We thank Rane and Shah for their interest in our article. We are familiar with the technique of hand-assisted laparoscopy, having introduced it into our practice some years ago [1,2]. Although it is argued that in many cases the incision used for specimen extraction can initially be used for a hand-port, we believe that use of an incision large enough to enable the operator's hand to be placed inside the abdomen rather defeats the point of the laparoscopic approach. Whilst hand-assisted laparoscopy may have a place in laparoscopic nephrectomy for carcinoma, where the specimen is removed intact, the use of this technique to accelerate learning can be no substitute for a structured laparoscopic training programme, and it is our view that those surgeons who undergo formal laparoscopic training of the sort outlined in our article will find the use of hand assistance unnecessary.
We thank Miss Shah for her detailed definition of spatial awareness. There will be many who recognise that this term, loosely applied by us, is perhaps an attempt to introduce some objectivity into the differentiation between what experienced surgeons will instantly recognise as the difference between the naturally gifted surgeon and those of us who improve our skills with experience.