Laparoscopy Today

Surgical Education, Simulation, and the Revolution in Training: Personal Observations and Predictions

PROFICIENCY BASED TRAINING

RICHARD M. SATAVA, MD

A revolution is occurring in surgical education, driven by the introduction of surgical simulators for the training and assessment (and eventually the certification) of surgical technical skills. The revolution is a combination of devices (simulators), processes (curriculum-based training), validation (objective assessment), and policy (criterion-based benchmarks) to usher in proficiency based training. This results in a fundamental shift in the way surgeons will be trained in the future.

Two factors initiated this revolution. First came the introduction of surgical simulators as a technical tool that can replace real objects (patients, animal surrogates, or inanimate objects) by computer images. The simulators are simultaneously a training and an assessment device, for the signals from the handles that change the video image of the simulation are also tracked by the computer and measure performance. As the decade of simulators has progressed, the visual realism has improved and haptics (touch) has been added to some models. Second came the process of objective assessment, as initially demonstrated by Reznick (Objective Structured Assessment of Technical Skills – OSATS) and Fried (McGill Inanimate System for Training and Evaluation of Laparoscopic Skills – MISTELS). This methodology applies a rigorous design to the training of fundamental surgical technical skills and then stringently evaluates performance by specific metrics. The result has been that technical skills can be quantitatively measured, and the individual student’s performance can be objectively and accurately assessed.

Once simulation started, in the 1980s and 1990s, acceptance was slow. It was necessary for 2 other factors to be introduced before the surgical community was willing to accept simulation as a legitimate tool for surgical training. The first step occurred as rigorous validation studies were conducted that proved unequivocally that training on simulators improved performance in the operating room. Numerous studies are now available on many different simulators, both computer based and mannequin based, to support the important contribution of simulators to training. Some of the earliest results (Reznick and Fried) presaged similar results in computer-based simulators. The second factor was understanding that simulators were not meaningful without the context of a total curriculum. A simulator is simply one “tool” in the surgical educator’s toolbox in training a resident. A curriculum that begins with anatomy, steps of the procedure, and error identification leads up to the skills performance on the simulator, and then is followed by the objective assessment, outcomes analysis, and feedback to the student for improvement of performance. The simulator must be embedded within such a comprehensive teaching curriculum.

Simulation for surgical skills is now firmly entrenched in the mindset of surgical education, but it is necessary to move implementation into training programs. Yet another step will be required—the establishment of levels of proficiency (for each simulator) by experienced (expert) surgeons. When the experienced surgeon performs on the simulator, the results can be considered the “criterion” that the student must achieve before being allowed to perform surgery or a specific procedure on a patient. This “proficiency-based” training will have 2 profound influences. First, students will continue to train until they have achieved proficiency—not in the operating room on a patient, but in the laboratory by objective performance metrics to ensure the highest quality of error-free surgery before ever operating on a patient. Second, the student will train for however long is needed to achieve proficiency—whether it be 5 trials on the simulator or 25 trials. Thus, the training of a surgeon may no longer be for a fixed time period or number of procedures, rather the student will train until proficient. This may well change how training programs are organized—some students will take 3 years to 4 years, while others may take 6 years to 7 years. What will be certain is that residents will not graduate until they have competency proven objectively and unequivocally.

The time has come to move beyond the Halsted model of surgical training and into a new era— proficiency-based training.

Address reprint requests to: Richard M. Satava, MD, Professor of Surgery, University of Washington Medical Center, Room BB 430, Seattle, WA 98195, USA. Telephone: 206 616 2250, E-mail: rsatava@u.washington.edu

Richard M. Satava, MD, is a Professor of Surgery at the University of Washington School of Medicine, a Special Assistant in Advanced Technologies at the US Army Medical Research and Material Command in Ft. Detrick, Maryland and will soon return as a program manager at the Defense Advanced Research Projects Agency. He has served on the White House Office of Science and Technology Policy Committee on Health, Food, and Safety is a Past President of the Society of Laparoendoscopic Surgeons.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

New Paradigms in Surgical Education: Web-Based Learning and Simulation

13TH INTERNATIONAL CONGRESS AND ENDO EXPO
A SIMULATION COURSE

HARRITH M. HASSON, MD

At some time in the future, the selection process of prospective high-risk surgeons such as laparoscopic surgeons will include psychomotor and psychosocial testing for pertinent abilities and traits. Some personality traits will be deemed desirable, others will not. For instance, high scores for perseverance, motivation, and the ability to respond appropriately to new information (judgment) may mitigate lower scores for inherent technical ability. Ideally, successful candidates would become involved throughout their career in ongoing training and assessment of their cognitive competence, decision making, and technical skills. In other words, ongoing assessment of knowledge (cognition), response to that knowledge (judgment), and the ability to implement the response (manual skills) are the 3 facets of surgical competence.

