BACKGROUND:A reliable method supplying graduated experience and practice is needed to develop and refine laparoscopic skills. The laparoscopic surgeon, like the microvascular surgeon, must have ongoing training to refine and maintain his or her skills.METHODS:The authors describe a new modular training unit. The unit consists of a box with a built-in television camera, a light source, and a rotating platform. A videotape recorder with a timing device documents the actual "operating time" required for the various exercises. The first phase of training consists of a basic skills board. This initial phase enhances the use of dominant and nondominant hand motor activity.RESULTS:The surgeon then progresses to lifelike models (biliary, suturing, hernia, gynecologic) to simulate the human operative setting. Ten surgeons spent 5 h each working with the module. The specific exercises were recorded and timed. Their progress is described.CONCLUSIONS:The modular laparoscopic skills center is an integral part of any laparoscopic educational program. It facilitates the acquisition and maintenance of laparoscopic skills.

We have evaluated in vitro, the security of laparoscopically applied clips, through two commercially available clip appliers: the Endo Clip II (US Surgical) and the Ligaclip (Ethicon). The clip performance was tested with respect to dislodgment and leakage. Dislodgment was attempted both transversely and at 45 degrees with respect to the main axis of the tubular structures tested. The mean maximum force (N = 24) necessary to dislodge a clip applied to silicone tubing (2.1, 2.4, 3.2 mm o.d.) and porcine vascular tissue was measured. The maximum force needed to transversely dislodge a clip applied to silicone tubing, ranged from 262 +/- 9 g (2.1 mm) to 315 +/- 11 g (3.2 mm) for the Endo Clip II applier, while the values for the Ligaclip were 220 +/- 28 g (2.1 mm) and 273 +/- 11 g (3.2 mm), respectively. To achieve dislodgment at 45 degrees pull, corresponding forces of 294 +/- 8 g (2.1 mm) and 369 +/- 14 g (3.2 mm) for the Endo Clip II, and 254 +/- 14 g (2.1 mm) and 297 +/- 13 g (3.2 mm) for the Ligaclip (N = 24) were required. Transverse dislodgment forces, for clips applied to tissue, were 556 +/- 146 g for the Endo Clip II and 356 +/- 170 for the Ligaclip (N = 6). Leakage tests were also performed under pulsatile blood circulation at mean pressure of approximately 800 mm Hg. No tested clips applied to either silicone tubing or tissue allowed for any blood leakage. The dislodgment test showed that the Endo Clip II exhibits superior performance compared to the Ligaclip, based on the fact that it requires more force for transverse and semiaxial dislodgment. In the leakage test, both clip appliers performed equivalently.

Laparoscopic cholecystectomy is rapidly evolving as a therapeutic modality for the treatment of gallstone disease. The technical details of this procedure and the method by which the gallbladder is dissected and removed are critical to the safe, effective execution of the procedure. Our technique has been developed through extensive practice in porcine models and through experience with more than 250 patients. To perform laparoscopic cholecystectomy we employ a high-resolution video endoscopy system, two high-resolution color monitors, a high-flow CO2 insufflator, a 300 W Xenon light source, electrocautery and/or lasers, and an endoscopic suction-irrigation system. This equipment permits the surgeon to obtain a clear field of view within the abdomen. With these tools, appropriately designed for laparoscopic surgery, including a laparoscope, graspers, dissectors, cholangiography equipment, scissors, and clip appliers, the surgeon can remove the gallbladder without opening the abdomen. The procedure requires the induction of a CO2 pneumoperitoneum, insertion of four trocars, and placement of a grasping retractor to set the operative field. An additional retractor placed on Hartmann's pouch provides countertraction for dissection of the hilum. Careful dissection around the cystic duct and cystic artery with a combination of electrocautery and blunt dissection allows the surgeon to skeletonize the cystic duct and artery. After intraoperative cholangiography confirms the anatomy, the cystic artery and cystic duct are clipped and divided. Electrocautery or laser techniques can be used to perform retrograde dissection of the gallbladder from the liver bed and insure hemostasis. The gallbladder is detached and removed intact through the large trocars. This basic technique can be applied in a wide variety of patients with cholelithiasis. The surgeon proficient in this technique may apply it to a broad range of patients with gallbladder disease.

From earliest times, visual aids - from crude diagrams to complex, beautiful wax anatomical models - have been created to enhance the surgical learning process. Surgical educators realized early that suitable models could be used to develop the needed technical expertise essential to the safe performance of surgery. Practice on models also assisted in developing surgical judgment.

The safe and effective performance of laparoscopic inguinal hernia repair requires a working knowledge of pre-peritoneal anatomy. Most surgeons are unfamiliar with the retro-peritoneal view of the groin. A model has been developed which allows surgeons to learn pre-peritoneal anatomy, to practice laparoscopic inguinal herniorrhaphy and to assess their repairs. This model is a valuable laparoendoscopic educational tool.

