in the lacrimal drainage system would be greatly aided by improvements in the ability to visualize the blockages. We describe a new method of observation using miniature fiberoptics to view the entire lacrimal excretory system. We employed flexible endoscopes of fiberoptic bundles with outside diameters of from 0.5 to 0.7 mm. These endoscopes were inserted through the puncta and canaliculi. Sixteen patients were examined. A range of pathologic conditions were found, including slightly stenosed passages and severely destroyed canalicular mucosal lining. Our results indicate that this technique is feasible and useful in the diagnosis of lacrimal excretory disease.

Laparoscopic cholecystectomy in acute cholecystitis.

Between August 1989 and December 1990, twenty-five patients with a preoperative diagnosis of acute cholecystitis underwent laparoscopic cholecystectomy. Twenty-one patients (84%) had abdominal tenderness, 16 (64%) had leukocytosis, and 10 (40%) had fever. Eleven patients (44%) came to the hospital with only one of these previously mentioned clinical signs. Six patients (24%) had two clinical signs. Eight patients (32%) came to the physician with all three findings. The length of surgery correlated directly with the number of presenting clinical signs. The average operating time was 119 minutes. Intraoperative cholangiograms were routinely performed on all patients. Four patients (16%) had common bile duct stones. The average hospitalization was 3.8 days and patients returned to work or routine physical activity between 3 days and 2 weeks (average 8 days) after surgery. There were three wound infections and two cases of hyperamylasemia. One patient developed urinary retention and another had a CO2 embolus. There were no intra-abdominal abscesses and no mortality. Laparoscopic cholecystectomy in acute cholecystitis is technically difficult. The incidence of common bile duct stones is greater than in elective cases, and routine cholangiography is crucial. With sufficient experience and skill, laparoscopic cholecystectomy can be performed safely in patients with acute cholecystitis.

Laparoscopic choledochoscopy: an effective approach to the common duct.

With increasing acceptance of routine cholangiography during laparoscopic cholecystectomy (for confirmation of anatomy) there has been increased identification of common duct calculi. A technique of laparoscopic transcystic common duct stone extraction is described and early clinical results are presented. Successful stone extraction was accomplished in 39 out of 41 consecutive attempts by one surgical team. Two cases required choledochotomy. There were four complications including hyperamylasemia (2), minor wound infection (1), and incidental pneumothorax (1). Recommendations regarding safety and indications are presented. Initial evaluation suggests laparoscopic transcystic stone extraction is safe and effective.

Laparoscopic exploration of the common bile duct: experience in 16 selected patients.

The authors' initial experience with transcystic duct and direct laparoscopic approaches to the exploration of the common bile duct is reported. The technique requires standard laparoscopic equipment, specialized endoscopes, and instruments developed for urologic stone manipulations. After cholangiography confirmed the presence of common bile duct stones, common duct stone extraction was performed in 16 selected patients age 20-88 years. Stones ranged in size from 1 mm to 30 mm and they were unsuspected in 60% of the patients. Five patients had normal liver function tests and only 3 had clinical evidence of jaundice. Ductal exploration and stone extraction was successful in all 16 patients. One patient required a direct laparoscopic ductal exploration due to the presence of a common hepatic duct stone and the anatomy of the cystic duct. No major complications or deaths were observed in this series. Appropriately trained surgeons can safely and effectively perform laparoscopic common bile duct exploration and stone extraction in selected patients.

Biliary calculi fragmentation by a 308 nm excimer laser: a preliminary study.

The use of a 308-nm XeCl excimer laser for biliary stone fragmentation is reported. The 130-nsec laser pulses are delivered via UV grade fused silica fibers to the target stones immersed in normal saline solution and placed in direct contact with the fiber. Sixty biliary calculi, 20 cholesterol and 40 pigment, were fragmented in vitro. The energy delivered per unit mass of the stone is kept constant at 50 mJ/mg. The effect of laser repetition rate, energy fluence, and fiber core size on stone fragmentation was studied. Fragmentation thresholds for a variety of biliary calculi of known composition were measured. It was found that higher fragmentation efficiency was obtained with larger fluence, lower repetition rate, and fiber of larger core. Our study indicates that the 308-nm excimer laser may be effective as a laser lithotriptor with low threshold and good efficiency for biliary stone fragmentation.

Falloposcopic observations of endotubal isthmic plugs as a cause of reversible obstruction and their histological characterization.