At this time, the rapidly evolving technology of Web-based learning represents a disruptive technology that requires realignment of traditional methods of surgical learning into new paradigms of knowledge acquisition.

Satava [1] has recently suggested that the ability to gain access to new information through the Web, screen it for reliability, and respond to it by possibly changing behavior is more important than having information of uncertain value in one’s memory bank. Outcome measures will not depend on what students know, but on what decisions they make when given new information.

Technical competence in laparoscopic surgery depends on the development of basic abilities and skills peculiar to the technique. Operating on 3-dimensional objects from a 2-dimensional image projected on a video screen is the basic fundamental ability required. This involves a visio-spatial depth perception component as well as a psychomotor component.

In simulation, it is manifested in coordination exercises that develop or assess spatial perception and orientation, tracking, hand-eye coordination using dominant and nondominant hands, translation, and precise manipulation and targeting. Although the distinction is not always clear, fundamental abilities are used to develop basic skills, a combination of which is needed to perform a task. A series of tasks are integrated to simulate a surgical procedure [2]. In simulation, the skills/task categories are manifested in exercises dealing with bimanual dexterity, precise suturing, knot-tying, cutting, and other manipulations.

Objective assessment of simulation performance is integral to the success of the concept. Without valid performance metrics, simulation training would lose much of its credibility and value. Several metrics have been proposed. For instance, skills assessment in the McGill system of metrics [3] is based on time to completion with penalty points deducted for errors and imprecision. However, the system does not measure qualitative details of laparoscopic movements. Such a refinement is now available in the Blue DRAGON Markov Model system developed by Rosen and associates [4], as well as the CELTS system developed by Stylopoulos and associates [5].

The postgraduate course Role of Simulation in Residency Training and Continuing Medical Education, held at the SLS 13th International Congress was developed to deliver information about the use of simulation as a new learning paradigm. The goal was to give attendees insight into skills training program which including an opportunity to test out some of the latest simulators. Eight simulator and simulation software developers participated in the course: Immersion Medical, Surgical Science, Simbionix, Medical Education Technologies Incorporated, The Simulation Group at CIMIT/MGH, Realsim Systems, Haptica, and Simulab.

Simulation and Web-based learning are synergetic and complementary technologies. E-learning can provide and test the knowledge basis of advanced simulation. Virtual reality simulators can be linked across continents through the Internet in a seamless environment. Even physical reality simulators that are computer based are Web-compatible. Although the actual physical performance cannot be linked or duplicated through the Internet, the performance data can be transmitted and pooled to central locations. When video performances of the normalized expert (reconfigured and duplicated robotically) become available with systems like the Blue DRAGON Markov Model and CELTS, it will be possible to conduct Web tutorials. The remote expert can point out specific qualitative differences between the subject tested and the normalized expert then recommend remedial action.

With rapid advances in 3-dimensional visualization of the human body and computing power, we can look forward to simulators capable of simulating an entire procedure. Total immersion virtual reality (TIVR) workbenches will offer realistic interactivity combining tissue modeling, haptics, graphics, and physiology in single-system architecture. These advanced simulators will be procedure specific and will require a certain amount of knowledge (through e-learning) about the patient, procedure, and disease that can be tested before simulation surgery. To increase the fidelity of the system, new information (in the form of altered anatomy and distorted cleavage planes) must be presented to the simulation surgeon to test judgment. Only then will simulation fulfill its promise by developing and evaluating all three facets of surgical competence: knowledge, response to the knowledge by making a judgment, and manual implementation of the response.

