Advances in Training for Laparoscopic and Robotic Surgery Henk Schreuder Advances in Training for Laparoscopic and Robotic Surgery Vooruitgang in training van laparoscopische en robot geassisteerde chirurgie (met een samenvatting in het Nederlands) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit van Utrecht op gezag van de rector magnificus, prof. dr. G.J. van der Zwaan ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op woensdag 2 november 2011 des middags om 12.45 uur Advances in Training for Laparoscopic and Robotic Surgery Author: Henk W.R. Schreuder Cover design: Gordon Nealy, Mimic Technologies, Seattle and Gerrit Cats Lay-out: Barbara Hagoort, Multimedia, UMC Utrecht, Netherlands Printed by: Ipskamp Drukkers, Enschede, The Netherlands ISBN/EAN: 978-94-6191-010-3 © Copyright 2011 H.W.R.Schreuder No part of this thesis may be reproduced, stored in a retrieval system of any nature, or transmitted in any form or by any means, without written permission of the author door Publication of this thesis was supported by 3-Dmed®, Bayer Schering Nederland, BMA BV (Mosos), Covidien Nederland BV, Division of Woman & Baby (UMC Utrecht), Dutch Society for Simulation in Healthcare (DSSH), Ferring B.V., Hendrik Willem Rudolf Schreuder GlaxoSmithKline, Ipsen Farmaceutica B.V., Johnson & Johnson Medical BV, Krijnen Medical geboren 19 oktober 1966 te Haarlem Innovations B.V., Medical Dynamics, Memidis Pharma b.v., Merck Sharp & Dohme BV, Mimic Technologies Inc., Nederlandse Vereniging voor Endoscopische Chirurgie (NVEC), Nycomed bv, Olympus Nederland B.V., Raadgevers Kuijkhoven, Sigma Medical, Simendo BV, Skills Meducation, Stöpler Instrumenten en Apparaten, Surgical Science Sweden AB, Toshiba Medical Systems Nederland, Van Beek Medical bv., Welmed B.V., ZekVinos Promotor: Prof. dr. R.H.M. Verheijen Co-promotoren: Dr. M.P. Schijven Dr. R.P. Zweemer Voor Anna Content Chapter 1 Introduction 8 Part II Robotic Surgery 126 History of laparoscopic surgery and simulation in laparoscopy Learning surgical skills Chapter 8 Robotic Surgery 128 Aim and outline of this thesis BJOG 2009;116:198-213. Part I Laparoscopy 26 Chapter 9 From open radical hysterectomy to robot assisted laparoscopic 160 radical hysterectomy for early stage cervical cancer: aspects of a Chapter 2 Implementation of simulation in surgical practice: 28 single institution learning curve Minimally invasive surgery has taken the lead: Gynecol Surg 2010;7:253-258. The Dutch experience Med Teach 2011;33:105-115. Chapter 10 Validation of a novel virtual reality simulator for robotic surgery 172 Submitted for publication Chapter 3 Laparoscopic skills training using inexpensive box trainers: Which 48 exercises to use when constructing a validated training course Chapter 11 Training and learning robotic surgery: time for a more structured 192 BJOG, in press approach: a systematic review BJOG, in press Chapter 4 An ‘Intermediate Curriculum’ for Advanced Laparoscopic Skills 68 Training using Virtual Reality Simulation Chapter 12 Discussion, conclusions and future perspectives 220 J Minim Invasive Gynecol 2011 Jul 23. [Epub ahead of print]. Chapter 13 Summary in English 234 Chapter 5 Face and construct validity of virtual reality simulation of 86 Samenvatting in het Nederlands 244 laparoscopic gynecologic surgery Am J Obstet Gynecol 2009;200:e1-e8. Chapter 14 Appendices 252 Manual skills training 254 Chapter 6 Grading surgical skills curricula and training facilities for minimally 100 Notes on co-authors 264 invasive surgery Thesis review committee 269 Submitted for publication Acknowledgements - Dankwoord 272 Chapter 7 Increasing experience in laparoscopic staging of early ovarian 112 List of publications 280 cancer Curriculum Vitae 284 Gynecol Surg 2011 Jul 14. [Epub ahead of print]. Grants 288 Introduction and outline of this thesis The word laparoscopy is derived from the Greek words lapara, meaning “the soft part of the body between ribs and hip, flank, loin,” and skopein, which means “to look at or survey” 1 Introduction Chapter 1 History In the following years laparoscopy became an accepted diagnostic procedure and gynecologists became the users and advocates of this new technique. After the introduc- History of laparoscopy tion of the dual puncture technique by Kalk, it became possible to perform therapeutic By the end of the 19th century, endoscopes had been well established for evaluating the interventions in the abdominal cavity.14 In the early 1930s the first reports of laparoscopic urinary tract, anorectum1,2, larynx, esophagus and stomach.3 At that time the chest and interventions, mainly adhesiolysis and biopsies, were published by Fervers and Ruddock.15 abdomen were not yet accessible for endoscopy. The first laparoscopy is attributed to Fervers still used oxygen as distention medium and noticed small explosions in the George Kelling, a German surgeon from Dresden, who started to follow Mikulicz with abdominal cavity while using instruments with high frequency electrical current for stomach insufflations and in 1901 examined the abdominal cavity from a