Original Article Cadaver as a model for laparoscopic training

Original Article

Cadaver as a model for laparoscopic training

Avinash Supe, Abhay Dalvi, Ramkrishna Prabhu, Chetan Kantharia, Pritha Bhuiyan*

Departments of Surgical Gastroenterology and *Anatomy,
Seth G S Medical College and K E M Hospital, Mumbai 400 012

Background: Though minimally invasive techniques We performed laparoscopy on human cadavers
now are routine world over, there is need to develop as one of the training modalities for surgeons par-
facilities for training surgeons. Laparoscopy performed ticipating in a laparoscopic training course. We re-
on anesthetized animals is an established model but late our experience with this training model and the
is costly and is not easily available. We report on trainees’ perception.
human cadaver as a training modality for surgeons
participating in a laparoscopic training course. Methods
Methods: Unembalmed cadavers were used for training
surgeons to appreciate anatomy, practice laparoscopic A clinical skills training center has been established
techniques, and deploy equipment and instruments at our institution in the Department of Anatomy for
during a laparoscopic training course. Trainees carried training post-graduates students in specialized surgi-
out procedures such as cholecystectomy, cal and other procedural skills such as sinus endo-
appendicectomy, splenectomy, intestinal explorations, scopy, temporal bone surgery, micro-neuro surgery
mesenteric lymph node biopsy, and varicocele-vein and arthroscopy. The center was inaugurated in August
occlusion. We analyzed the trainees’ perspective 2003 and nine workshops in different medical spe-
regarding cadaver as a model using the 5-point Likert cialties have been conducted since; five of these
scale. Results: Thirty-two trainees from five consecutive workshops dealt with laparoscopy training. The cen-
training courses held at our institution expressed ter is equipped for performing laparoscopic surger-
general satisfaction over cadaver as a training model, ies, along with facilities simulating an operation the-
and 96.9% (31/32) rated the training model as highly ater. This clinical skills laboratory project has been
satisfactory. The trainees ranked as highly satisfactory approved by the ethics committee of our institution.
their understanding of surgical anatomy (29/32; 90.6%),
understanding of laparoscopic technique (29/32; 90.6%) We have been conducting laparoscopy training
and use of instruments (32/32; 100%). The trainees courses for practicing surgeons, defined as surgeons
thought such an approach improved spatial perception with more than 5 years of practice. These courses
of anatomy and they perceived it as a valuable include live demonstration of surgical procedures,
educational experience. Conclusions: Human hands-on assistance, and supervised training sessions
cadaveric laparoscopy may offer an ideal surgical on the endo-trainers.2 We added cadaveric training
environment for laparoscopy training courses, allowing as a training model to this course. Unembalmed human
dissection and performance of complicated procedures. cadavers that were lying unclaimed in municipal
[Indian J Gastroenterol 2005;24:111-113] hospitals mortuaries and were preserved within one
hour of death in low-temperature (0-4 degrees Cel-
SSeeee eeddiittoorriiaall oonn ppaaggee 9955 sius) walk-in coolers were used for this purpose. On
the day of laparoscopic training session, these bod-
The application of minimally invasive techniques ies were thawed for one hour in the operating room.
for the performance of abdominal surgery has
been a great advance in the history of general surgery. Three participants along with a guide worked
The safe adoption of many of these procedures, on each cadaver for each procedure. The trocar was
however, has been hampered by significant obstacles, introduced by the open technique taking universal
mainly due to the problem of providing adequate precautions and was secured by an encircling stitch.
training to the surgeons. Developing models for The abdominal cavity was inflated with air; the pres-
surgical training in minimally invasive procedures has sure required was 12-14 mmHg. A zero-degree tele-
been complex. Laparoscopy performed on anesthetized scope was used along with standard equipment for
pigs is an established training model but is not available laparoscopic training. Trainees carried out operations
universally and is costly. such as cholecystectomy, appendicectomy, splenec-
tomy, intestinal explorations, mesenteric lymph node
biopsy, and varicocele-vein occlusion (4-6 procedures