Immersion Medical's Endoscopy AccuTouch System

BlueDRAGON CAD rendering. More info at http://brl.ee.washington.edu/

Realsim System's LTS2000-ISM60

Address reprint requests to: Harrith Hasson, MD, 6250 Winter Haven Rd, NW, Albuquerque, NM 87120. Telephone: 505 792 0240, Fax: 505 792 0241, E-mail: DrHasson@aol.com

Harrith M. Hasson, MD, currently serves as a Clinical Professor at the University of Chicago. Dr. Hasson holds 52 patents and is the Secretary-Treasurer of the Society of Laparoendoscopic Surgeons.

References

1.    Satava RM. Disruptive visions: surgical education. Surg Endosc. 2004;18(5):779-781.

2.    Satava RM, Cuschieri A, Hamdorf J. Metrics for objective assessment of surgical skills workshop. Metrics for objective assessment. Surg Endosc. 2003;17(2):220-226.

3.    Derossis AM, Fried GM, Abrahamowicz M, Sigman HH, Barkun JS, Meakin JL. Development of model for training and evaluation of laparoscopic skills. Am J Surg. 1998;175:482-487.

4.    Rosen J, Chang L, Brown JD, Hannaford B, Sinanan M, Satava RM. Minimally invasive surgery task decomposition-etymology of endoscopic suturing.  In: Westwood JD, Hoffman HM, Mogel GT, Phillips R, Robb RA, Stredney D, eds. Studies in Health Technology and Informatics: Medicine Meets Virtual Reality. Vol 94. Amsterdam, The Netherlands: IOS Press; 2003:295-301.

5.    Stylopoulos N, Cotin S, Dawson S, et al. CELTS: A clinically-based computer enhanced laparoscopic training system. In: Westwood JD, Hoffman HM, Mogel GT, Phillips R, Robb RA, Stredney D. Studies in Health Technology and Informatics: Medicine Meets Virtual Reality. Vol. 94. Amsterdam, The Netherlands: IOS Press, 2003:336-342.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Expert Videotape Analysis

Expert Videotape Analysis and Critiquing Benefit Laparoscopic Skills Training of Urologists • Nakada SY, Hedican SP, Bishoff JT, Shichman SJ, Wolf JS Jr. 2004;8:183-186. The authors conclude that urologists with laparoscopic experience can improve their laparoscopic skills by using mentored videotape analysis and experience gained from a 2-day hands-on course.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Surg Endosc Learning Curves and Psychomotor Training

Learning Curves and Impact of Psychomotor Training on Performance in Simulated Colonoscopy: A Randomized Trial Using a Virtual Reality Endoscopy Trainer • Eversbusch A, Grantcharov TP. 2004;18:1514-1518. This study analyzed the learning curve for the GI Mentor II and looked at whether psychomotor training can contribute to an improvement in the performance of virtual colonoscopy. Assessment of the learning curve was based on three parameters, and assessment of endoscopic skills was based on nine parameters. The study included 28 participants, and showed significant differences in the familiarization curves on the simulator among experienced surgeons, residents, and medical students; and the learning rate was proportional to the endoscopic experience of the participants.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

The Top Gun Laparoscopic Skills and Suturing Program

A MODEL FOR SURGICAL TRAINING

JAMES C. ROSSER, JR, MD, STEVEN M. YOUNG, MD

INTRODUCTION

As we stand at the dawn of a new century, it has been over 30 years since Kurt Semm initiated the era of operative laparoscopy. The entrance of general surgeons into the practice of minimal access surgery has accelerated the appearance of new applications and techniques. But as we bask in the glory of this achievement, a bittersweet residue hangs over what has been accomplished. At the 10th International Congress of the Society of Laparoendoscopic Surgeons in 2001, French gynecological surgeons reported that only 15% of their surgeons were routinely practicing advanced videoscopic procedures. General surgeons in this country have not fared better. This has to represent one of the most noted examples of underachievement in the history of surgery. Many reasons have been offered as an explanation to this stagnation. But, the key factor is that the majority of surgeons practicing today do not possess the skills necessary to execute advanced videoscopic procedures safely and efficiently.

