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Laparoscopy: Learning a New Surgical Anatomy?

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

necessarily depend on knowledge of basic anatomy as taught
Anatomy, the science of human biology, is a central discipline in earlier years (Dozois, 2008).
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 UNIQUE FEATURES OF ANATOMY
anatomy education (Older, 2004; Korf et al., 2008). Such ba-
sic anatomy is the basis on which surgical practice is built SEEN THROUGH A LAPAROSCOPE
during postgraduate/residency training. Laparoscopy first involves approaching the surgical field
Gross anatomy seems as an ‘‘anatomical continuum’’ of through high-resolution optical equipment under two-dimen-
organs and structures of different embryological origins sional vision. There is both a restriction of dissection move-
bound together by connective tissue. This connective tissue ments and some difficulty or impossibility in performing cer-
network supports and cushions with its many layers of differ- tain fundamental maneuvers of conventional surgery, includ-
ing texture and density. Visual identification of organs and ing tissue palpation and finger dissection. Laparoscopy
anatomical structures requires manipulation of the connective requires a distinct vision and manipulation of the connective
tissue, which creates an artificial set of spaces and planes tissue, resulting in a different surgical anatomy (Martı́n-
known as the surgical anatomy. While the more difficult to Jiménez and Torrent-Colomer, 2008).
conceptualize surgical anatomy should be learned during 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
*Correspondence to: Dr. Angel Martı́n Jiménez, Unidad de
to the visual characteristics and handling of this technology.
Ginecologı́a, Hospital Son Llátzer, Carretera Manacor km. 4, E-07198 In this respect, the concepts of basic anatomy are not modi-
Palma de Mallorca, Islas Baleares, Spain. E-mail: fied, but horizons for the interpretation of anatomic struc-
Received 11 February 2009; Revised 18 February 2009; Accepted 3 tures are significantly expanded (Gogalniceanu et al., 2008).
March 2009. With the rapid progress of operative laparoscopy in recent
Published online 10 April 2009 in Wiley InterScience (www. years, this alternative to the conventional approach of ab- DOI 10.1002/ase.75 dominal surgery has allowed the description of new planes,
spaces, and anatomic references. More detailed approxima-
© 2009 American Association of Anatomists 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 It is of course absolutely necessary to minimize the num-
and spaces as the ‘‘anatomical continuum’’ is artificially rup- ber of animals used in experimental surgery. Russell and
tured. All this novel anatomical knowledge will eventually be Burch (1959) summarized our ethical obligations in their
consolidated in accordance with its usefulness for performing book, The Principles of Humane Experimental Technique,
the necessary surgical maneuvers of dissection and resection. with their 3R principle of replacement, reduction, and refine-
We believe that knowledge of basic anatomy plays an even ment. While adhering to these principles, we recognize that
more important role with each new technological advance animal experimentation improves surgical technique by
because it represents the background for integration, interpre- increasing our knowledge of the surgical field and surgical
tation, and consolidation of novel variations of surgical anat- instrumentation. For teaching purposes, technological advan-
omy. Magnified laparoscopic views and the ability to deeply ces have allowed the substitution of many experimental ani-
explore anatomic features help in better understanding the mal models with mechanical simulators, video recordings,
basic anatomy, and even as laparoscopy requires a more pro- and three-dimensional virtual reality (Sweet and McDougall,
found knowledge of basic anatomy, it enhances our under- 2008; van der Meijden and Schijven, 2009). A great deal of
standing of the same. 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
TEACHING LAPAROSCOPIC ANATOMY laboratory has become indispensable for the development of
technologies, transmission of knowledge, and progress of
Familiarization with the laparoscopic view, in particular of surgery (Magrina et al., 2009).
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 We believe that developments in laparoscopic surgery in the
value as educational material for early learners. Published past 15 years have revolutionized the concepts of conven-
reports have also documented undergraduate anatomy tional surgical anatomy and forced surgeons to deepen their
teaching by way of laparoscopy in unembalmed cadavers. knowledge of basic anatomy. It has therefore been necessary
Fitzpatrick et al. (2001) reported that 78% of students felt a to rediscover this anatomy to adapt basic anatomy education
laparoscopy demonstration enhanced learning, and 86% to new and more demanding dynamics of practice. Surgical
believed it should be continued. Glasgow et al. (2006) found manipulation has become more anatomical, and anatomy has
that more than 95% of responding students agreed that become more comprehensive. In the future, we must face the
cadaver-based laparoscopy demonstrations enhanced their challenge of integrating, in a regulated and orderly manner,
understanding of abdominal anatomy. Regardless of planned these processes of knowledge at the different levels of teach-
area of specialization, students felt that the demonstration ing anatomy and surgery.
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 NOTES ON CONTRIBUTORS
technical skills related to laparoscopy must be acquired. ANGEL MARTIN JIMÉNEZ, M.D., is Head of the Depart-
One such skill is the hand-eye coordination required to ment of Gynecology, Hospital Son Llátzer, Balear Health
work at distance from the surgical field and under two- Institute, Palma de Mallorca. Ib-Salut Baleare, Spain, and
dimensional vision. For this, practice in the experimental President of the Endoscopy Section of the Spanish Gynecol-
surgical laboratory is essential. ogy and Obstetrics Society (SEGO).
The history of surgery is replete with examples of the im- JOSE-FRANCISCO NOGUERA AGUILAR, M.D., is
portance of the experimental theater in training physicians Head of the Department of General Surgery, Hospital Son
and surgeons. Also, new knowledge in the fields of anatomy Llátzer, Balear Health Institute, Palma de Mallorca. Ib-Salut
and surgery has often been acquired and then disseminated in Baleares, Spain.
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 Dozois E. 2008. Laparoscopic anatomy for medical students. Anat Sci Educ
today (Guerrini, 2003). 1:135.
In the experimental laboratory, different surgical proce- Fitzpatrick CM, Kolesari GL, Brasel KJ. 2001. Teaching anatomy with sur-
dures are developed and tested before their use in human geons’ tools: Use of the laparoscope in clinical anatomy. Clin Anat 14:349–
beings. Simulated procedures allow trainees to progress up
Glasgow SC, Tiemann D, Frisella MM, Conroy G, Klingensmith ME. 2006.
the learning curve of a new technology or technique without Laparoscopy as an educational and recruiting tool. Am J Surg 191:542–
endangering patients. Even after achieving the technical skills 544.
of a particular procedure, it is necessary to maintain one’s Grunwald T, Krummel T, Sherman R. 2004. Advanced technologies in plastic
abilities and further develop others, and to test new instru- surgery: How new innovations can improve our training and practice. Plast
Reconstr Surg 114:1556–1567.
mentation and surgical approaches. This has become espe-
Gogalniceanu P, Madani H, Paraskeva PA, Darzi A. 2008. A minimally
cially true in the fields of endoscopic and minimally invasive invasive approach to undergraduate anatomy teaching. Anat Sci Educ 1:46–
surgery. 47.