dog by inserting coagulation. He concluded it was safer to use carbon oxide as distention medium.16 a cystoscope through a small incision in the abdominal wall and using pneumoperitone- Boesch, a Swiss gynecologist performed the first tubal ligation by electro coagulation in um for better visualization.4 Subsequently, he wanted to apply this method, called ‘celios- 193617 and the first ectopic pregnancy diagnosed by laparoscopy was published in 1937.18 copy’, in humans, but his first putative subjects either refused or died prematurely, so In 1938, Janos Veress, a Hungarian physician, developed a needle to create a pneumo- hence he was not the first to publish the use of celioscopy in humans. A Swedish inter- thorax in patients with tuberculosis. This spring-loaded needle consisted of an inner nist, Hans Christian Jacobaeus, who developed his method in the same period, was the stylet that automaticly converted the sharp edge to a rounded and incorporated a side first to publish about this new endoscopic technique used in humans and called it ‘lapa- hole.19 The needle was quickly adopted by laparoscopists for creating the pneumoperito- roscopy’.5,6 (Figure 1) In the same year, Bernheim, a surgeon at John Hopkins School of neum with minimal risk of injuring intra abdominal organs and for most gynecologists Medicine described his early experiences with the technique and called it ‘organoscopy’.7 the ‘Veress Needle’ is still the instrument of choice. In the decades thereafter, several refinements for the laparoscopic technique were invent- The next revolution in laparoscopy was the development of the rod-lens system by Har- ed. The trocar endoscope in 19128, the sharp pyramidal point of the trocar for puncture in old Hopkins20 and the cold light by Karl Stortz. This development allowed laparoscopists 19209, the needle for induction of the pneumoperitoneum in 192110, the insufflator in to see more clearly and reduced the risk of thermal injuries due to incandescent light. 192111, and widening of the viewing angle of the laparoscope in 1923.12 For insufflation of After the publication of Raoul Palmer, a French gynecologist, in the mid 1950s there was a the abdominal cavity, filtered air or oxygen was used until in 1924 Zollikofer, a Swiss rapid growth of laparoscopy. He changed the approach form culdoscopy in lithotomy gynecologist, introduced carbon dioxide, which is used until today.13 position to the upper abdomen and later to the lower abdomen while placing the patient in Trendelenburg position. For patient safety he stressed to monitor the abdominal Figure 1. Pioneers of laparoscopy 105 pressure and to maintain it at 25 mmHg.21 In 1961, Palmer was the first gynecologist to recover an oocyte for in vitro fertilization using laparoscopy.22 Interestingly, Patrick Step- toe was inspired by Palmer whom he met for the first time at a conference in Amsterdam in 1959. His laparoscopic experience was noted by Richard Edwards and their co-opera- tion eventually led to the first laparoscopic oocyte retrieval (on November 10th, 1977) to result in a successful pregnancy.23 Unfortunately, the wider use of laparoscopy lead to a higher incidence of complications and the enthusiasm for laparoscopic surgery was tempered in the 60s and 70s. The Ger- man gynecologist Kurt Semm, who was a strong advocate for laparoscopic surgery, played a vital role in keeping laparoscopy alive in those years. (Figure 2) He contributed greatly to the development of operative laparoscopy and his team provided several im- portant new developments in instrumentation. Examples are an automatic insufflation device, a bipolar coagulation instrument, a tissue morcellator, a suction and irrigation system and many others.24,25 Forty year after the development of the Verris needle, Harrith Hasson, an American gynecologist, improved the safety of laparoscopy with the develop- ment of the ‘Hasson trocar’, an instrument applied for an open entry technique.26 Semm’s commitment to laparoscopy and teaching also lead to the invention of the Pelvi- trainer (box trainer), which allows trainee’s until today to learn the specific psychomotor skills needed for laparoscopic surgery.27 In 1982, Semm performed the first laparoscopic appendectomy. However, he did not report this breakthrough not until 1983 as the public 10 11 Introduction Chapter 1 and professional perception of laparoscopic surgery was still hostile at the time.28 In the Robot assisted laparoscopic surgery is considered by many to be the next major evolution 70s, he was even forced to change the name laparoscopy into pelviscopy.29 in minimal invasive surgery. The first concept of surgical robotics was developed in the In the late 70’s and early 80’s there was a turning point due to the development of video late 80’s at the National Aeronautics and Space Centre (NASA).35 In 1994 the FDA laparoscopy by Camran Nezhat, an American gynecologist. Initially this new technique approved the first robotic system for laparoscopy, a voice driven camera holder, the Auto- was heavily criticized and labeled as “dangerous”.