Ⅰ. The Exploration Of Basic Skills For Training Urologic Laparoscopic SurgeryⅡ. Clinical Application Of Double J Tube With Line In The Male Transurethral Lithotripsy

BackgroundAs a stimulating factor, surgery may produce stress, inflammation, immunity response, leading to a certain degree of damage to the body. For surgical patients, how to implement the best therapeutic effect with minimal damage has been the target of the clinical surgeons.The development of modern minimally invasive surgical techniques deeply affects the concept of surgical treatment. Among them, laparoscopic surgery is a successful combination of modern technology and traditional operation. As the main content of minimally invasive surgery, it has become the important direction in the future.Compared with the traditional surgery, it have less trauma, better stable internal environment, the more accurate results, the shorter length of hospital stay and better psychological effect, opened a new era of modern surgery.Over the past20years, laparoscopic surgery in the field of clinical urology has become more mature, and increasingly widely used. At present, in many traditional operations, laparoscopic surgery has achieved a revolutionary success. From the past simple removal damaged surgery, such as renal cyst unroofing, adrenal tumor resection, no function renal resection, etc, to the present complicated functional reconstruction surgery, such as renal pelvis ureteroplasty, partial nephrectomy, radical resection of prostate cancer, bladder resection with new bladder in situ technique, etc, it basically covers all the category of specialized operation.Part of the laparoscopic surgery has replaced traditional surgery, become the preferred classic such as adrenal tumor resection. Minimally invasive advantage of the laparoscopic surgery quickly won the wide recognition of surgeon and patient. This specialized subject is indispensable important component of modern surgery.But, laparoscopic surgery is a new skill totally, fundamentally different from the traditional surgery. It has a very distinctive technical characteristic. Demand in the operation of three-dimensional space perception, hand-eye coordination and so on ability, must be gradually improved through training. Among them, the laparoscopic suture operation is particularly difficult to grasp, limiting the technology in clinical application extremely.Researches have been reported: after all kinds of different laparoscopic training, the ability of trainers can be a certain degree of increase. Training is very important for operation safety of laparoscopic surgery, and can avoid the problems caused by the surgery skills unskilled, and can minimise the risk of surgical complications.In view of factors of expensive training equipments and the lack of formal, standard, unified training courses, limited teaching resources extremely, how to train basic laparoscopic skills for clinical doctors has not been solved. The development status of urologic laparoscopic surgery in the domestic various regions is unbalanced, and lots of medical units are still in the initial stage.Thus, strengthening laparoscopic training of clinical surgeons is necessary extremely. How to improve efficiently laparoscopic surgical training is an important subject. Seeking a convenient mode for self training is the urgent request of clinicians also.Chapter1:Application of homemade training box to improve basic skills of laparoscopic surgeryObjectiveTo introduce a homemade training box to acquire basic laparoscopic skills by the way of3training courses of laparoscopic suturing operation.MethodsGroup A is made of12young doctors without the experience of laparoscopic procedure, participating the training program. Through using this kind of homemade training box,3training items are gloves intermittent, intestinal continuous and chicken skin graphic suture. Trainees practice2h every day,10h weekly, including continuous4w. Learning curves of3tasks weekly were observed. At the end of training, participants were assessed by the use of a self-made training model of ureteral calculi, including opening wall, removing stone, placing internal double J tube and intermittent suturing incision. The time of3operations and the test in group A at the end of the training respectively, compared with the completion time in group B who are4doctors having all kinds of laparoscopic experiences at least100cases.Results12young doctors in group A are successfully completed training and assessment. After4w training, the time of suturing tasks significantly shortened. The time of gloves intermittent, intestinal continuous and chicken skin graphic suturing declined respectively from the first week (51.93±8.34)min,(34.76±7.32)min and (44.48±8.32)min to the final (32.08±5.59)min,(22.27±4.69)min and (26.42± 7.10)min, and the difference was statistically significant (P<0.05). Compared the final time in group A with the completion time in group B (26.48±4.83)min,(16.40±6.36)min and (24.63±5.30)min, the difference was not statistically significant (P>0.05).Otherwise, during the course of training process later, we observed that participants controlling stitch and edge distance are more accurate when sewing, and quality of appearance has been improved. At last, group A can complete successfully the testing task, and operational completion time (29.93±9.03)min compared with the time (27.95±6.67)min in group B. The difference was not statistically significant (P=0.696>0.05).ConclusionThe application of homemade laparoscopic training box by the way of training of suturing operation can well improve the comprehensive basic skills of surgery, suitable for clinical doctors to perform primary self training. Chapter2:To introduce a kind of model for intensive training laparoscopic bladder-urethral anastomosisObjectiveTo introduce a kind of model for intensive training laparoscopic bladder-urethral anastomosis, and evaluate two different ways of anastomosis of continuous suture and intermittent suture. MethodsThe human pelvic was simulated by the chicken trunk, and bladder and urinary tract were simulated by chicken proventriculus and rectum respectively. Using this model placed in homemade training box, 12residents without the experience of laparoscopic procedure who have completed some basic technologic training were randomly divided into2groups, training with10rounds of anastomosis.6residents in group A suture from3:00to3:00clockwise;6residents in group B suture the chicken rectum and proventriculus at6:00first, followed by suturing4,8,2,10,12. Each operating time was recorded.ResultsParticipants in two groups have successfully completed the entire training. The time of group A declined from the first (43.58±6.66)min to7th times, the final (32.07±7.00) min,(28.77±3.40)min; the