Research ArticleABSTRACT
Objective: Iatrogenic injury to major vessels is a rare but potentially life-threatening
complication during laparoscopic hepato-pancreato-biliary surgery. This experimental
study aimed to assess the usefulness of an in-vivo animal model for the management of
such injuries.
Methods: During three editions of advanced live animal laparoscopy courses
12 participants were exposed to 19 intraoperative iatrogenic vessel injuries. The
participants were free to control the bleeding using maneuvers of their choice. The
participants’ heart rate was measured, and their movements were video recorded. The
study was evaluated by all participants using a Visual Analogue Scale at the end of the
course.
Results: Temporary vessel control was obtained in all cases. One animal died due
to relapse of bleeding. Heart rate (HR) of participants ranged from 52 to 97 per minute
before the task and from 75 to 120 per minute during the task. Eleven participants gave
this exercise a 5/5 score and one gave it a score of 3/5. The HR was higher in experienced
surgeons vs. inexperienced residents although this difference did not reach statistical
significance.
Conclusion: In-vivo pig and sheep model can be used for training in major bleeding
control during HPB surgery. It is highly appreciated by trainees. It seems that stress level
during advanced exercises is higher in experienced surgeons than in beginners.
Keywords: Animal Model; Laparoscopic Simulation; Major Vessel Damage; Laparoscopic Training
Introduction
Iatrogenic injury to major vessels with the ensuing bleeding is a rare but potentially life-threatening complication during laparoscopic major HPB surgery. The most commonly injured vessels are aorta, the iliac vessels, and the inferior vena cava [1]. Contrary to traditional approach suggesting immediate conversion to open surgery it is suggested nowadays that this kind of injury and bleeding should be approached laparoscopically [2]. An obvious requirement for such an approach is an appropriate training [3]. Advanced laparoscopy training currently includes box-trainers [4], virtual reality training [5], live animal training [6] and training that combines all of the above [7]. Unfortunately, the majority of training modalities in laparoscopy concentrate on purely technical knowledge not considering psychological burden of a major intraoperative disaster. While obtaining and maintaining technical skills is clearly important [8] the possibility of testing these skills in a stressful environment imitating operating room disaster could be the way to prepare surgeons to adequately react to the unexpected [9]. In this study we have tried to create an environment as similar to real life laparoscopic disaster as possible and observe trainees’ reactions and their ability to use technical skills to control the situation.
Materials and Methods
During three editions of advanced laparoscopic training course 12 participants faced a task of controlling a major vessel damage. Training course was designed for both experienced surgeons and novices in advanced laparoscopy. Each course lasted for two days. At the beginning of the first day the tutors explained the methods of laparoscopy bleeding control with a video footage. Each day of the course there were 7 hours of live animal laparoscopy training. The first part of the training was designed to achieve technical abilities in various steps of advanced laparoscopy procedures depending on the level of experience of each participant. In the second part of the training during the last 60 minutes of each day the participants were exposed to iatrogenic injury of a major vessel performed with an electrocautery on an area of approximately 1cm and were asked to control the bleeding and repair the damage. During these maneuvers their Heart Rate (HR) was monitored, and their reactions were video recorded. After successfully completing the task and if time permitted the same animal was used for another iatrogenic injury with another participant operating. Animals used for training were pigs and sheep. During the whole procedure the animals were taken care of by an experienced veterinary anesthesiologist. At the end of each course participants were asked to evaluate their experience in controlling the bleeding in a stressful environment using Visual Analogue Scale from 1 (very bad experience with no value for training) to 5 (the best type of training one can imagine).
Results
Altogether there were 19 episodes of iatrogenic injury in 10 animals controlled by 12 participants. One animal died after exsufflation due to relapse of bleeding after non-complete hemostasis. There were no conversions to open procedure. Temporary vessel control was obtained with a grasper, gauze, intraabdominal pressure elevation or temporary clip application. For final hemostatic purposes participants used Vicryl 2.0 or PDS II 3.0 suture. Heart rate of participants before the injury, during the repair and after obtaining a haemostasis is shown in Table 1. HR ranged from 52 to 97 per minute before the task and from 75 to 120 during the repair of injury. There was a tendency towards higher HR values before and during the task in experienced surgeons than in novices although this difference did not reach statistical significance. When evaluating this approach to training in disaster control eleven participants gave the exercise 5 points on a VAS scale and one participant gave it 3 points resulting in a total of 4.8 points for the whole group.
Table 1: Changes in participants’ heart rate before, during and after the vessel injury.
Discussion
With growing number of advanced laparoscopic HPB surgery
worldwide there is a clear need for a structured laparoscopy
training [3]. In order to prepare surgeons for these demanding
procedures a variety of simulation models have been proposed so
far. Advanced laparoscopy techniques can be taught in a simple boxtrainer.
The box trainer however, apart from giving the opportunity
to learn purely technical skills is much less effective in preparing
for conditions in real life surgery [4]. A Virtual Reality (VR) training
offers interesting approach to teaching without the need for the
use of animal tissue and creating close to real life conditions.