As we search for answers, we can draw similarities from the plight of United States naval aviation during the early days of the Vietnam War. During this time, the Navy and Air Force began to show signs of years of de-emphasis on air combat maneuvering training and an increased reliance on technology and air-to-air missiles. As the result of this neglect, their kill ratio sank alarmingly from 12:1 during previous wars to 2:1. This refers to the number of aircraft lost for every one of the enemy that is shot down. Out of this dark and gloomy period of aviation history, a rededication was born to the credo, “We fought to fly, we fly to fight, and we fight to win,” and a command decision was made to go “back to basics.” The special school that served as the launching pad of this policy was called Top Gun.

Top Gun is a 6-week long boot camp for fighter pilots that pushed the aircrews and equipment beyond their previously believed envelope of performance and made them better. A stressing of the fundamentals of air combat maneuvering was “prosecuted with extreme prejudice.” These “best of the best” pilots were then redeployed to the fleet and the kill ratio for the Navy went back up to 12:1. Today in any sky on this planet, our pilots prowl with a “controlled arrogance” that is predicated on the philosophy “train as you fight and fight like you train.”

In a similar fashion, surgeons and industry at one time had the notion that technology would minimize the need to establish the unique skill set required for the videoscopic environment. As surgeons today face the daunting task of developing skills necessary for advanced minimally invasive procedures, there must be a willingness to recommit to training in basic and advanced skills including suturing. In the open surgical arena, most attending surgeons would not allow a resident to perform a procedure without being able to suture. That standard must not be abandoned today. The Top Gun Laparoscopic Skills and Suturing Program is meant to provide an effective and rapid development platform for skills acquisition and suturing excellence in the videoscopic environment. It proudly patterns itself after a similar training methodology that forms the core curriculum of the Navy’s Top Gun school for fighter pilots. This includes a breakdown of complex tasks to their most elemental level, preparatory drills to facilitate complex task execution, teamwork building, and the use of metrics to evaluate performance. In addition, each time a course is conducted, it honors the men and women who defend our country and make the extraordinary seem routine. Excellence is not built on just talent but also on superior tactics and techniques. Surgeons are not born to greatness but rather they are made by a willingness to be trained.

HISTORY

The first Top Gun Laparoscopic Skill and Suturing Program was held in 1992 on the island of Aruba, sponsored by the Academic Medical Center in Amsterdam, Holland. The 20 participants representing 8 countries could not tie an intracorporeal knot within 10 minutes at the beginning of the course, and all could perform the task in less than 2 minutes at the end of the course. With the positive feedback from this course, it was offered in the US with the support of Carlos Babini and the United States Surgical Corporation (USSC). In 1995, the program crossed over into cyberspace with production of a CD-ROM whose effective knowledge transfer capability as described by Rosser et al1 will be pivotal to the development of a distance education program. In 1996, under the visionary guidance of Charlie Johnson of USSC, a Top Gun Course kit was distributed to over 50 university and community programs in the US and abroad. Many of those programs still feature Top Gun training as an element of their minimally invasive training program.

In 1996, Top Gun the competition debuted at the annual clinical congress of the American College of Surgeons, serving as a fun, competitive venue to put videoscopic skills acquisition front and center. From the preliminary elimination match open to the general membership of the congress, the top 7 qualifiers received a chance to compete for the title of “Top Gun.” The final Top Gun competition is a hard-hitting multimedia extravaganza with the moderator continually attacking each contestant in an effort to simulate the pressures of the operating room. This competition has now been showcased at the SLS International Congress and SAGES for the last 4 years.

Some traditional academic educators think that the Top Gun shootout is an undignified demonstration that has a carnival atmosphere and fully breaks with surgical education tradition. For the over 1000 individuals who have participated, they would probably beg to differ. This number does not include the throngs of people who have witnessed the event, or the unknown number of surgeons who did not participate but have been inspired to work on their skills.

METHODOLOGY

The Top Gun training philosophy separates itself from other training methodologies by several distinguishing characteristics. In addition to ergonomic correctness as exemplified in its trocar placement strategy, the Top Gun methodology also stresses utilization of the nondominant hand in all maneuvers including suturing. In fact, Level II, the Masters Program, requires that the participant show proficiency in suturing with the nondominant hand. The operative circumstance rather than hand dominance should dictate the choice of suturing options. It also believes that preparatory drills can impact skill transference. As described by Rosser et al in 1997 [2] and 1998 [3], 3 validated preparatory drills, the “Cobra Rope Drill” (Figure 1), the “Pea Drop Drill” (Figure 2), and the “Terrible Triangle Drill” (Figure 3), prepare the student for execution of a standardized suturing algorithm. The suturing drill (Figure 4) requires the ability to incorporate the skills developed from the dexterity drills to place a suture videoscopically by throwing 3 square knots. All of this is done under the pressure of time and dynamic supervision meant to improve quality control. Verbal instruction and distraction simulate the pressure profile of the operating theater. All times required to perform drills are recorded, and a performance report with standardized percentiles is given to every student.

