Web Extra

by Marcia Hill Gossard ’99, ’04 Ph.D. | Photos by Henry Moore Jr.

In a small, windowless room, four veterinarians simultaneously tie sutures, biopsy a liver, and perform minimally invasive abdominal surgery. No, this is not a typical operating room. It is a veterinary laparoscopic training laboratory—the first of its kind in the nation.

Nearly four years ago, Dr. Boel Fransson, a board-certified small animal surgeon, designed what is now the Veterinary Applied Laparoscopic Training (VALT) laboratory at Washington State University. Although laparoscopic simulation training has been widely used in human medicine for more than a decade, similar training had not been available in animal medicine. A laparoscope is essentially a telescope used by surgeons to see inside body cavities while doing minimally invasive surgery through tiny incisions, often called keyholes.

“Our laboratory is the first in the country to develop veterinary simulation training in laparoscopic surgery,” said Dr. Boel Fransson, director of the VALT laboratory. “I was very interested in technique development for the additional skills required for the minimally invasive surgeries we perform in clinical practice here at WSU.”

Laparoscopic surgery is being used more often in veterinary medicine because of the same advantages to patients as seen in humans. Risks associated with traditional open surgery are minimized, pain is reduced and easier to control, and patients often recover much more quickly. It is also a valuable tool that allows veterinarians to run diagnostic tests they may not otherwise be able to perform.

“We want to train better and safer surgeons.”

–Dr. Boel Fransson, WSU veterinary surgeon and director of the VALT laboratory.

Although the American College of Veterinary Surgeons requires training in minimally invasive surgical techniques, there was no other learning platform for surgeons in training except to participate in actual surgeries with a mentoring surgeon. Dr. Fransson and her colleague, Dr. Claude Ragle, a WSU board-certified equine surgeon and pioneer in equine laparoscopy, believe additional training outside the operating room is necessary to achieve higher competency levels. More training also means less risk to the patients.

“We want to train better and safer surgeons,” said Dr. Fransson, “before they perform surgery on someone’s beloved pet.”

With proper training laparoscopic surgery can be simpler and safer than other surgical techniques. Training in the VALT lab, surgeons become accustomed to using actual surgical tools in small spaces while watching the magnified procedures on a television screen.

“Training in the lab improves dexterity and familiarity,” said Dr. Courtney Watkins, a WSU small animal surgery resident who has trained in the VALT lab. “It is a good way to practice skills without the stress and urgency of an actual surgery.”

Practicing the precise movements of laparoscopic surgery also helps the techniques to become second nature. Additional training minimizes unnecessary movements, surgery time, and increases accuracy.

“The training builds confidence and better surgeons,” said Dr. Stavros Yiannikouris, WSU equine surgery resident. “In the VALT lab, I have the freedom to explore different surgical techniques to learn what will be most efficient and effective during surgery.”

The VALT lab began training veterinarians in 2008 with very basic equipment, such as a box trainer that uses real instruments to teach hand-eye coordination necessary for routine procedures such as suturing. Dr. Fransson later added canine abdomen models that train surgeons in the feel and size of the abdominal cavity and organs. The virtual reality, or VR, trainer was added to the lab earlier this year.

“The virtual laparoscopic trainer has a real feel,” said Dr. Ragle, WSU equine surgeon and VALT lab co-director. “It provides immediate feedback by showing if you’ve made a patient bleed or if you are going out of bounds.”

After working on the VR trainer, surgeons receive printouts to learn how their techniques can be more efficient and safe. The software tracks the surgeon’s performance and provides an assessment of the surgeon’s skills.

“Sometimes it is that the tools need to be adjusted, or it could be how the surgeon is standing or even holding their arms that makes a difference,” said Dr. Ragle.

One of the criticisms of virtual reality trainers is that they do not provide physical, or haptic, feedback that a surgeon would feel during an actual surgery. Although the canine abdomen model does provide some haptic feedback, the VALT lab will also be adding an augmented reality trainer, a hybrid that combines virtual reality with haptic feedback. As the lab grows, Dr. Fransson would like to expand training to more veterinarians.

“Currently we are training residents and veterinarians at WSU in our lab,” said Dr. Fransson. “Our plan is to open it up to DVM students as an elective. We hope in the future to even invite surgeons from other universities to come train in our lab.”

Since Dr. Fransson has begun training in the VALT lab, WSU veterinarians have gone from having basic skills in laparoscopic surgery to now being at the highest competency level.

“By having everyone trained at this level, it has increased the safety for our patients,” said Dr. Fransson. “Increasing safety means we are offering the best possible care.”

Established in 2008, the VALT laboratory’s mission is to develop, validate, and implement veterinary laparoscopic training programs. The aim is to bring basic laparoscopic skills training out of the operating room, where different techniques can be practiced and explored. The long-term goal is to create safer surgeons for the benefit of animal patients.Unlike traditional surgical techniques, laparoscopic surgery can be performed using very small incisions. With minimally invasive procedures, there are fewer risks for the patient and recovery time is much quicker. Also sometimes called keyhole surgery, surgeons look at magnified images on television screens while using long instruments to perform the surgery or diagnostic procedures. Because a very different skill set is used in laparoscopic surgeries, additional training in the VALT lab has shown in research studies to improve skill levels.