**5. Simulation in Hepatopancreaticobiliary (HPB) surgery**

#### **5.1 Liver surgery**

Laparoscopic liver surgery necessitates a high level of hepatobiliary and minimally invasive surgery training and experience. Laparoscopic liver resection (LLR) is increasingly indicated for minor hepatectomies and major hepatectomies in specialist units [39]. The main methods of simulation used in training in liver surgery are animal and cadaver models (**Table 5**).

White et al. created a 2-day intensive course that included basic skills, laparoscopic left lateral sectionectomy, and laparoscopic right hepatectomy on cadavers [40]. Thirty-two people took part in the study and only their input was considered, with


*Perspective Chapter: Simulation in Complex Laparoscopic Digestive Surgery DOI: http://dx.doi.org/10.5772/intechopen.108224*

> **Table 5.** *Methods of simulation in hepatopancreaticobiliary (HPB) surgery.*

the overall assessment for training sessions being excellent in 43% of cases, good in 32%, and fair in 25% of situations. Rashidian et al. [38], assessed participant feedback after a laparoscopic liver surgery course on THCs. Participants found training on Thiel cadavers was superior (49%) to other training modalities, including proctoring in the operating room (35%), virtual reality (6%), video training (5%), and practicing on pigs (5%).

ProMIS augmented reality surgical simulator (Haptica, Dublin, Ireland) and an *ex vivo* ovine liver is another model for learning the technical skills required for LLR [18] and could also be used to assess and measure surgical performance. The model was put to the test by twenty candidates with varying levels of laparoscopic surgery experience. Candidates had to identify a liver tumor via ultrasound, mark and transect the *ex vivo* liver, and place two laparoscopic stitches with intracorporeal knots to control bleeding from the liver. The performance data was recorded by the simulator, which included instrument path lengths and time. For time and path length, all four tests indicated construct validity (confirms that based on performance score, the simulator can discriminate between skilled and novice surgeons) [46].

Several groups have attempted to find a meaningful animal model with educational value in LLR. Komorowski et al. [41] showed that an anesthetized pig provided a realistic learning environment in which exposure of the liver, Pringle maneuver mobilization, and management of surgical injuries could be taught. Teh et al. [42] carried out surgical dissection and contrast studies to show the inflow and outflow structures of the sheep liver were similar to human liver anatomy. This information can be used to simulate an accurate laparoscopic left hepatic resection in anesthetized sheep. An *ex vivo* ovine liver model with portal veins perfused with a red-dyed liquid gelatin solution was used to simulate bleeding [43]. Construct validity was evaluated in 33 participants (from novices to experts) who were instructed to execute one superficial and one deep suture for hemostasis. The educational value was compared to that of a typical box trainer, and the results were determined to be superior.

#### **5.2 Pancreas surgery**

Laparoscopic pancreatic surgery has evolved over the last three decades and is now utilized more frequently in the management of tumors and other conditions. There are no peer-reviewed publications on simulation specifically to perform laparoscopic distal pancreatectomy and laparoscopic pancreaticoduodenectomy. However, there are publications on simulation in robotic-assisted pancreatic surgery although robotic-assisted surgery is not the focus of this chapter [47].

Training programs have been developed to facilitate training in minimally invasive pancreatic surgery [48, 49]. Biotissue exercises are a useful model to hone reconstructive abilities for a specific treatment. The pancreaticojejunostomy (PJ), hepaticojejunostomy (HJ), and gastro-/duodenojejunostomy (GJ) are all examples of procedures that can be carried out on biotissue models. Biotissue drills are especially important for the PJ and HJ since porcine models often have a different pancreas shape and a smaller pancreatic duct. Training on human cadavers is problematic owing to fast tissue deterioration and autophagy of the pancreatic tissue [50].

#### **5.3 Biliary surgery**

There are limited simulators to assist with complex bile duct surgery. Simulation for laparoscopic cholecystectomy will not be discussed in this chapter as it is not

*Perspective Chapter: Simulation in Complex Laparoscopic Digestive Surgery DOI: http://dx.doi.org/10.5772/intechopen.108224*

defined as a complex laparoscopic surgery (see **Table 1**). Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. LCBDE requires specific technical skills. A simulator for LCBDE was developed and evaluated using latex tubing for cystic and common bile ducts and a plastic bead to represent the gallstone [44]. A procedure algorithm was developed for key steps of the operation. Sixteen novices and five experienced surgeons trialed the model. Novices scored less on the technical skills in both transcystic and transcholedochal exploration. The LCBDE simulator is a low-cost, realistic physical model that enables the performance and evaluation of technical skills needed for LCBDE.

Three-dimensional (3D) printing has been used to simulate surgery for choledochal cysts. Hepatic anatomy images were used to 3D print a model of a liver. This mold was then used to create a silicone model of the liver and combined with a surgical glove finger to simulate dilated bile duct and an electrical wire-insulating tube to represent the common bile duct and pancreatic duct [45]. This model was placed in a laparoscopic trainer. Ten senior pediatric surgical trainees trialed the model and felt the tactile likeness was good and the model was useful. This model highlights the potential use of 3D printing to simulate a rare and complex operation.