The surgical treatment of choledocholithiasis has traditionally relied on the exploration of the common bile duct. The advent of laparoscopic cholecystectomy now permits the surgeon direct access to the common bile duct. Currently, one fourth to one third of all cholecystectomies are performed through the laparoscope. The use of this technique is expected to increase dramatically over the next several years.

The advent of the laparoscopic revolution and the wider applicability of laparoscopic procedures has caused surgeons to re-think the dynamics of intraoperative problem-solving. Problems of body habitus, previous surgery, exposure, bleeding, and anesthesia, as well as the problem cholangiogram, require new and innovative approaches, a practical approach to each of these common laparoscopic problems is presented.

We investigated various energy sources and delivery systems suitable for fragmentation of common duct calculi by a laparoscopic technique. We evaluated electrohydraulic lithotripsy (EHL) using 1.9-Fr probe delivering 80 W and laser lithotripsy using a 200-μm fiber delivering 30–70 mJ/pulse at 5–20 Hz. In vitro biliary stone fragmentation analysis suggested that the laser lithotripsy produced a more controllable fragmentation than EHL. Initial attempts to employ EHL techniques in animal models resulted in common bile duct injury or inadequate fragmentation of stones. In contrast, biliary lithotripsy was accomplished in pigs using the pulsed-dye laser at 10 Hz and 60 mJ/pulse. Histologic evaluation revealed no evidence of ductal injury related to laser stone fragmentation. Subsequently, laser common duct lithotripsy was used in two human subjects. One patient had a 1.8-cm impacted ampullary stone and one patient had a 3-cm intrahepatic stone. In both cases, the stones were removed laparoscopically after laser fragmentation. Our experience suggests that the laser lithotripsy may facilitate laparoscopic common duct stone extraction procedures.

Various strategies have been proposed for the treatment of common bile duct stones encountered during laparoscopic cholecystectomy (LC). Eighty-three patients who had choledocholithiasis discovered during or just prior to LC are included in this study. These patients were treated by various modalities including preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic choledochotomy, transcystic duct-common bile duct (TCD-CBD) exploration, and conventional ''open'' common duct exploration. Sixty-six patients were successfully treated with TCD-CBD exploration. They were discharged on average 2.6 days postoperatively and were able to return to normal physical activities within 7 days of discharge. There was minimal morbidity and no mortality. The technique of TCD-CBD exploration is described in detail. The role of laparoscopic choledochotomy and endoscopic sphincterotomy for management of common duct stones in patients undergoing laparoscopic cholecystectomy appears limited.

Between August 1989 and December 1990, twenty-five patients with a preoperative diagnosis of acute cholecystitis underwent laparoscopic cholecystectomy. Twenty-one patients (84%) had abdominal tenderness, 16 (64%) had leukocytosis, and 10 (40%) had fever. Eleven patients (44%) came to the hospital with only one of these previously mentioned clinical signs. Six patients (24%) had two clinical signs. Eight patients (32%) came to the physician with all three findings. The length of surgery correlated directly with the number of presenting clinical signs. The average operating time was 119 minutes. Intraoperative cholangiograms were routinely performed on all patients. Four patients (16%) had common bile duct stones. The average hospitalization was 3.8 days and patients returned to work or routine physical activity between 3 days and 2 weeks (average 8 days) after surgery. There were three wound infections and two cases of hyperamylasemia. One patient developed urinary retention and another had a CO2 embolus. There were no intra-abdominal abscesses and no mortality. Laparoscopic cholecystectomy in acute cholecystitis is technically difficult. The incidence of common bile duct stones is greater than in elective cases, and routine cholangiography is crucial. With sufficient experience and skill, laparoscopic cholecystectomy can be performed safely in patients with acute cholecystitis.

Management of obstructions in the lacrimal drainage system would be greatly aided by improvements in the ability to visualize the blockages. We describe a new method of observation using miniature fiberoptics to view the entire lacrimal excretory system. We employed flexible endoscopes of fiberoptic bundles with outside diameters of from 0.5 to 0.7 mm. These endoscopes were inserted through the puncta and canaliculi. Sixteen patients were examined. A range of pathologic conditions were found, including slightly stenosed passages and severely destroyed canalicular mucosal lining. Our results indicate that this technique is feasible and useful in the diagnosis of lacrimal excretory disease.

With increasing acceptance of routine cholangiography during laparoscopic cholecystectomy (for confirmation of anatomy) there has been increased identification of common duct calculi. A technique of laparoscopic transcystic common duct stone extraction is described and early clinical results are presented. Successful stone extraction was accomplished in 39 out of 41 consecutive attempts by one surgical team. Two cases required choledochotomy. There were four complications including hyperamylasemia (2), minor wound infection (1), and incidental pneumothorax (1). Recommendations regarding safety and indications are presented. Initial evaluation suggests laparoscopic transcystic stone extraction is safe and effective.

