Help with laparoscopic surgery...

[surfsurg]

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Did anyone have problems initially working on the opposite side of the camera during laparoscopic surgery (the mirror image effect)? how did you overcome this by practicing outside the OR? we don't have lap simulators at our program just the FLS box which doesnt use the laparoscope. also learning in the OR is not an option......please help....

 

[SLUser11]

Did anyone have problems initially working on the opposite side of the camera during laparoscopic surgery (the mirror image effect)? how did you overcome this by practicing outside the OR? we don't have lap simulators at our program just the FLS box which doesnt use the laparoscope. also learning in the OR is not an option......please help....

Operating backwards is tough even for experienced laparoscopic surgeons. It's best to try and position your body and position the screens in a way that allows you to work forward.

When that can't be done, my honest answer is that you just get better at it with time. When you get lost, take your eyes off the screen, and look down at the patient. That will allow you to re-orient.

Also, you absolutely can practice in the OR...just do it with less complicated tasks, such as passing suture with the fascial closure device.

When I am working truly backward, i.e. reaching across the table to re-position an assistant or help explain a move, I imagine a screen on the patient's body that follows my hands....I've drawn a picture to help explain, but I apologize if it just increases confusion instead.

 

[LucidSplash]

Agreed with the esteemed SLUser11. I still find driving the 30-degree scope difficult at times. Specifically we have one attending who is very... demanding... in the OR and I have never seen them pleased with ANYONE's camera skills. Add to this the fact that many of this person's cases position the camera driver in awkward positions on the same side of the table (trying to drive and avoid the attending's elbow at the same time) or across from the attending but trying to avoid the hand inside the abdomen (lap hand-assist cases) and its all I can do sometimes not to just walk out. But I HAVE gotten better with time and if I'm honest about it this attending's frequent criticism probably improved my skills for other more routine camera driving.

I'm not sure why you feel that "learning in the OR" is not an option but sometimes in residency you just have to take the (sometimes unfair) criticism, do your best at that time, and leave it behind you in the OR when you walk out the door.

 

[Elach]

Talking about laparoscopy, I have one question for you guys.

Maybe is kinda of a dumb one. I've only been in french technique cholelap procedures during med school, but do you guys get trained in using both french and american laparoscopic technique, or just american? Or maybe is program dependant? Or maybe you just choose whatever you like?

 

[ESU_MD]

Operating backwards is tough even for experienced laparoscopic surgeons. It's best to try and position your body and position the screens in a way that allows you to work forward.

Working backwards is difficult for everyone.
I think the really slick lap surgeons I've seen almost never work in backwards configuration, they setup everything so its always foreward.

the equivalent in cardiovascular is to set up everything as a forehand shot.

chances are if you are looking at things backwards, upside down or placing backhand sutures, you are doing it the wrong way. surgery shouldnt be hard.

 

[GreatSaphenous]

I would say that the only procedure that routinely requires working backwards is the lap ventral hernia. Otherwise, I agree that setting yourself up for success is key.

My advice to anyone wishing to improve their ability to reverse their left-right laparoscopic movements is to scrub some shoulder arthroscopy. By its nature, the ports are placed on opposite sides.

As for French laparoscopic techniques, Qu'est-ce que c'est?

all for now, go back to your Mirepoix.
I am the Great Saphenous!!!!

 

[tussy]

How is "french laparoscopy' any different than "english laparoscopy" (or for that matter, german, italian or even swahili laparoscopy.

 

[45408]

Agree with SLUser. When I can't figure out which way is which, I just look down at the patient and think about where the other instruments are pointing.

I've been a skilled video gamer for most of my life, and my spatial skills on-screen are pretty good (flying video games often use inverted controls), but operating backwards is hard.

 

[dpmd]

We just got a new attending who is quite skilled laparoscopically. The rare times he has had to work backwards he ends up looking as awkward as I do (ok, maybe not as bad). He just doesn't get all worked up about it like I do.

I have seen a few ways to do lap ventrals. The one that involves a lot of working backward may make the tacking easier, but it sucks ass if there are a lot of adhesions to take down.

 

[SLUser11]

How is "french laparoscopy' any different than "english laparoscopy" (or for that matter, german, italian or even swahili laparoscopy.

Je ne sais pas.

Maybe french laparoscopy uses cologne instead of CO2.....

 

[surfsurg]

thanks.

 

[ESU_MD]

Je ne sais pas.

Maybe french laparoscopy uses cologne instead of CO2.....

I think the French use cigarette smoke to insufflate, or they just give up and convert to open.

 

[Elach]

Wasn't laparoscopic surgery developed in Europe?

Anyway, the difference between french technique and american technique would be the position of the surgeon/trocars in relation to the patient. In french technique the surgeon would go between the patient's legs (kinda like in lithotomy position) instead of the patient's left side.

It also uses a different approach exposing the cystic pedicle.

Always heard is supposed to be a safer technique and have lower complication rate.

Well, I guess that answers my original question.

 

[SLUser11]

In french technique the surgeon would go between the patient's legs...

Figures....

 

[bucks2010]

Figures....

had to look that one up for myself.

Googled "France laparascope" ...

http://www.sciencephoto.com/media/276842/enlarge

 

[toxic-megacolon]

For most,the hardest part of "working backwards" is when the camera and the instruments are pointing at each other (as opposed to in the same direction like in your picture...)

When I am working truly backward, i.e. reaching across the table to re-position an assistant or help explain a move, I imagine a screen on the patient's body that follows my hands....I've drawn a picture to help explain, but I apologize if it just increases confusion instead.

 

[Buzz Me]

I've been a skilled video gamer for most of my life, and my spatial skills on-screen are pretty good (flying video games often use inverted controls), but operating backwards is hard.

Unfortunately being particularly dextrous doesn't always translate to good advanced laparoscopic skills. I consider myself having a fairly good pair of hands (piano since age 6, video games, can draw decently with both hands, type with either hand by itself, etc.) but backwards laparoscopy is hard. I basically look at the video screen but think more about what I want the instruments to do, rather than focus on the screen (e.g. think "I want to pull the bowel towards the pelvis" rather than "I need to move to screen right...or is that left?").

 

[lapdoc]

Just submitted a study looking at novices randomized to box drills working forwards, backwards, and doing warm-up style drills with a reversed camera view. Practicing in the box definitely helps, even after just six repetitions. There are prior studies showing residents are about six times slower with a reversed camera view compared to a foward camera view.