Value of orientation training in laparoscopic cholecystectomy

Sir,

We would like to thank Mr Noorani for his insight of future applications for targeted orientation training in neurosurgery. Of course we completely agree that neurosurgeons may greatly benefit from this mode of training due to the complex and often disorientating anatomical conditions faced in many operations. In fact, we feel that many other specialties, including all those that employ minimally invasive techniques may benefit from structured training in orientation to avoid surgical error. Furthermore, the assessment methodology used to characterise high performance orientation strategies may be used as a tool in the evaluation of innovative technologies and comparison with current gold standard in surgical devices. This is a relatively new but very exciting area of research which links with behavioural psychology as well as engineering, and in an era of increasing structure and scrutiny of surgical training is highly applicability across all specialities.

Mikael Sodergren
Imperial College London, London
m.sodergren@imperial.ac.uk

• Commentor: Mikael Sodergren - Imperial College London, UK
• Date: Sep 29, 2011

Sir,

I commend the randomised controlled trial by Sodergren and colleagues showing that understanding of laparoscopic orientation can be improved by simple training, which is likely to benefit those in early laparoscopic surgical training. However, they did not mention the potential importance of these findings to training in other surgical specialties, in particular neurosurgery.

Excellent understanding of anatomical orientation is essential in neurosurgery, as nervous tissue is particularly prone to damage and such damage can have devastating consequences for the patient. As for laparoscopic procedures in abdominal surgery, understanding anatomical orientation in neurosurgery is challenging, particularly in microscopic and endoscopic neurosurgical procedures, for example clipping arterial aneurysms, resecting intraparenchymal brain tumours, and pituitary surgery. In such neurosurgical procedures, there will be a number of stages, each requiring good understanding of anatomical orientation in order to perform the operation safely. The operator may have to access deep brain regions containing minute anatomical structures within a small space, making orientation inherently more difficult. Consequently, computer-based surgical simulators are being developed to provide a virtual-environment for training neurosurgeons1, for example in endoscopic transsphenoidal pituitary surgery2, and one of the aspects that these simulators focus on is anatomical education. However, these simulators are clearly expensive and have other training objectives, so simpler and cheaper training methods purely for understanding orientation would obviously be preferred. Simple orientation training methods as used by Sodergren and colleagues may greatly improve performance by basic neurosurgical trainees too, and must therefore be considered in neurosurgery curricula.

Imran Noorani
School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
inoorani226@gmail.com

References
1. Malone HR, Syed ON, Downes MS, D'Ambrosio AL, Quest DO, Kaiser MG. Simulation in neurosurgery: a review of computer-based simulation environments and their surgical applications. Neurosurgery. 2010 Oct;67(4):1105-16.

2. Wolfsberger S, Neubauer A, Bühler K, Wegenkittl R, Czech T, Gentzsch S, Böcher-Schwarz HG, Knosp E. Advanced virtual endoscopy for endoscopic transsphenoidal pituitary surgery. Neurosurgery. 2006 Nov;59(5):1001-9; discussion 1009-10.

• Commentor: Imran Noorani - School of Clinical Medicine, Addenbrooke's Hospital, Univers
• Date: Sep 03, 2011