SHORT COMMUNICATION

Laparoscopy: Learning a New Surgical Anatomy?

Angel Martin Jiménez,1* Jose-Francisco Noguera Aguilar2
1
Department of Gynecology, Hospital Son Llátzer, Balear Health Institute, Palma de Mallorca,
Ib-Salut Baleares, Spain
2
Department of Surgery, Hospital Son Llátzer, Balear Health Institute, Palma de Mallorca,
Ib-Salut Baleares, Spain

Operative laparoscopy has progressed rapidly in recent years, and this alternative to the
conventional approach for abdominal surgery has allowed the description of new planes,
spaces, and anatomic references as a result of the artificial rupture of the ‘‘anatomical
continuum.’’ Magnified laparoscopic views and the ability to deeply explore anatomic
features better demonstrate the basic anatomy. Therefore, even as laparoscopy requires a
more profound knowledge of basic anatomy, it enhances our understanding of this anat-
omy. Current technology for recording and editing video-taped sequences facilitates pre-
sentation on screen and can detail all aspects of interest, making such videos high value
educational material for learners. Likewise, the experimental surgical laboratory is an in-
dispensable setting for the development of these and other new technologies, transmission
of their knowledge, and surgical progress. Anat Sci Ed 2:81–83, 2009 © 2009 American Associa-
tion of Anatomists.

Key words: laparoscopic anatomy; surgical anatomy; postgraduate/residency training

INTRODUCTION postgraduate/residency training, such understanding will

Anatomy, the science of human biology, is a central discipline
of biomedical sciences. We agree with others that traditional
teaching of basic anatomy from embryogenesis to cadaveric
dissection must remain a fundamental pillar of undergraduate
anatomy education (Older, 2004; Korf et al., 2008). Such ba-
sic anatomy is the basis on which surgical practice is built
during postgraduate/residency training.
Gross anatomy seems as an ‘‘anatomical continuum’’ of
organs and structures of different embryological origins
bound together by connective tissue. This connective tissue
network supports and cushions with its many layers of differ-
ing texture and density. Visual identification of organs and
anatomical structures requires manipulation of the connective
tissue, which creates an artificial set of spaces and planes
known as the surgical anatomy. While the more difficult to
conceptualize surgical anatomy should be learned during
*Correspondence to: Dr. Angel Martı́n Jiménez, Unidad de
Ginecologı́a, Hospital Son Llátzer, Carretera Manacor km. 4, E-07198
Palma de Mallorca, Islas Baleares, Spain. E-mail: amartin@hsll.es
Received 11 February 2009; Revised 18 February 2009; Accepted 3
March 2009.
Published online 10 April 2009 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ase.75
© 2009 American Association of Anatomists
necessarily depend on knowledge of basic anatomy as taught
in earlier years (Dozois, 2008).
UNIQUE FEATURES OF ANATOMY
SEEN THROUGH A LAPAROSCOPE
Laparoscopy first involves approaching the surgical field
through high-resolution optical equipment under two-dimen-
sional vision. There is both a restriction of dissection move-
ments and some difficulty or impossibility in performing cer-
tain fundamental maneuvers of conventional surgery, includ-
ing tissue palpation and finger dissection. Laparoscopy
requires a distinct vision and manipulation of the connective
tissue, resulting in a different surgical anatomy (Martı́n-
Jiménez and Torrent-Colomer, 2008).
As a consequence of laparoscopy’s novel surgical anatomy,
the laparoscopic surgeon must have a deep knowledge of ba-
sic anatomy to explore new surgical approaches better suited
to the visual characteristics and handling of this technology.
In this respect, the concepts of basic anatomy are not modi-
fied, but horizons for the interpretation of anatomic struc-
tures are significantly expanded (Gogalniceanu et al., 2008).
With the rapid progress of operative laparoscopy in recent
years, this alternative to the conventional approach of ab-
dominal surgery has allowed the description of new planes,
spaces, and anatomic references. More detailed approxima-
tion and amplification of the surgical field has shown how