Copyright © 2005 by Indian Society of Gastroenterology

Supe, Dalvi, Prabhu, Kantharia, Bhuiyan Cadaver model for laparoscopic training

on each cadaver). The cadaver was disposed off by were the absence of active bleeding, the absence of
incineration as per rules in force. breathing perception, and limited hours of working
as the cadavers tend to become malodorous after 6-
To study the trainees’ perception on the use of 8 hours. Overall experience was rated as excellent
cadaver as a model for laparoscopic surgical train- by all.
ing, a questionnaire was prepared in consultation
with experienced laparoscopic surgeons and educa- Discussion
tionists. The questionnaire evaluated perceptions
regarding understanding of surgical anatomy, under- Performing laparoscopic surgery demands specific
standing laparoscopic technique, and use of capabilities in a surgeon, which can only be gained
laparoscopic instruments. Each item was scaled on with extensive training. Currently, the basic optical
the five-point Likert scale3 as highly satisfactory, and manipulative skills can be learned by using in-
satisfactory, average, unsatisfactory, and highly un- expensive, traditional endo-training devices.4 The
satisfactory. Thirty-six surgeons participated in five various techniques used for this purpose are didac-
laparoscopy workshops; four of them did not take tic lectures, video sessions, endo-trainer models, live
part in the cadaveric dissection. Hence 32 surgeons demonstrations, hands-on apprenticeships, and ani-
participated in the study. mal laboratories. In all endo-training programs the
trainee learns navigating under monoscopic visual
Results feedback where real-life effect is lost. Experiments
on animals are sometimes used for testing new sur-
All 32 trainees in the workshops were practicing gical techniques but practical as well as ethical rea-
surgeons. One participant had been performing sons strongly restrict their use in everyday surgical
laparoscopic procedures with assistance and eight training.5 Animal laboratory is also extremely expen-
others had been assisting other surgeons. Four had sive to maintain and hence this training is not avail-
previously received laparoscopic training using ani- able in most developing countries.
mal models Nine cadavers were used for these five
workshops. A total of 42 operations were carried We have explored the human cadaver as a train-
out by the 32 trainees; these included cholecystec- ing model for laparoscopic training and have found
tomy (9), appendicectomy (9), laparoscopic varico- it feasible and useful, as was perceived by other
celectomy (14; both sides), intestinal exploration (3), surgical training centers.6,7,8 The cadaver has also
mesenteric lymph node biopsy (6) and splenectomy been used to teach clinical anatomy to students and
(1). Distension of the cadaveric abdomen was ad- residents.9,10 Trainees preferred cadaveric laparoscopy
equate and all operations could be performed com- to porcine laparoscopy.1 The cadaveric model has
fortably by the participants under guidance of the the advantages of human anatomy and real-size ex-
faculty. The time spent on each cadaver was mean perience and is much closer to live patient in han-
3.5 (range 2.5 to 4.5) hours. Four to six procedures dling instruments and tissues. Most importantly,
were carried out on each cadaver. As expected, there surgeons gain valuable experience in operative
was no active bleeding. laparoscopic surgery in an environment free of the
limitations of the operating room. The handicaps of
All 32 trainees expressed satisfaction with ca- this approach are absence of active bleeding and
daver as training model, and 31 of 32 (96.9%) rated limited period of the use of the cadaver. There is
the training model as highly satisfactory and one initial moderate cost of developing these facilities,
graded the satisfaction as average. The trainees in- but these can be shared by many departments in an
dicated that the cadaver model provided a highly institution.
satisfactory understanding of surgical anatomy (29/
32; 90.6%), understanding of laparoscopic technique In a well developed center, the cost of cadaver
(29/32; 90.6%), and use of instruments (32/32; 100%). training is moderate and affordable in developing
Understanding of surgical anatomy and understanding countries. In a large metro city like Mumbai, obtain-
of laparoscopic technique were scored as unsatisfac- ing unclaimed cadavers or cadavers donated for
tory by 2 particpants each, and as average by one anatomical dissection is quite easy. Medical colleges
participant each. in India attached to public hospitals have similar
access to human cadavers for dissection, and it is
The trainees thought it improved spatial percep- legal.11
tion of anatomy, and they perceived it as a valuable
educational experience. In conclusion, cadaveric laparoscopy may offer
an ideal surgical environment allowing dissection and
In the trainees’ opinion, limitations of the model

112 Indian Journal of Gastroenterology 2005 Vol 24 May - June

Supe, Dalvi, Prabhu, Kantharia, Bhuiyan Cadaver model for laparoscopic training

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Correspondence to: Dr Supe, Professor and Head. E-mail:
5. http://www.nlm.nih.gov/research/visible/vhpconf98/AUTHORS/ [email protected]
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Received November 20, 2004. Received in final revised form
February 21, 2005. Accepted March 8, 2005

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