Unfortunately, at its current level of performance, it does not meet
expectations. No additional benefit is observed from VR training
in a multimodality laparoscopy training program [5]. A very
interesting model with perfused pig liver can simulate almost lifelike
conditions [7]. It is one of the few training modalities to offer
trainees a highly simulated bleeding in order to acquire advanced
laparoscopic suture skills and train under the pressure of bleeding
[10]. The setting of such a training modality seems however too
complex to be widely used for teaching laparoscopy. Also, contrary
to the model described herein it does not offer the trainee the
possibility to observe the effect of bleeding on a general status of
the patients, concentrating only on the bleeding itself. In this sense,
it seems closer to a box-trainer concentrating merely on a technical
control of bleeding without the stress of observing worsening vital
signs that clearly simulates real-life disaster.
The closest to life experience can probably be achieved in live
animal models [11]. It has been successfully used in creating a model
for the intravascular treatment of IVC injury. In live anesthetized
pigs after iatrogenic IVC injury a bleeding was controlled
successfully by trainees using balloon insertion via femoral vein
[12]. Live animal laparoscopy training using pigs has been shown
to be useful in acquiring advanced liver laparoscopy skills [6].
While the benefits of this model over other approaches in teaching
purely technical skills can be discussed it offers unique opportunity
to create a simulation for a life-threatening intraoperative event.
There are much less reports on the use of sheep as a model for
advanced surgical training [12]. It is however known to be an
interesting model for advanced colon resections [13]. During our
study we have observed a higher level of stress measured as a rise
in HR in more experienced trainees. While it was a bit surprising
it can be explained by the fact that more senior surgeons are well
aware of the potentially fatal complications of a major vessel injury
during laparoscopy. Almost all participants including experienced
and inexperienced surgeons agreed that this training modality was
close to perfect in creating a stressful environment simulating reallife
disastrous intraoperative event.
Conclusion
In-vivo pig and sheep models can be used for training in the management of major bleeding during HPB surgery. It is a modality that is highly appreciated by trainees. It seems that stress level during advanced exercises is higher in experienced surgeons than in newcomers.
Funding Statement
None.
Conflicts of Interest
All authors have no conflicts of interest to declare.
Ethical Statement
The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Experiments were performed under a project license Reference code: 001/20/Cert granted by “The Ethics Committee in Animal Experimentation of the “Jesús Usón” Minimally Invasive Surgery Center”, in compliance with compliance with existing laws for the use of experimental animals (Royal Decree 53/2013, of February 1st)” for the care and use of animals.
References
- Sandadi S, Johannigman JA, Wong VL, Blebea J, Hurd WW, et al. (2010) Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol 17(6): 692-702.
- Abu Hilal M, Aldrighetti L, Dagher I, Bjorn Edwin, Roberto Ivan Troisi, et al. (2018) The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation. Ann Surg 268(1): 11-18.
- Cai X (2018) Laparoscopic liver resection: the current status and the future. Hepatobiliary Surg Nutr 7(2): 98-104.
- Nepomnayshy D, Whitledge J, Fitzgibbons S, Biba Nijjar, Aimee Gardner, et al. (2019) Advanced laparoscopic skills: Understanding the relationship between simulation-based practice and clinical performance. Am J Surg 218(3): 527-532.
- Nickel F, Bintintan VV, Gehrig T, Hannes G Kenngott, Lars Fischer, et al. (2013) Virtual reality does not meet expectations in a pilot study on multimodal laparoscopic surgery training. World J Surg 37(5): 965-973.
- Komorowski AL, Mituś JW, Sanchez Hurtado MA, Sanchez Margallo FM (2015) Porcine Model In The Laparoscopic Liver Surgery Training. Pol Przegl Chir 87(8): 425-428.
- Liu W, Zheng X, Wu R, Yinbin Jin, Shu Kong, et al. (2018) Novel laparoscopic training system with continuously perfused ex-vivo porcine liver for hepatobiliary surgery. Surg Endosc 32(2): 743-750.
- Krenzien F, Schöning W, Brunnbauer P, Christian Benzing, Robert Öllinger, et al. (2020) The ILLS Laparoscopic Liver Surgery Fellow Skills Curriculum. Ann Surg 272(5): 786-792.
- Shipper ES, Miller SE, Hasty BN, Merrell SB, Lin DT (2017) Evaluation of a technical and nontechnical skills curriculum for students entering surgery. J Surg Res 219: 92-97.
- Xiao J, Cui Z, Fu M, Xiangxue Kong, Lei Tang, et al. (2016) An ex vivo liver training model continuously perfused to simulate bleeding for suture skills involved in laparoscopic liver resection: development and validity. Surg Endosc 30(10): 4553-4561.
- Iwashita Y, Uchida H, Takayama H, Michihiro Ichimanda, Katsuya Taniguchi, et al. (2018) Control of inferior vena cava injury during laparoscopic surgery using a double balloon-equipped central venous catheter: proof of concept in a live porcine model. Surg Endosc 32(5): 2397-2401.
- Gan P (2014) A novel liver retractor for reduced or single-port laparoscopic surgery. Surg Endosc 28(1): 331-335.
- Alba Mesa F, Amaya Cortijo A, Romero Fernandez JM, Komorowski AL, Sanchez Hurtado MA, et al. (2012) Totally transvaginal resection of the descending colon in an experimental model. Surg Endosc 26(3): 877-881.