Eighty falloposcopies were performed in fallopian tubes of women with suspected tubal disease. In three falloposcopies (4%), isthmic plugs were observed occluding the entire isthmic lumen. In all cases these plugs were mobilized by falloposcopic-directed, selected tubal cannulation and aquadissection techniques. Restoration of tubal patency, verified by concurrent chromopertubation under laparoscopic monitoring was achieved in all cases. On one occasion, the isthmic plug was mobilized and identified on the fimbria, and tubal patency was confirmed. When this plug was retrieved and examined histologically, it was found to consist of a cast of debris containing aggregates of histiocyticlike cells of endometrial stromal or mesothelial origin. The genesis of these plugs is unknown. In another subgroup, white to yellow mucus like fragments were observed within the intramural and isthmic lumen during a further 8 of 80 falloposcopies (10%). Whether these mucus like fragments are of physiological or pathophysiological significance remains to be determined. Objective demonstration that isthmic plugs can cause reversible proximal tubal obstruction (PTO) has been achieved using falloposcopy. Falloposcopy offers the diagnostician the ability to objectively classify the cause of PTO. A useful falloposcopic classification and scoring system of tubal lumen lesions has been utilized and is described.

Falloposcopic identification of a fimbrio-ovarian mucus connection as a possible mechanism for tubal oocyte capture.

Falloposcopy combined with laparoscopy was performed in 11 women during the late follicular phase of spontaneous menstrual cycles, and a preovular follicle was confirmed to be present in each case. The fimbrial end of the tube and the ipsilateral ovary containing the preovular follicle were suspended in a fluid environment of 200 ml of lactated Ringer's solution which acted as a support medium for visualization of tubal mucus and facilitated the endoscopy procedure. As the falloposcope was passed through the fimbrial opening, it was observed to carry clear, elastic and filamentous strands of mucus material from within the distal tubal lumen in 4 of 11 procedures. As these mucus strands were carried on the tip of the falloposcope to touch the surface of the ovary containing the preovular follicle, they attached, on contact, in all cases. The fimbrio-ovarian mucus bridge created was quite strong and could be stretched for up to 7 mm before it detached from the ovarian surface. The mucus attachment appeared to be equally secure over the preovular follicle and adjacent ovarian surfaces. These fimbrio-ovarian mucus connections, which have a high affinity for ovarian surface attachment about the time of ovulation, may play an important role in securing tubal oocyte capture in humans.

The importance of intraoperative cholangiography during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out of 58 selected patients. Cholangiography was performed in 53 patients. Six patients had common duct stones; five were unsuspected preoperatively. After the gallbladder was removed, three patients underwent open common duct exploration. In another five cases, anatomical anomalies were discovered. Cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication--common duct injury. Cholangiography should be attempted on all patients undergoing LC.

Falloposcopy: a microendoscopic technique for visual exploration of the human fallopian tube from the uterotubal ostium to the fimbria using a transvaginal approach.

A transvaginal microendoscopic technique has been developed for safely exploring the human fallopian tube from the utero tubal ostium to the fimbria and adjacent peritoneal cavity. Falloposcopy was performed without complication or evidence of endotubal damage in 44 women, 38 of whom also underwent a concurrent laparoscopy. Eight women with normal tubes served as controls and 36 women with tubal damage underwent falloposcopy in an attempt to document endotubal defects. Previous salpingectomy in 13 women and ostial obstruction in 4 cases left 71 tubes available for falloposcopy. Technical failures, defined as an inability to negotiate the tubal lumen in the absence of obstructive disease occurred in 8 of 71 (11%) procedures. In 63 successful procedures, the tubal lumen was considered to be falloposcopically normal in 28 cases (44%) and contained defects ranging from partial to total obstruction secondary to intraluminal fibrosis within the intramural, isthmic, and ampullary segments in the remaining 35 tubes (56%). Falloposcopy provides a nonincisional modality for defining the normal and abnormal surface anatomy of the tubal epithelium.

Falloposcopy. A microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboplasty.