FUTURE

The possibility of mass distribution of the Top Gun program is now possible with the development of the Top Gun remote education program that features a CD-ROM tutorial, videoconference lectures, and skill development exercises. The feasibility of this program was demonstrated with Operation Validation where the Top Gun program was conducted in England while the course director was headquartered at the Yale University School of Medicine. The success of this project suggests the possibility of multiple programs being given simultaneously around the world. With the availability of the performance database representing 5000 surgeons, follow-up evaluation of a student’s progress can be done on an ongoing basis via the Internet.

In response to a critique by Smith et al [4] of the Top Gun training program’s reliance on speed as the primary evaluation tool, Rosser et al5 have introduced a training arena called the Gabriel-Rosser Inanimate Proctor. This appliance represents a “hybrid” training platform that retains the advantages of traditional tabletop trainers while evaluating the participant’s control of economy of motion and registers errors. When the participant exhibits poor instrument control, a light flashes, a buzzer sounds, and an error is recorded. This platform has now been used in almost 400 participants and feasibility and validation studies are pending.

At the Medicine Meets Virtual Reality Conference (MMVR) in January 2004, Rosser et al [6] presented data that showed that participants with past, current, and demonstrated video game experience performed better during the Top Gun Laparoscopic Skill and Suturing Program. In addition, preliminary data suggest that warming up with video games may contribute to increasing videoscopic task performance [7]. In light of these data, future Top Gun programs will feature video gaming as one of the preparatory exercises in the course curriculum. As an interesting spin-off, 2004 saw the appearance of the Top Gun for Kids program. This program is meant to be an “edutaining” component of an effort meant to attract more of our youth to cutting edge career choices in science, engineering, technology, and medicine. The children first demonstrate their video gaming prowess, and then they show their ability to perform in the videoscopic environment using the same drills that surgeons have to perform during Top Gun. The hope is that this can lead to local, regional, and finally a national competition with multiple corporate sponsors and scholarships for the children.

In 2004, a concerted effort was started to make the Navy aware of this training program with the hope that it could be adopted as a training component for Navy surgeons. This can also serve as a high profile public relations tool to bring added exposure for the Top Gun Laparoscopic Skills and Suturing Program. The first phase began with an official visit to the USS Harry Truman and Naval Air Station Oceana, in Norfolk, Virginia. This is the home of an F-14 Tomcat air wing, and the commodore was presented with a special honorary Top Gun Laparoscopic Skill and Suturing Program award and proclaimed an honorary Top Gun Cyber Surgeon (Figure 5). It is hoped that this will be followed up with an official Top Gun skills course in 2005 for Navy surgeons and resident staff. The future of Top Gun has never been brighter and hopefully these efforts can assist in placing skill and suturing as an achievable priority for surgeons. We are hopeful that this can lead to a day when 85% of surgeons routinely perform advanced minimally invasive procedures worldwide.

Figure 1. Cobra Rope Drill. One of 3 validated drills to prepare for the execution of a standardized suturing algorithm.

Figure 2. Pea Drop Drill. One of 3 validated drills to prepare for the execution of a standardized suturing algorithm.

Figure 3. Terrible Triangle Drill. One of 3 validated drills to prepare for the execution of a standardized suturing algorithm.

Figure 4. Suturing Drill. Requires placement of a suture videoscopically by throwing 3 square knots.

Figure 5. USS Harry Truman and Naval Air Station Oceana in Norfolk, Viginia. Dr. Rosser presents the commodore with an honorary Top Gun Laparoscopic Skill and Suturing Program Award.