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Guerrini A. 2003. Experimenting with Humans and Animals: From Galen to Ani- Older J. 2004. Anatomy: A must for teaching the next generation. Surgeon
mal Rights. 1st Ed. Baltimore, MD: The Johns Hopkins University Press. 184 p. 2:79–90.
Martı́n-Jiménez A, Torrent-Colomer A. 2008. An update of anatomical referen- Russell WMS, Burch RL. 1959. The Principles of Humane Experimental Tech-
ces in total laparoscopic radical hysterectomy: From surgical anatomy to ana- nique. 1st Ed. London, UK: Methuen & Co. Ltd. 238 p.
tomical surgery. J Minim Invasive Gynecol 15:4–10. Sweet RM, McDougall EM. 2008. Simulation and computer-animated devices:
Korf HW, Wicht H, Snipes RL, Timmermans JP, Paulsen F, Rune G, Baumgart- The new minimally invasive skills training paradigm. Urol Clin North Am
Vogt E. 2008. The dissection course—necessary and indispensable for teaching 35:519–531.
anatomy to medical students. Ann Anat 190:16–22. van der Meijden OA, Schijven MP. 2009. The value of haptic feedback in
Magrina JF, Kho R, Montero RP, Magtibay PM, Pawlina W. 2009. Robotic ex- conventional and robot-assisted minimal invasive surgery and virtual reality
traperitoneal aortic lymphadenectomy: Development of a technique. Gynecol training: A current review. Surg Endosc; DOI 10.1007/s00464-008-0298-x
Oncol 113:32–35. (in press).

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