Monopolar Energy Simulation Chicken Thigh Model. Contributors to this Simulation

Transcription

1 Monopolar Energy Simulation Chicken Thigh Model Contributors to this Simulation Lisa Chao, MD, Magee-Women's Hospital of UPMC Nicole Donnellan, MD, Magee-Women's Hospital of UPMC Amanda Ecker MD, Oregon Health and Science University Ted Lee, MD, Magee-Women's Hospital of UPMC Deirdre Lum, MD, Stanford University Medical Center Christina Ramirez, MD, Magee-Women's Hospital of UPMC Learning Objectives: 1. Describe normal retroperitoneal anatomy 2. Explain the use of monopolar energy 3. Identify and explain appropriate use of common laparoscopic instruments, including atraumatic graspers and scissors 4. Demonstrate skill in performing surgical dissection with monopolar energy 5. Adequately perform ureterolysis and excision of deep endometriosis nodules 6. Demonstrate surgical communication skills between participants Description of Lab: This simulation presents a model to safely practice surgical dissection techniques with monopolar energy on an inexpensive chicken thigh module. This lab will lead to improvement in laparoscopic tissue handling, safe utilization of monopolar energy, and surgical communication skills. This lab is ideal for 2-3 student surgeons and 1-2 instructors. Set-up time is about 15 minutes. The hands-on portion of the lab should last about an hour. Materials Needed: Open laparoscopic trainer box 4 Laparoscopic trocars Dispersive electrode pad (ex: Bovie pad) Monopolar generator Laparoscopic scissors Laparoscopy tower (camera, light source, display monitor) In-and-out bladder catheter Laparoscopic trocar inlet closure device (ex: Carter Thomason) Lone Star retractor (3307G) 3 Lone Star Elastic Stays (3311-8G) 8.5 x 11in plastic cutting board Dyed multifilament suture Needle driver, suture scissors o Laparoscopic needle driver/needle assist (optional) 2 Skin-on, bone-in chicken thighs

2 Drill driver with ¼ in. high-speed steel bit Two ¼ in. x 1-1/4 in. crown bolts Two ¼ in. hex nuts Method: Tissue Retractor Device: 1. Use drill and ¼ in. high-speed drill bit to drill two holes into the Lone Star retractor 2. Place Lone Star retractor in desired location on top of plastic cutting board and use a pen to mark the location of the holes on the cutting board. 3. Remove Lone Start retractor and drill the two pre-marked holes completely through the cutting board 4. Use the two ¼ in. crown bolts and hex nuts to secure the Lone star retractor to the plastic cutting board (Figure 1, 2, 3) 5. This retractor device can be cleaned with soap and water and reused Two bolts and hex nuts Figure 1. Lone star retractor secured to cutting board Crown bolts Figure 2. Cutting board (back side)

3 Crown bolt Hex nut Figure 3. Lone star retractor secured to cutting board (magnified view) Chicken Thigh Assembly: 1. Place chicken skin side up on the table 2. Use the laparoscopic trocar inlet closure device to tunnel underneath the chicken thigh skin 3. Grasp the in-and-out bladder catheter with the inlet closure device and pull back on the catheter to thread it underneath the chicken thigh skin (Figure 2) a. This will simulate the ureter underneath the peritoneum Figure 2. Tunneling the inlet closure device 4. Use the dyed multifilament suture to place several figure-of-eight sutures randomly along the chicken thigh. These figure-of-eight sutures should incorporate both the chicken thigh skin and muscle at various depths

4 a. This will simulate both superficial and deep endometriosis nodules **For more advanced learners, interrupted stitches can be sutured laparoscopically to practice laparoscopic suturing, intracorporeal and/or extracorporeal knot tying skills** 5. Slide dispersive return electrode sticky side up between the cutting board and the Lone star retractor 6. Firmly place chicken thigh skin side up on the dispersive return electrode 7. Use Lone Star elastic stays to secure chicken thigh on top of the dispersive return electrode (Figure 3) Figure 3. Chicken thigh on dispersive electrode with endometriosis nodules and ureter. See VIDEO 1 (Setup) 8. Place chicken thigh model within open laparoscopic trainer box and place box on top of a surface that can mimic an operating table. Be sure that the student surgeon and assistant can be on opposites of the table. The open laparoscopic trainer box allows for dissipation of any smoke generated during the simulation. 9. Connect dispersive return electrode to monopolar generator. 10. Connect monopolar cord to generator and laparoscopic scissors. Ensure camera and light source are connected to the laparoscopy tower. 11. The student surgeon should be left side of the laparoscopic trainer box and the assistant on the right. 12. Ensure that student surgeon can easily access the monopolar energy foot pedal.

5 Figure 4. Chicken thigh model in laparoscopic trainer box Figure 5. Chicken thigh model in laparoscopic trainer box (aerial view) Lab 1: Ureterolysis 1. The student surgeon should now identify the bladder catheter underneath the chicken skin as the ureter underlying the peritoneum. 2. The student surgeon should be able to describe important vascular structures that normally would be encountered along the pelvis within this retroperitoneal space. 3. While grasping the peritoneum overlying the ureter the student surgeon should direct their assistant to provide appropriate counter-tension. 4. The student surgeon should then use short bursts of monopolar energy in addition to careful blunt dissection to complete a ureterolysis along the length of the ureter. See VIDEO 2 (Ureterolysis) Lab 2: Excision of endometriosis The student surgeon should identify the chicken skin as the peritoneum and identify an endometriosis nodule to perform an excision of endometriosis.

6 a. Advanced student surgeons can also place deep interrupted sutures laparoscopically to simulate the endometriosis nodules in order to practice their laparoscopic suturing and knot-tying skills. 2. The student surgeon should grasp and elevate the endometriosis nodule off of the underlying structures. 3. It is crucial that the student surgeon direct the assistant to provide appropriate tissue counter-tension and camera work. 4. The student surgeon should then use short bursts of monopolar energy to completely circumscribe the endometriosis nodule. 5. The student surgeon and assistant should then switch roles so that each can practice using monopolar energy and directing the camera. See VIDEO 3 (Excision of endometriosis)