The authors' initial experience with transcystic duct and direct laparoscopic approaches to the exploration of the common bile duct is reported. The technique requires standard laparoscopic equipment, specialized endoscopes, and instruments developed for urologic stone manipulations. After cholangiography confirmed the presence of common bile duct stones, common duct stone extraction was performed in 16 selected patients age 20-88 years. Stones ranged in size from 1 mm to 30 mm and they were unsuspected in 60% of the patients. Five patients had normal liver function tests and only 3 had clinical evidence of jaundice. Ductal exploration and stone extraction was successful in all 16 patients. One patient required a direct laparoscopic ductal exploration due to the presence of a common hepatic duct stone and the anatomy of the cystic duct. No major complications or deaths were observed in this series. Appropriately trained surgeons can safely and effectively perform laparoscopic common bile duct exploration and stone extraction in selected patients.

Falloposcopy combined with laparoscopy was performed in 11 women during the late follicular phase of spontaneous menstrual cycles, and a preovular follicle was confirmed to be present in each case. The fimbrial end of the tube and the ipsilateral ovary containing the preovular follicle were suspended in a fluid environment of 200 ml of lactated Ringer's solution which acted as a support medium for visualization of tubal mucus and facilitated the endoscopy procedure. As the falloposcope was passed through the fimbrial opening, it was observed to carry clear, elastic and filamentous strands of mucus material from within the distal tubal lumen in 4 of 11 procedures. As these mucus strands were carried on the tip of the falloposcope to touch the surface of the ovary containing the preovular follicle, they attached, on contact, in all cases. The fimbrio-ovarian mucus bridge created was quite strong and could be stretched for up to 7 mm before it detached from the ovarian surface. The mucus attachment appeared to be equally secure over the preovular follicle and adjacent ovarian surfaces. These fimbrio-ovarian mucus connections, which have a high affinity for ovarian surface attachment about the time of ovulation, may play an important role in securing tubal oocyte capture in humans.

A transvaginal microendoscopic technique has been developed for safely exploring the human fallopian tube from the utero tubal ostium to the fimbria and adjacent peritoneal cavity. Falloposcopy was performed without complication or evidence of endotubal damage in 44 women, 38 of whom also underwent a concurrent laparoscopy. Eight women with normal tubes served as controls and 36 women with tubal damage underwent falloposcopy in an attempt to document endotubal defects. Previous salpingectomy in 13 women and ostial obstruction in 4 cases left 71 tubes available for falloposcopy. Technical failures, defined as an inability to negotiate the tubal lumen in the absence of obstructive disease occurred in 8 of 71 (11%) procedures. In 63 successful procedures, the tubal lumen was considered to be falloposcopically normal in 28 cases (44%) and contained defects ranging from partial to total obstruction secondary to intraluminal fibrosis within the intramural, isthmic, and ampullary segments in the remaining 35 tubes (56%). Falloposcopy provides a nonincisional modality for defining the normal and abnormal surface anatomy of the tubal epithelium.

Eighty falloposcopies were performed in fallopian tubes of women with suspected tubal disease. In three falloposcopies (4%), isthmic plugs were observed occluding the entire isthmic lumen. In all cases these plugs were mobilized by falloposcopic-directed, selected tubal cannulation and aquadissection techniques. Restoration of tubal patency, verified by concurrent chromopertubation under laparoscopic monitoring was achieved in all cases. On one occasion, the isthmic plug was mobilized and identified on the fimbria, and tubal patency was confirmed. When this plug was retrieved and examined histologically, it was found to consist of a cast of debris containing aggregates of histiocyticlike cells of endometrial stromal or mesothelial origin. The genesis of these plugs is unknown. In another subgroup, white to yellow mucus like fragments were observed within the intramural and isthmic lumen during a further 8 of 80 falloposcopies (10%). Whether these mucus like fragments are of physiological or pathophysiological significance remains to be determined. Objective demonstration that isthmic plugs can cause reversible proximal tubal obstruction (PTO) has been achieved using falloposcopy. Falloposcopy offers the diagnostician the ability to objectively classify the cause of PTO. A useful falloposcopic classification and scoring system of tubal lumen lesions has been utilized and is described.

The use of a 308-nm XeCl excimer laser for biliary stone fragmentation is reported. The 130-nsec laser pulses are delivered via UV grade fused silica fibers to the target stones immersed in normal saline solution and placed in direct contact with the fiber. Sixty biliary calculi, 20 cholesterol and 40 pigment, were fragmented in vitro. The energy delivered per unit mass of the stone is kept constant at 50 mJ/mg. The effect of laser repetition rate, energy fluence, and fiber core size on stone fragmentation was studied. Fragmentation thresholds for a variety of biliary calculi of known composition were measured. It was found that higher fragmentation efficiency was obtained with larger fluence, lower repetition rate, and fiber of larger core. Our study indicates that the 308-nm excimer laser may be effective as a laser lithotriptor with low threshold and good efficiency for biliary stone fragmentation.

This paper reports on the application of angioscopic technology to the endoscopy of previously inaccessible body cavities. Necessary instruments including endoscopes, light sources, cameras, video recorders, monitors, and other accessories are described. Practical considerations for effective instrumentation are discussed. An overview of our clinical microendoscopic applications in more than 630 patients is presented.