Laparoscopic surgery in gynecology : studies about
implementaion and training
Kolkman, W.
Citation
Kolkman, W. (2006, November 14). Laparoscopic surgery in gynecology :
studies about implementaion and training. Retrieved from
https://hdl.handle.net/1887/4980
Version: Corrected Publisher’s Version
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Introduction
Introduction | Chapter 1
11
Introduction
In the early 90’s of the past century laparoscopic surgery was presented as a new medical technology. Nowadays, it has evolved into a major surgical approach used to treat a variety of gynecological indications. The best example is the laparo-scopic resection of an ectopic pregnancy, being the ‘gold standard’ for its surgical approach. [Clasen 1997]
However, the actual implementation of laparoscopy into daily gynecological practice and residency training has not been effortless. [SAGES 1998, Navez 1999, Brölmann 2001, Nussbaum 2002, Loh 2002, Cuschieri 2005] The initial adoption of the laparoscopic cholecystectomy in general surgery progressed rapidly and has led to a relatively alarming number of significant complications of this procedure due to not adequately trained and skilled surgeons. [Forde 1993]
Furthermore, the emergence of minimal invasive surgery created two worlds: the ‘open’ surgeons and the ‘laparoscopists’. Many ‘open’ surgeons were and still are ‘suspicious’ of minimal invasive surgery and feel laparoscopy is merely a technical ‘trick’ used by a select and dedicated group to expand their playground. With the technical development of instruments and the mounting evidence of the beneficial aspects of the laparoscopic approach for many gynecological indications, bridges should be built between the two worlds of ‘open’ and minimal invasive surgery in the advantage of the patient.
The diffusion and acceptance of laparoscopy is a worldwide matter of concern, especially the implementation of gynecological laparoscopy in The Netherlands, since only 28% of ectopic pregnancies were removed laparoscopically in 1998, compared to 88% in other countries. [Clasen 1997, Brölmann 2001] In addition, only 0.8% of all hysterectomies were performed laparoscopically in 1998, [Brölmann 2001] compared to 3% to 24% in other countries. [Garry 2005] From these data we have to conclude that the implementation of gynecological laparoscopy in The Neth-erlands seems to be slower compared to other countries.
imple-Laparoscopic surgery in gynecology
12
mentation of the technology into daily practice. MTA-studies have shown that there are many factors impeding and stimulating the implementation of a medical innova-tion. [Vondeling 1993]
It is well established that laparoscopy is technically more challenging than laparotomy and poses specific demands on the surgeon. Therefore, specific skills training is required since transfer of skills, building on surgical dexterity already learned during open surgical procedures, is shown not to be sufficient. [Figert 2001, Lehmann 2005] As a result the question raised how to acquire these specific skills without compromising patient care and it is suggested to train outside the operating room on a simulator, [Aggarwal 2004] which is a device that recreates conditions as a substitute for real life circumstances.
It is well known that simulation has been a basic principle for aviators for the past 40 years. Over the decades, the simulation has become so realistic that pilots now spend their initial hours of “flying” in the simulator, making perfect takeoffs and landings before they ever set foot in an airplane. The benefit and savings in time, cost, equipment, and safety are enormous. [Satava 1993, Wentink 2003]
In surgery, the first surgical simulators were described in the early 90’s of last decade. [Sackier 1991, Noar 1991, Satava 1993]Sackier et al. were the first to describe 6 inanimate tasks on a black training box. They tested the box trainer on surgical
Figure 1 | A scheme for development and diffusion of medical technologies.
Reference with permission: Office of Technology Assessment. Development of Medical Technology: Opportunities for Assessment Washington, DC: US Government Printing Office, August 1976.
Introduction | Chapter 1
13 residents who attended a training workshop and found it to be an inexpensive and easy method of objective evaluation.[Sackier 1991] Furthermore, Noar [Noar 1991] and Satava [Satava 1993] made the first steps in developing a virtual reality (VR) device for surgical simulation. However, the computer-generated graphics of these devices detracted from believability due to the cartoon level of the graphic representation. [Satava 1993] Since then, laparoscopic simulators have developed enormously and nowadays they play an increasingly important role in trainingand objective assessment of laparoscopic skills. [Aggarwal 2004] More importantly, simulator training has shown to be effective in providing skills that are transferable to the operating room. [Aggarwal 2004]
Issues such as quality control, patient safety, which have gained the attention of the public as well as health authorities, [Raad voor de Volksgezondheid en Zorg] combined with increasing financial constraints which necessitates more efficiency and cost-effectiveness in the operating room, resulted in the need for skills training outside the operating room. [Munz 2004, Fried 2004]
Besides simulator training and skills assessment, the aviation industry has also taken the lead in safety aspects of aircraft operations, known as Crew Resource Management (CRM). [Helmreich 2000] CRM encompasses a wide range of knowledge, skills and attitudes including communications, situational awareness, problem solving, decision making, and teamwork. CRM can therefore be defined as a management system which makes optimum use of all available resources - equipment, procedures and people - to promote safety and enhance efficiency. Aviation and performing laparoscopic surgery show similarities since they both require specific training and need teamwork to be completed successfully. Since patient safety in laparoscopic surgery has increasingly become a point of attention, the Institute of Medicine as well as Healthcare Research and Quality suggest patient safety can be improved by introducing CRM into health care. [van Meurs 1997] The implementation of laparoscopic simulator training and assessment in our profes-sion is merely a start.
