Surgeon’s Stress during Laparoscopic Surgery

Laparoscopic techniques have proved to be beneficial for the surgical patient with respect to decreased post-operative pain, decreased postoperative hospital stay, less would complications, and overall faster recovery allowing return to work. In summary, trauma is markedly less than with open surgery. However, the effects of this stressful surgery on the laparoscopic surgeon rarely have been investigated. Minimally invasive surgery causes greater mental strain for laparoscopic surgeons than consecutive open surgical cases. Laparoscopic surgery causes higher mental strain for laparoscopic surgeons than conventional surgery and is significantly more stressful in consecutive few initial cases for beginners. One study was conducted at laparoscopy hospital, New Delhi aimed to investigate whether individual stress responses are associated with intraoperative alterations of manual surgical skill and technical errors of the laparoscopic surgeon. Prof. Mishra performing laparoscopic surgeryFor this study specially designed human shape virtual reality simulator was used. Stress measurement was carried out for 20 trainee surgeons who have come for getting training at Laparoscopy Hospital, New Delhi. During their task performance harvested animal viscera is introduced inside the abdominal cavity and defferent task were assigned and activity of the sympathetic nervous system was evaluated by skin resistance with the help of a sympathicograph. The conclusion of this study was that the mental load of the laparoscopic surgeons is much more during tough tasks like intracorporeal suturing, coagulation of any active bleeder, and during dissection of any big vessel and this strain might be highly optimized by continuous activity of the sympathetic nervous system. This comes with repeated practice in lab environment. The question of what extent or quality of stress produces adverse effects remains unclear. Presently there is no valid data exist on the surgeon’s reactions in the face of complications and “crisis” situations with stress corresponding to that in a laparoscopic surgery in the operating room. In contrast, for a similar challenge, many years of simulation training in aviation has allowed air crews to coordinate and standardize recovery strategies. The use of laparoscopic endotrainer based simulators for evaluation of stress and the corresponding reaction to the operative situation have not been examined previously in any institute. Furthermore, publications on learning curve in laparoscopic simulation include only ideal situations and exclude specific stress and critical situations as they are frequently manifest in reality. Thus, laparoscopic simulation may not be able to imitate a “real” stress scenario completely, and the realism of the settings used remains limited. Surgeon’s mental strain in the laparoscopic operating room, obviously more important than stress, is difficult to define and to measure. The results of our study indicate that mental load might be highly optimized by activity of the sympathetic nervous system.Our lab setup laparoscopic operating room scenario identified different types of surgeon-specific stress reaction. Interestingly,  the subgroup with the highest activity of the sympathetic nervous system without recovery during the course of the procedure required the largest extensions of movement to cope with the laparoscopic task, but experienced fewer intraoperative failures and complications.  Varied age group and different experience range of surgeon were participated in the study group and due to the low number of test persons involved, validation of the conclusions drawn from this study must be regarded with care. Further studies involving larger subgroups are necessary to evaluate the relevance of our findings.

How to get trained in Laparoscopy?

General surgeon, gynaecologists and medical industry at one time had the impression that advanced technology would minimize the need to establish the unique surgical skill set required for the videoscopic environment. As all the surgical specialization today face the daunting task of developing skills necessary for advanced minimal access laparoscopic procedures, there must be a willingness to recommit to training in basic and advanced skills including suturing. In the open surgical area, most attending surgeons, gynaecologists would not allow a resident to perform a procedure without being able to suture. That standard must not be abandoned today. The good training program should have didactic training, animal dissection and Top Gun Drill exersices together with exposure in operation theatre. 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 and gynaecologists are not born to greatness but rather they are made by a willingness to be trained.

In 1992 on the island of Aruba, first Top Gun Laparoscopic Skill and Suturing Program were held. It was sponsored by the Academic Medical Center in Amsterdam, Holland. In this top gun drill program 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. Similar top gun drill program was held at Laparoscopy Hospital, New Delhi during international conference on recent advances in minimal access surger. This international conference was approved by ministry of health Government of India and financially supported by Medical council of India. During this Top Gun Drill program surgeons were asked to tie tumble square knot 30 participants were not able to tie this not within 8 minutes. With the positive feedback from this course, it was offered in the US and UK with the support of Carlos Babini and the United States Surgical Corporation (USSC). The program crossed over into cyberspace with production of a DVD whose effective knowledge transfer capability as described by Rosser et al1 will be pivotal to the development of a distance education program.

Top Gun training as an element of their minimally invasive training program.

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.

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 DVD tutorial, videoconference lectures, and skill development exercises in good training institute.

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 laparoscopic procedures worldwide.