time of group B from the first (44.92±2.92)min to6th times, the final (33.97±6.10) min,(28.55±3.74)min; the differences were statistically significant(P<0.05). Compared the operating time of two groups, the differences were not statistically significant (P>0.05).ConclusionThe simple realistic and effective model can simulate operation steps of laparoscopic bladder-urethral anastomosis, suitable for no laparoscopic experience student to improve the suturing techniques. Chapter3:To introduce a kind of model for training laparoscopic dismembered pyeloplastyObjectiveTo introduce a kind of model for training laparoscopic dismembered pyeloplasty.MethodsThe model of ureteropelvic junction obstruction was simulated by pig kidney and chicken crop. Using the model placed in homemade training box, eight residents without the experience of laparoscopic procedure who have completed some basic technologic training were trained with10rounds of anastomosis according to the standard operation steps. Each operating time and quality were recorded.Results8trainees completed the entire training successfully. The operating time decreased from (73.75±6.69)min to (55.38±6.21)min, and anastomotic errors score decreased from (7.00±1.86) min to (3.13±1.36) min. The difference was statistically significant (P<0.05).ConclusionThis simple, realistic and effective model can simulate the operation steps of laparoscopic pyeloplasty, suitable for no laparoscopic experience student. Chapter4:Development of rabbit models for training basic skills of urologic laparoscopic surgeryObjectiveTo value rabbit models for training basic skills of urologic laparoscopic surgery.MethodsRabbit models of laparoscopic nephrectomy, ureteral anastomosis and pyeloplasty were developed. In the self-made simulation, eight trainees with no actual laparoscopic surgery participated10rounds of simulation training by taking the models according to the standard steps. Each operating time was recorded. The learning curves of laparoscopic nephrectomy, ureteral anastomosis and pyeloplasty were observed.ResultsEight doctors are successfully completed training. The time of laparoscopic nephrectomy declined from the first (45.75±6.88)min to the final (25.86±3.31)min; the time of laparoscopic ureteral anastomosis from the first (56.75±7.13) min to the final (35.50±4.04) min; the time of laparoscopic pyeloplasty from the first (77.38±5.34)min to the final (59.13±7.26) min. The differences were statistically significant (P<0.05). Otherwise, sewing mistakes declined obviously, and controlling stitch and edge distance were more accurate, and the quality and appearance were significantly improved in the training later.ConclusionRabbit can be conveniently used to set up some animal models to train laparoscopic nephrectomy, ureteral anastomosis and pyeloplasty, suitable for clinical urologic doctors to train basic skills of laparoscopic surgery. Section2:Clinical application of double J tube with line in the male transurethral lithotripsyBackgroundChina is one of high incidence of urinary calculi in the world, and its incidence is about1%～5%, and the south about5%-10%. New incidence is about150～200/100,000. Ureteral calculi is the most common urinary tract stone, and often causes acute unbearable renal pain suddenly. Ipsilateral kidney seeper, urinary tract infection and kidney damage can been caused by obstruction easily. It is a serious threat to the health of the patient.With the development of modern science and technology, the high quality of ureteroscopy and medical holmium laser and other high-tech products successively have been used in clinical. Currently, transurethral ureteroscopy cavity operation widely has been used in the treatment of ureteral calculi.Considering that ureteral calculi often leads to the surrounding ureteral wall mucosal edema, inflammation, polyp, narrow, upper tract expansion and impaired renal function, indwelling double J tube is one of the standard procedure in the course of operation. Its purpose is to keep the upper tract unobstructed drainage after operation, protect renal function, reduce waist back pain and infection, prevent ureteral stricture. It also has the effect of passive expansion of the ureter, and may be help gravel out of body in an orderly fashion. But, indwelling double J tube is bound to bring a serious problem: it must be taken by cystoscopy in the postoperative. Clinically, cystoscopy is a highly invasive operation. Because there are more length, two bending, three physiological anatomical narrow in male urethral, cystoscopy must be particularly painful. And it may cause serious hematuria, urinary pain, urethra injury and urinary tract infection, urethral stricture and iatrogenic complications.The literature reported that patients were serious anxiety and pain before and after checking due to the lack of understanding of the cystoscopy. The study of other scholars to cystoscopy tolerance of outpatients show that cystoscopy operation is painful significantly, adopting digital classification method used to evaluate patients.Therefore, for male patients with ureteral calculi of intraoperative indwelling double J tube, whether can avoid postoperative routine cystoscopy is worthy of clinical research.ObjectiveTo explore clinical value of double J tube with line in the male transurethral lithotripsy extubating tube by reserved line.Methods80cases of male patients with ureteral calculi, according to the operational time, were randomly divided into A, B groups, and each group has40cases. After transurethral holmium laser lithotripsy, group A was placed double J tube with line, extubating tube by reserved line after surgery; group B was placed double J tube without line, extubating tube by cystoscopy. Quality of life and lower urinary tract symptoms with double J tube, the visual analog pain score extubating tube and the recovery time of normal urination were observed. ResultsAge structure, the stone diameter, operation completion time and clearance rate of stone in two groups were no statistically significant (P>0.05). Quality of life score and lower urinary tract symptoms with double J tube were (2.63±0.93) points VS (2.53±0.75) points and87.5%(35/40) VS82.5%(33/40), and the differences were no statistically significant (P>0.05). Visual analog pain score extubating tube and recovery time of normal urination were (2.73±1.01) points VS (5.98±1.76) points and (23.23±4.49)h VS (47.25±6.83)h, and the differences were statistically significant (P<0.05).ConclusionDouble J tube with line in the urethra holmium laser lithotripsy to male patients with ureteral calculi does not affect quality of life, and increase complications. But the degree of pain extubating tube reduced significantly and normal urination can be recovered fastly.