Development of a Novel Ex-Vivo Porcine Laparoscopic Heller Myotomy and Nissen Fundoplication Training Model

Hideki Ujiie¹, Tatsuya Kato¹, Patrycja Bauer¹, Hsin-pei Hu¹, Priya Patel¹, Hironobu Wada¹, Daiyoon Lee¹, Kosuke Fujino¹, Colin Schieman², Andrew Pierre¹, Gail Darling¹, Kazuhiro Yasufuku¹. ¹Division of Thoracic Surgery, Toronto General Hospital, ²Division of Thoracic Surgery, McMaster University

Introduction: Trainees in General & Thoracic Surgery are required to develop competency in a variety of laparoscopic operations. There is a need to develop a training simulation that can facilitate the trainees’ transition to performing laparoscopic procedures in a clinically relevant model. Developing technical skills for laparoscopic heller myotomy and Nissen fundoplication is difficult as there has been a decrease in the number of procedures performed. These procedures are technically difficult as it requires the ability to perform the surgery in multiple planes in a three-dimensional environment with two-dimensional visual feedback. This study aims to develop a cost-effective and anatomically relevant model to be used for training in laparoscopic foregut procedures. We developed an ex-vivo porcine model to teach surgical trainees the fundamentals of performing a laparoscopic myotomy and fundoplication.

Methods: An ex-vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen (Figure). To simulate the normal anatomy, we used an arch system to simulate the normal radial shape and tension of the diaphragm. A basic laparoscopic box-trainer housed the model. Fifteen surgical trainees and five faculty members were tested during a training course using this model. They were later asked to complete a course evaluation survey and provide feedback on the ex-vivo porcine training model.

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Results: Fifteen trainees completed the survey. They agreed that the exercise was a valuable use of their limited time, and that repeating the exercise would be of additional benefit, and that the exercise will improve their ability to perform or assist in an actual case in the operating room. Significant subjective improvements in mean pre- versus post training in the – (1) knowledge level (4.3 vs 7.5, P< 0.001), (2) comfort assisting (5.1 vs 6.9, P< 0.05), and (3) comfort performing as the primary surgeon (3.9 vs 6.7, P< 0.001) are depicted. The trainees and faculties unanimously agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy. They commented that skills obtained from training with this model are transferable to other laparoscopic procedures.

Conclusions: We developed an inexpensive, durable, and easily reproducible training model for laparoscopic procedures. This newly developed ex-vivo porcine model with an arch system simulates human anatomy and increases trainees’ comfort level in performing and assisting with myotomy and fundoplication. We believe that this training model will become a significant addition to laparoscopic training.