**8. Training in laparosopic liver surgery**

An important consideration certainly in Europe is the recent introduction of the European Working Time Directive (EWTD) which has threatened surgical training by a reduction in working hours and doctor/patient contact. Surgical trainees are therefore not exposed to as many opportunities to learn new or advanced techniques in laparoscopic surgery. There is no doubt that laparoscopic training programs need to be developed to keep pace with the introduction of new techniques and to allow surgical trainees adequate exposure and applies to all surgical specialities.

A growth area in this field has been the introduction of various structured programs, virtual reality systems and laparoscopic simulators which have been reviewed in detail elsewhere. <sup>91</sup> 92. Alternative approaches to facilitate training has been the use of porcine or canine simulators 93 . Nevertheless these can be expensive to implement and can be problematic for licensing. An alternative approach which has not been widely reported is the use of a Cadaver Lab Training Facility 94.

The Newcastle Surgical Training Centre (NSTC) based at the Freeman Hospital opened in September 2007 **(Figure 9).** The laparoscopic training facility provides a specialist forum for the development of advanced laparoscopic skills and is part of the national drive to improve the delivery of near-patient technology. It is a unique, state of the art facility providing advanced cadaveric education which enables surgeons to gain cadaveric training in a unique and extremely high specification "wet lab" environment on fresh frozen cadavers. This centre is one of the very first anatomical examination units of its kind in the UK to carry a formal license from the Human Tissue Authority (HTA). The Human Tissue Act 2004

Laparoscopic Liver Surgery 105

With rapid progress in the field of electronics, computers and robotics, training of residents/junior surgeons through surgical simulation is slowly gaining popularity as it provides an opportunity for the trainee to develop the necessary skills for the clinical situation. Furthermore with advanced software technologies, visual fidelity , manual dexterity, hand eye co-ordination, real time response to emergency situations can now be assessed. The down side of the virtual reality simulators is their computing power and the initial set up costs. Oversimplification of complex reality isolates the trainee from the clinical situation. As far as the authors are aware there are no virtual reality simulators for LLR

Though basic psychomotor skills can be learnt on a surgical simulator or virtual reality simulator, learning to use high energy devices like diathermy or dissectors, tissue handling need a more realistic model like an animal or human cadaver. A synthetic model though attractive in terms of cost benefit falls short in recreating training outcomes. Rodents have been used extensively in both open and laparoscopic training models as they are well suited for laboratory based research activities, are expensive to buy, breed and house in a laboratory. Krahenbuhl et al. 95 have reported a safe technique of LLR in rats for liver physiology research. Canine models have also been advocated but their major drawback are anatomical constraints having multiple liver lobes but also stringent laws in the United Kingdom which prevent their routine use in the laboratory for training 96 97. Porcine models have been used extensively in Europe because of size and more favourable anatomy. Unfortunately their overall cost and safety regulations prohibit their use in the UK. Sheep

have also been used for LLR because they are anatomically similar to human 98.

The use of a cadaver in a dissection laboratory for imparting anatomical knowledge is well established 99. Cadaver training has also been used successfully in a workshop to train residents in internal medicine to perform bedside procedures like thoracocentesis, paracentesis, lumbar puncture and bone marrow biopsy 100. Fresh cadavers have also been

Using cadavers for learning laparoscopic procedures holds immense potential. Katz et al. 102 described a cadaver model to be superior to porcine models for urological laparoscopic training. Cadaver laparoscopic dissection has been used to enhance resident comprehension of pelvic anatomy 103. In the UK with the introduction of the Human Tissue Act 2004, it is possible to store and use cadavers for laparoscopic training. The advantages of using cadavers are perfect for reproducing anatomical landmarks, tissue consistency and flexibility, tactile feedback and tissue handling, use of gravity and retraction to make it more realistic and almost near perfect reproduction of critical steps. Furthermore, the use of proper instruments, patient positioning and an operation room setup helps the surgeon to

We have been conducting cadaver laparoscopic liver surgery courses for both practising and training surgeons at NSTC since 2007. We have shown that the overall rating of the course

[1] Jarnagin WR, Gonen M, Fong Y, Dematteo RP, Ben-Porat L, Little S et al. Improvement in

over the past decade. *Ann Surg* 2002; 236(4):397-406.

perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases

available for training.

used for vascular surgery training 101.

train in a more conducive atmosphere.

**9. References** 

by the trainees attending has been very good.

received Royal Assent in November 2004 and the act sets out standards and provides guidance to clinicians carrying out education and training in using human cadaveric materials.

