In recent years laparoscopy in urology has become increasingly popular because it is less invasive and requires a shorter convalescence. It is now necessary for Residents and new urologists to learn the basic principles and advanced steps of urological laparoscopy. Appropriate training is mandatory to acquire the necessary laparoscopic skills. Indeed, there is an entirely different set of skills involved and a different way of viewing the anatomy; this minimally invasive surgery requires that beginners gain considerable training and experience .
If practised by unskilful hands there is a real risk of having a higher rate of complications. Some authors have underlined the importance of laparoscopic training courses as a more rapid and safe process for learning laparoscopy . Therefore we need selected centres where it is possible to acquire the technical ability needed to perform this surgery safely. In this way a surgeon, after training in a centre of excellence, should be able to use laparoscopy with less training and a lower complication rate.
At our institution we devised a programme of four steps; observation, theoretical learning, assisting and operating. Before proceeding to a subsequent step perfect comprehension of the previous step is mandatory.
From 2001 to 2005, 14 trainees visited our department to learn laparoscopy; initially they learn about all the laparoscopic instruments, materials and sutures needed for the procedures. They learn how to set up the operating table and the position of the patient for either the different approaches or procedures (first step).
They observe the surgeons and assistants, noting the way they move in the laparoscopic field, the gestures they do and the ‘tricks’ they use. During these activities they are assisted by the surgeons and by an experienced Fellow. In this way they learn several steps of the different procedures and understand correct laparoscopic gestures. They have also the possibility to train themselves in suturing with the pelvic trainer (second step).
They then assist in all the procedures to reach perfect coordination between surgeon and assistant (third step). Finally, they begin endoscopic suturing, in several steps of progressively increasing difficulty, until they can carry out the whole operation (fourth step).
One year after their fellowship, we contacted all the Fellows that attended our institution; currently 12 of the 14 are performing laparoscopic urology in their country. They reported no major complications and their conversion rate was <2%.
Many urologists are interested in attending laparoscopic courses , and previous studies show that about half of participants in laparoscopic training courses used laparoscopic surgery after the course . This shows that laparoscopic courses are an essential contribution to training in this kind of surgery. Furthermore, urologists who had a lengthy laparoscopic training period performed ≈ 25 cases per year .
Our experience can help to improve the diffusion of laparoscopy; initially Fellows become more familiar with a different view of the anatomy and with the technique by watching experienced surgeons. They practised on pelvic trainers to learn how to move within a two-dimensional space and become confident with a different perception of the operative field. During this phase they also attend courses using live pigs (courses run by the European Institute of Telesurgery). The porcine model is another essential part, as a direct step from the pelvic trainer to the operating theatre would be too difficult for a trainee. They learn the correct way to work with laparoscopic materials, such as clips and the different sources of energy, and they can reproduce in these animals the gestures that they would use when operating on patients. Beginning with an animal model would be a waste of time and cost, as only when basic laparoscopic skills and dexterity are acquired is it possible to transfer the practical ability correctly to an animal.
For a urologist, accustomed to the vision during open surgery, it is not easy to gain confidence with the two-dimensional vision, lack of depth perception and direct tactile feedback. Many movements and the dexterity that are uncommon in open surgery must be mastered to perform effective laparoscopy without increasing the risk of an injury to the patient . There is a different vision of the anatomy, and even for experienced surgeons it is not easy to recognize anatomical landmarks. The first part of the stage is planned to comply with these deficiencies. Only by watching several procedures under the guidance of an expert, who can accurately explain all the details of different technical steps, is it possible to acquire the principles essential for laparoscopy.
The mentor approach has already proved to be a safe and valid way to teach laparoscopy [6,7]. We think that our schedule, which provides progressively increasing surgical difficulty, can fulfil the needs of a laparoscopic beginner. Our model was devised to answer to common questions about how to start and how to progress. The training programme is planned to expose the Fellow progressively to increasingly advanced laparoscopic tasks, learning by a combination of observation, direct instructions and guided practice.
We cannot establish in how many procedures the Fellow needs to be assistant before operating alone, because the general preparation is specific to an individual, and the innate technical skills can vary widely among students. Only the mentor can decide when the Fellow is ready to operate.
Even if technically demanding, laparoscopic surgery is safely reproducible and teachable. The learning path comprises several progressive steps, each of which is crucial. The best conditions to learn laparoscopy are in selected centres where this technique is used routinely. A broad schedule of courses and practice can provide a real benefit for acquiring the theoretical and technical skills needed for optimum performance.