Address reprint requests to: James “Butch” Rosser, Jr, MD, Beth Israel Medical Center, 350 East 17th St, 16BH, New York, NY 10003, USA. Telephone: 212 420 4337, Fax: 212 844 1039

James C. Rosser, Jr, MD, is the Chief of Minimally Invasive Surgery at Beth Israel Medical Center in New York and is also Director of Beth Israel Advanced Medical Technology Institute. Dr. Rosser travels the globe teaching his Rosser Top Gun Laparoscopic Skills and Suturing Program.

Steven M. Young, MD, is a laparoscopic fellow at the Beth Israel Medical Center. Since beginning his fellowship, Dr. Young has helped instruct numerous Top Gun Laparoscopic Suturing courses. At the SLS 13th International Congress he moderated the Top Gun competition.

References

1.    Rosser JC, Herman B, Risucci DA, Murayama M, Rosser LE, Merrell RC. Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training. Am J Surg. 2000;179(4):320-324.

2.    Rosser JC, Rosser LE, Savalgi RS. Skill acquisition and assessment for laparoscopic surgery. Arch Surg. 1997;132(2):200-204.

3.    Rosser JC Jr, Rosser LE, Savalgi RS. Objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons. Arch Surg. 1998;133(8):911-912.

4.    Smith CD, Farrell TM, McNatt SS, Metreveli RE. Assessing laparoscopic manipulative skills. Am J Surg. 2001;181(6):547-550.

5.    Rosser JC, Ryan M, Lynch P, Brief J, Young SM. Validation of the internal guidance capability of the Gabriel-Rosser inanimate proctor for acquisition of laparoscopic surgical skills. Presented at: 13th International Congress and Endo Expo 2004, SLS Annual Meeting; September 29-October 2, 2004; New York, NY.

6.    Rosser JC, Lynch P. Video Gaming in Laparoscopic Skills Training. Presented at: 12th Annual Medicine Meets Virtual Reality Conference; January 14-17, 2004; Newport Beach, CA.

7.    Rosser JC, Lynch P, Haskamp L, Brief J, Ryan M, Young SM. The Effects of video game play on time and errors during laparoscopic skill development. Presented at: 13th International Congress and Endo Expo 2004, SLS Annual Meeting; September 29-October 2, 2004; New York, NY.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS De Novo Adhesions

Prevention of De Novo Adhesions by Ferric Hyaluronate Gel After Laparoscopic Surgery in an Animal Model • Detchev R, Bazot M, Soriano D, Daraï E. 2004;8:263-268. Results obtained with a rabbit model suggest that routine intraperitoneal application of hyaluronate gel does not prevent adhesion formation after laparoscopic surgery.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Surg Endosc Impact of Resident's Seniority

The Impact of a Resident’s Seniority on Operative Time and Length of Hospital Stay for Laparoscopic Appendectomy • Shabati M, Rosin D, Zmora O, et al. 2004;18:1328-1330. Reviews patient records for 341 appendectomies by residents alone. Operating times, conversion rates, and lengths of stay for surgical teams lead by residents with 3 or fewer years were compared with those lead by residents with 3 or more years and with those consisting of two residents with 3 or fewer years.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Outpatient Surgery Magazine Facility Facelift

Does Your Facility Need a Facelift? • Cook D. September 2004:34-47. Transforming your surgery center or office using some of the 20 ideas presented in this article could enhance your patients’ experience and raise their level of customer satisfaction. The author discusses indoor and outdoor environments and covers everything from the OR to the staff lounge, custom curtains to soothing sounds.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Application of Doppler Technology

Application of Doppler Technology as an Aid in Identifying Vascular Structures During Laparoscopy • Neff M, Cantor B, Koren J, Geis WP, Curtiss S, Rosen S, Konigsberg S. 2004;8:259-261. A laparoscopic Doppler probe was found to provide useful information in identifying the cystic artery during laparoscopic cholecystectomy, to assess mesenteric blood vessels during laparoscopic colectomy, and to identify femoral vessels during laparoscopic preperitoneal hernia repair.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Outpatient Surgery Magazine Troubleshooting Your Laparoscope

Troubleshooting Your Laparoscopes Hitches and Glitches • Taylor D. September 2004:66-71. Highlights 14 ways to deal with fog, blurry/distorted pictures and flickering and discusses preventive maintenance and problem solving approach. A complete Laparoscopy Troubleshooting Guide is available on the SAGES website, www.sages.org.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source