Urology residents training in laparoscopic surgery. Development of a virtual reality model.

INTRODUCTION: The training and learning of residents in laparoscopic surgery has legal, financial and technological limitations. Simulation is an essential tool in the training of residents as a supplement to their training in laparoscopic surgery. The training should be structured in an appropriate environment, with previously established and clear objectives, taught by professionals with clinical and teaching experience in simulation. The training should be conducted with realistic models using animals and ex-vivo tissue from animals. It is essential to incorporate mechanisms to assess the objectives during the residents' training progress. OBJECTIVE: We present the training model for laparoscopic surgery for urology residents at the University Hospital Valdecilla. The training is conducted at the Virtual Hospital Valdecilla, which is associated with the Center for Medical Simulation in Boston and is accredited by the American College of Surgeons. MATERIAL AND METHOD: The model is designed in 3 blocks, basic for R1, intermediate for R2-3 and advanced for R4-5, with 9 training modules. The training is conducted in 4-hour sessions for 4 afternoons, for 3 weeks per year of residence. Residents therefore perform 240 hours of simulated laparoscopic training by the end of the course. For each module, we use structured objective assessments to measure each resident's training progress. RESULTS: Since 2003, 9 urology residents have been trained, in addition to the 5 who are currently in training. The model has undergone changes according to the needs expressed in the student feedback. The acquisition of skills in a virtual reality model has enabled the safe transfer of those skills to actual practice. CONCLUSIONS: A laparoscopic surgery training program designed in structured blocks and with progressive complexity provides appropriate training for transferring the skills acquired using this model to an actual scenario while maintaining patient safety.

[Congenital cysts of the choledochus]. / Quistes congénitos del colédoco.

We describe six cases of congenital choledochal cyst of the Toddani type I. All were female, with a mean age of 33.5 years (16-52). The onset of symptoms ranged 8-192 months (mean 92.8), with an unexpected finding. Ultrasound scan was performed in five patients, with two accurate diagnoses, one suspicious and two wrong results. In two cases a C.T. was performed and the diagnosis was confirmed in both. A cholelithiasis was associated in four cases. Four patients (66.4%) were treated by cyst excision, Roux-en-Y hepaticojejunostomy and cholecystectomy, three of them as a primary procedure, and one more after failure of some derivative operations. All evolved well but one, requiring sphincterotomy and Wirsungtomy. Two patients (33.6%) were treated by cholecystectomy only, with a favourable evolution. Nevertheless, we emphasize the good results achieved with cyst excision and we recommend it as the procedure of choice.

[Gastric necrosis secondary to acute gastric dilatation in children]. / Necrosis gástrica secundaria a dilatación aguda gástrica en el niño

We present a new case of acute dilatation gastric with fundus, in a three years old girl with Beckwith Syndrome and infection respiratory disease. The diagnosis and treatment were done early we performed a Friederich of necrosis wall and simple suture. The evolution postoperative was satisfactory.

[Cancer of the gallbladder]. / Cáncer de vesícula biliar.

We present 118 cases of cancer of the gallbladder out of 4,165 operations for gallbladder disease (6.2%) compiled over a period of 18 years at the Hospital Nacional "Valdecilla". Females were predominant, 82.2%, and the mean age was 73.2 years. The most relevant clinical finding was pain in the right upper quadrant in 73.7%, and a mass at this level in 43.2%. The diagnosis was correct in 36 cases (30.5%). All patients were treated surgically; the resectability rate was 58.5% and potentially curative cholecystectomy was performed in 15.2%. The tumor was adenocarcinoma in 91.5%, one stage I of Nein, 5 stage II, 12 stage III, 33 stage IV and 67 stage V. The 5-year survival was 100% for stage I-II and 41.6% for III; stages IV-V did not survive more than a year.