Direct visualization of the entire length of the fallopian tube lumen, from the uterotubal ostium to the fimbria, using a transvaginal approach, has been achieved. Small, flexible hysteroscopes with outside diameters (ODs) ranging from 3.3 to 4.5 mm and operating channel diameters of 1.5 to 1.8 mm were used to pass guide wires, over-the-wire catheters and a falloposcope with an OD of 0.5 mm safely along the fallopian tube lumen. Forty-three falloscopy procedures were performed. The normal falloposcopic appearance of the fimbrial, ampullary, isthmic and intramural tubal epithelium was characterized in eight cases. In 35 falloposcopies, endotubal lesions were found and characterized. They included 5 cases of intramural stenosis; 10 of isthmic stenosis; 5 of isthmic obstruction; 2 of salpingitis isthmica nodosa; 10 of nonobstructive endotubal disease from intraluminal adhesions, associated devascularization and epithelial atrophy in the intramural, isthmic and ampullary segments; 2 of hydrosalpinx; and 1 of an intratubal polyp. A technique of guide wire cannulation and balloon tuboplasty under hysteroscopic-falloposcopic-laparoscopic control was developed for attempting to dilate a stenotic tube, open up an obstruction or break down intraluminal adhesions. A combination of 32 guide wire cannulation and direct balloon tuboplasty (DBT) procedures was performed. Guide wire cannulation and DBT were effective in breaking down non-obstructive intraluminal adhesions in 6/10 cases (60%), dilating intramural or isthmic stenoses in 6/15 cases (40%) and negotiating an isthmic stricture secondary to salpingitis isthmica nodosa in 1/2 cases (50%). Those procedures failed to bypass complete fibrotic obstructions in 5/5 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Removal of cornual polyps with flexible hysteroscopy and a wire basket. A case report.

The hysteroscopic removal of large uterine polyps often can assist infertile women in conceiving. This report describes the removal of bilateral cornual polyps in a diethylstilbestrol-deformed, T-shaped uterus using a flexible operating hysteroscope and an 0.8-mm ureteral wire stone basket.

Development and application of a falloposcope for transvaginal endoscopy of the fallopian tube.

A small flexible microendoscope with an outside diameter (OD) of 0.5 mm has been developed for effective visualization of the entire length of the human fallopian tube. Using a transvaginal approach, a small flexible operating hysteroscope with an OD ranging from 3.3 to 4.5 mm, was used to visualize the uterotubal ostium (UTO) for cannulation of the tube. A coaxial technique, incorporating guidewire cannulation, placement of an "over the wire" Teflon catheter, and replacement of the guidewire with a falloposcope, for video documentation of endotubal surface anatomy has been carried out without complication in 55 women who had a total of 84 tubes available for tubal endoscopy. Characterization of normal and abnormal epithelial changes has been documented for the intramural, isthmic, ampullary, and fimbrial tube. Technical difficulties related to failure to negotiate the entire tubal lumen in the absence of obstructive disease occurred in 9 (11%) of the 84 endoscopy cases. These technical difficulties have been partly overcome by the incorporation of smaller directional guidewires, softer distortion-free Teflon catheters, improved microendoscopes, and the acquisition of new surgical skills necessary for safe and successful endoscopy of the fallopian tube. Minor difficulties were experienced in 7 (8%) of 84 endoscopies due to ostial spasm secondary to attempted guidewire cannulation. Cannulation was successful once spasm ceased. Of the 75 (89%) remaining successful tubal endoscopies, documentation of endotubal lesions ranging from accumulated debris, nonobstructive intraluminal adhesions, stenosis, polyps, to total fibrotic obstruction were observed in 43 (57%) examinations. The majority (70%) of these lesions were confined to the medial third of the tube, between the UTO and ampullary isthmic junction (AIJ). The tubal lumen was considered to be endoscopically normal in 32 (42%) examinations. Techniques of tubal aquadissection (TA), guidewire cannulation (GC), wire guide dilitation, and direct balloon tubuloplasty (DBT) under hysteroscopic-falloposcopic-laparoscopic control were devised for attempting to break down intraluminal adhesions, dilate a stenosis, or open up an obstruction in 35 of the 43 tubes containing a lesion. Combinations of these tubuloplasty techniques were effective for dislodging debris, breaking down adhesions, or dilating stenoses in 16 (58%) of 29 cases and consistently ineffective for bypassing true fibrotic obstructions in 6 (100%) of 6 cases. A detailed description of the falloposcope, its accessory instrumentation, and technique of falloposcopy is outlined. Additionally, preliminary evaluation of falloposcopically directed tuboplasty techniques and their effects on tubal lesions are described. This transvaginal endoscopic technique has been termed falloposcopy and the microendoscopic instrument, a falloposcope.