Fig. 9. Laparoscopic cadaver training lab

A course has been designed by a faculty of experienced, advanced laparoscopic surgeons providing an intensive 2 day course of lectures, debate, exchange and practical hands on with a live link to clinical laparoscopic liver resection operations. All participants are given an opportunity to perform 8 key tasks in order to develop their laparoscopic liver surgery skills. These include the following;


Although safety, efficacy and reproducibility of LLS has been established, the same cannot be said of the training and accreditation of junior surgeons. The specialist surgical societies both at National and International levels are yet to establish guidelines for training and mentoring.

received Royal Assent in November 2004 and the act sets out standards and provides guidance to clinicians carrying out education and training in using human cadaveric

A course has been designed by a faculty of experienced, advanced laparoscopic surgeons providing an intensive 2 day course of lectures, debate, exchange and practical hands on with a live link to clinical laparoscopic liver resection operations. All participants are given an opportunity to perform 8 key tasks in order to develop their laparoscopic liver surgery

2. Tape placement around the hepatoduodenal ligament for a safe Pringle's manoeuvre 3. Dissection of hilar structures, portal vein, hepatic artery, and confluence of the hepatic

5. Left lateral sectionectomy with an ultrasonic aspirator and stapling of the left hepatic

7. Right hepatectomy with dissection of RHA, RPV, RHD and IVC dissection with

Although safety, efficacy and reproducibility of LLS has been established, the same cannot be said of the training and accreditation of junior surgeons. The specialist surgical societies both at National and International levels are yet to establish guidelines for training and

materials.

Fig. 9. Laparoscopic cadaver training lab

skills. These include the following;

ducts and common bile duct. 4. Left lateral liver mobilisation.

6. Right lobe mobilisation

stapling of the RHV.

vein.

mentoring.

1. Port Positioning for left lateral liver resection

8. Use of hand ports for facilitating right hepatectomy.

With rapid progress in the field of electronics, computers and robotics, training of residents/junior surgeons through surgical simulation is slowly gaining popularity as it provides an opportunity for the trainee to develop the necessary skills for the clinical situation. Furthermore with advanced software technologies, visual fidelity , manual dexterity, hand eye co-ordination, real time response to emergency situations can now be assessed. The down side of the virtual reality simulators is their computing power and the initial set up costs. Oversimplification of complex reality isolates the trainee from the clinical situation. As far as the authors are aware there are no virtual reality simulators for LLR available for training.

Though basic psychomotor skills can be learnt on a surgical simulator or virtual reality simulator, learning to use high energy devices like diathermy or dissectors, tissue handling need a more realistic model like an animal or human cadaver. A synthetic model though attractive in terms of cost benefit falls short in recreating training outcomes. Rodents have been used extensively in both open and laparoscopic training models as they are well suited for laboratory based research activities, are expensive to buy, breed and house in a laboratory. Krahenbuhl et al. 95 have reported a safe technique of LLR in rats for liver physiology research. Canine models have also been advocated but their major drawback are anatomical constraints having multiple liver lobes but also stringent laws in the United Kingdom which prevent their routine use in the laboratory for training 96 97. Porcine models have been used extensively in Europe because of size and more favourable anatomy. Unfortunately their overall cost and safety regulations prohibit their use in the UK. Sheep have also been used for LLR because they are anatomically similar to human 98.

The use of a cadaver in a dissection laboratory for imparting anatomical knowledge is well established 99. Cadaver training has also been used successfully in a workshop to train residents in internal medicine to perform bedside procedures like thoracocentesis, paracentesis, lumbar puncture and bone marrow biopsy 100. Fresh cadavers have also been used for vascular surgery training 101.

Using cadavers for learning laparoscopic procedures holds immense potential. Katz et al. 102 described a cadaver model to be superior to porcine models for urological laparoscopic training. Cadaver laparoscopic dissection has been used to enhance resident comprehension of pelvic anatomy 103. In the UK with the introduction of the Human Tissue Act 2004, it is possible to store and use cadavers for laparoscopic training. The advantages of using cadavers are perfect for reproducing anatomical landmarks, tissue consistency and flexibility, tactile feedback and tissue handling, use of gravity and retraction to make it more realistic and almost near perfect reproduction of critical steps. Furthermore, the use of proper instruments, patient positioning and an operation room setup helps the surgeon to train in a more conducive atmosphere.

We have been conducting cadaver laparoscopic liver surgery courses for both practising and training surgeons at NSTC since 2007. We have shown that the overall rating of the course by the trainees attending has been very good.