Anatomical Sciences Education MARCH/APRIL 2009 Anat Sci Ed 2:81–83 (2009)

handling the connective tissue may reveal infinite new planes
and spaces as the ‘‘anatomical continuum’’ is artificially rup-
tured. All this novel anatomical knowledge will eventually be
consolidated in accordance with its usefulness for performing
the necessary surgical maneuvers of dissection and resection.
We believe that knowledge of basic anatomy plays an even
more important role with each new technological advance
because it represents the background for integration, interpre-
tation, and consolidation of novel variations of surgical anat-
omy. Magnified laparoscopic views and the ability to deeply
explore anatomic features help in better understanding the
basic anatomy, and even as laparoscopy requires a more pro-
found knowledge of basic anatomy, it enhances our under-
standing of the same.
TEACHING LAPAROSCOPIC ANATOMY
Familiarization with the laparoscopic view, in particular of
body regions such as the abdomen and the pelvis, should
probably be included in undergraduate anatomic training
programs. Current technology for recording and editing
video-taped sequences facilitates presentation on screen and
can detail all aspects of interest, giving such videos high
value as educational material for early learners. Published
reports have also documented undergraduate anatomy
teaching by way of laparoscopy in unembalmed cadavers.
Fitzpatrick et al. (2001) reported that 78% of students felt a
laparoscopy demonstration enhanced learning, and 86%
believed it should be continued. Glasgow et al. (2006) found
that more than 95% of responding students agreed that
cadaver-based laparoscopy demonstrations enhanced their
understanding of abdominal anatomy. Regardless of planned
area of specialization, students felt that the demonstration
reinforced the clinical relevance of gross anatomy. On the
other hand, the surgeon in the period of training will need a
deeper understanding of basic anatomy to efficiently realize
the many potentials of the laparoscopic approach. New
technical skills related to laparoscopy must be acquired.
One such skill is the hand-eye coordination required to
work at distance from the surgical field and under two-
dimensional vision. For this, practice in the experimental
surgical laboratory is essential.
The history of surgery is replete with examples of the im-
portance of the experimental theater in training physicians
and surgeons. Also, new knowledge in the fields of anatomy
and surgery has often been acquired and then disseminated in
the experimental theater. Animal experimental practice was
initiated in the second century by the prominent Roman phy-
sician Galen, who used pig and monkey models to demon-
strate ideas about the circulatory system that are still in force
today (Guerrini, 2003).
In the experimental laboratory, different surgical proce-
dures are developed and tested before their use in human
beings. Simulated procedures allow trainees to progress up
the learning curve of a new technology or technique without
endangering patients. Even after achieving the technical skills
of a particular procedure, it is necessary to maintain one’s
abilities and further develop others, and to test new instru-
mentation and surgical approaches. This has become espe-
cially true in the fields of endoscopic and minimally invasive
surgery.
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It is of course absolutely necessary to minimize the num-
ber of animals used in experimental surgery. Russell and
Burch (1959) summarized our ethical obligations in their
book, The Principles of Humane Experimental Technique,
with their 3R principle of replacement, reduction, and refine-
ment. While adhering to these principles, we recognize that
animal experimentation improves surgical technique by
increasing our knowledge of the surgical field and surgical
instrumentation. For teaching purposes, technological advan-
ces have allowed the substitution of many experimental ani-
mal models with mechanical simulators, video recordings,
and three-dimensional virtual reality (Sweet and McDougall,
2008; van der Meijden and Schijven, 2009). A great deal of
future research will focus on the new fields of minimally
invasive surgery, nanosurgery, robotics, telerobotics, and tele-
presence surgery (Grunwald et al., 2004; Sweet and McDou-
gall, 2008), and the experimental surgical laboratory will be
the setting for much of this work. The experimental surgical
laboratory has become indispensable for the development of
technologies, transmission of knowledge, and progress of
surgery (Magrina et al., 2009).
CONCLUSIONS
We believe that developments in laparoscopic surgery in the
past 15 years have revolutionized the concepts of conven-
tional surgical anatomy and forced surgeons to deepen their
knowledge of basic anatomy. It has therefore been necessary
to rediscover this anatomy to adapt basic anatomy education
to new and more demanding dynamics of practice. Surgical
manipulation has become more anatomical, and anatomy has
become more comprehensive. In the future, we must face the
challenge of integrating, in a regulated and orderly manner,
these processes of knowledge at the different levels of teach-
ing anatomy and surgery.
NOTES ON CONTRIBUTORS
ANGEL MARTIN JIMÉNEZ, M.D., is Head of the Depart-
ment of Gynecology, Hospital Son Llátzer, Balear Health
Institute, Palma de Mallorca. Ib-Salut Baleare, Spain, and
President of the Endoscopy Section of the Spanish Gynecol-
ogy and Obstetrics Society (SEGO).
JOSE-FRANCISCO NOGUERA AGUILAR, M.D., is
Head of the Department of General Surgery, Hospital Son
Llátzer, Balear Health Institute, Palma de Mallorca. Ib-Salut
Baleares, Spain.
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