Rassweiler J J, Henkel T O, Potempa D M, Frede T, Stock C, Günther M, Alken P
Urologische Klinik Klinikum Mannheim, Fakultät für klinische Medizin, Universität Heidelberg.
Urologe A. 1993 Sep;32(5):393-402.
The main problem with clinical introduction of laparoscopic techniques in urology is that despite experience with endoscopy no significant endoscopic training is given. Laparoscopic nephrectomy, in particular, is a rather complicated procedure and needs an adequate training concept: The beginner should have the possibility of practising in vitro in a closed "pelvi-trainer" to learn video-optical coordination and orientation; then it is necessary to get used to handling the instruments and practise the different steps of the procedure (i.e. clipping of vessels, sacking of the kidney) either in phantom models or in explanted animal organs. On this basis, we performed laparoscopic nephrectomy in an animal model (n = 18 porcine kidneys). We were able to standardize the technique of creating a pneumoperitoneum, the positioning of the animal, the site and size of the trocars, and preparation and clipping techniques (i.e. Endo-GIA) and entrapment of the kidney (testing different organ bags). A step-by-step approach was used for the introduction to clinical application. For simulation and training of video-assisted preparation techniques in patients and step-wise introduction to laparoscopy (instruments, endocoagulation, trocars), we created a "lap-tent", which was placed over the wound after exposition of Gerota's fascia. Further preparation was performed under laparoscopic conditions (without pneumoperitoneum) with a limited time allowed (1 h). Thereafter, we started with time-limited laparoscopy and laparoscopic lymphadenectomy prior to pelvic surgery (prostatectomy, cystectomy) to introduce the staff to the technique of pneumoperitoneum and placement of the trocars and to the use of the instruments in general. Based on this step-by-step training concept, after a 6-months period we were successful in introducing transperitoneal laparoscopic nephrectomy (TLN) to our clinical routine. So far, we have performed 20 laparoscopic nephrectomies, 1 nephro-ureterectomy, 4 tumour nephrectomies (inducing adrenalectomy), 2 adrenalectomies, and 6 modified retroperitoneal lymphadenectomies. In the lesser pelvis we have experience with 20 laparoscopic varicocelectomies, 23 pelvic lymphadenectomies, and 5 diagnostic laparoscopies for cryptorchidism (February 1993).
泌尿外科临床引入腹腔镜技术的主要问题在于，尽管有内镜检查经验，但却未提供重要的内镜培训。特别是腹腔镜肾切除术，是一个相当复杂的手术，需要一个适当的培训理念：初学者应该有机会在封闭的“盆腔训练器”中进行体外练习，以学习视频光学协调和定位；然后有必要习惯操作器械，并在模拟模型或离体动物器官中练习手术的不同步骤（如血管夹闭、肾脏装袋）。在此基础上，我们在动物模型（n = 18个猪肾）上进行了腹腔镜肾切除术。我们能够标准化建立气腹的技术、动物的体位、套管针的位置和大小，以及准备和夹闭技术（如Endo - GIA）和肾脏的包埋（测试不同的器官袋）。采用逐步推进的方法引入临床应用。为了模拟和训练患者的视频辅助准备技术，并逐步引入腹腔镜检查（器械、内镜下凝血、套管针），我们制作了一个“腹腔镜帐篷”，在暴露肾周筋膜后放置在伤口上方。在有限的时间（1小时）内，在腹腔镜条件下（无气腹）进行进一步的准备。此后，我们在盆腔手术（前列腺切除术、膀胱切除术）之前开始进行限时腹腔镜检查和腹腔镜淋巴结清扫术，以使工作人员熟悉气腹技术、套管针的放置以及器械的一般使用。基于这种逐步培训理念，6个月后我们成功地将经腹腹腔镜肾切除术（TLN）引入我们的临床常规操作。到目前为止，我们已经进行了20例腹腔镜肾切除术、1例肾输尿管切除术、4例肿瘤肾切除术（包括肾上腺切除术）、2例肾上腺切除术和6例改良腹膜后淋巴结清扫术。在小骨盆区域，我们有20例腹腔镜精索静脉曲张切除术、23例盆腔淋巴结清扫术和5例隐睾症诊断性腹腔镜检查的经验（1993年2月）。
