to provide satisfactory simulation of the laparoscopic environment , one must establish what the minimum criteria of that environment are .
the first requirement is the presence of set entry ports by which laparoscopic instruments are directed into the operative practice field .
the second is a system by which to project the work area onto a video monitor .
the third is a method that allows use of as many different tissue substitutes as possible , thereby broadening the practice experience .
presumably , meeting the above criteria in a simulation model should allow practice in such a model to transfer to the real environment .
an abstract drawing of the borinquen ring ( br ) shows that it consists of a base holding up a vertical pole that is attached to a ring with a horizontal stem ( figure 1 ) . a coupling device and screw
are used to hold both the vertical pole and the ring stem together . through the center of this small ring ,
the coupler provides a means to change the angle of the ring and allow it to simulate the outer convex abdominal wall surface .
a flexible membrane can also be attached to the ring to simulate the local elasticity of the abdominal wall and allow trocar placement . the borinquen ring .
( a ) stand , ( b ) turning screw , ( c ) ring stem , ( d ) coupler , ( e ) vertical pole , ( f ) instrument handle , ( g ) entry port ring , ( h ) instrument shaft , ( i ) instrument blades .
the tissue suspender ( ts ) device has a similar abstract design as the br , but the ring in this case is much larger and has a mesh surface attached to it ( figure 2 ) .
this simulates the different tissue plane angles present along the inner concave surface of the different cavities encountered while performing video surgery .
these can be the peritoneal , retroperitoneal , thoracic , or other formed working cavities .
multiple working angles are involved in laparoscopic surgery , and training sessions should be used to maximize practice in as many of these as possible . the laparoscopic - ring ( lap - ring ) simulation trainer comprises the ts , two br , a cam - corder , and a television monitor .
( a ) stand , ( b ) turning screw , ( c ) coupler , ( d ) vertical pole , ( e ) ring stem , ( f ) large ring , ( g ) support mesh , ( h ) tissue specimen , ( i ) incision site , ( j ) practice sutures , ( k ) restraining wire .
the above 2 usa patented devices and the work that follows represent the author 's attempt to create a learning environment that is unique to the needs of each individual surgeon .
figure 3 shows a ts with a piece of bovine stomach , which has been placed on the mesh surface , with u - shaped nails passed through it .
this material can be used to practice suturing and stapling . to remove some of the strong odor of bovine stomach
when preparing it for use , it is best to soak it in sodium bicarbonate solution . during suturing practice , it is helpful to stain the  incision 
the lap - ring simulation trainer is demonstrated in figure 4 with the video monitor visible in the background .
suturing practice being done at the ts is displayed on the monitor . in this exercise ,
the ts is placed at approximately 110 to simulate the location of a ventral hernia .
. lap - ring simulation trainer with ts at 110 and television monitor in background .
the ts wire mesh can be covered with a white circular plastic cover , on top of which artificial models can be placed .
these can be used for additional practice sessions . to simulate vascular and other tubular structures ,
narrow balloons can be placed on the ts and used for practicing interrupted and continuous anastomoses .
a close - up of a completed practice session , demonstrates an end - to - end and a running anastomosis .
these have been placed on a white plastic disk that is covering the ts mesh .
narrow tubular balloons can also be used to simulate ductal structures , such as the common bile ducts , ureters , the urethra , and fallopian tubes .
catheterization practice can also be performed using these simple models , as demonstrated in figure 7 . when practicing anastomosis with narrow balloons , it is best to place small cylindrical plugs just inside the cut ends .
this maneuver helps maintain the 2 ends open , while the surgeon is trying to anastomose them together .
catheterization practice using a cone tip ureteral stent placed into a pink balloon and tied in 2 places .
when practice on more complex natural tissues is desired , the ts can be used to suspend pieces of small bowel , or an entire animal heart , as demonstrated in figure 8 .
bovine hearts , or bowel , can be ordered from local meat markets and used repeatedly .
all that is required is to occasionally sprinkle the specimens with dilute salt water solution during practice sessions . for short - term storage , the specimens
the heart model allows practice dissecting the cardiac arteries and practice tying off these vessels .
bovine heart placed on ts to use the cardiac vessels to practice dissection techniques and vessel tying or stapling . for more advanced dissections , one can dispense with the ts and use larger natural tissue specimens placed on a flat surface below the lap - ring simulation trainer .
different animals like rabbits , pigs , and dogs can be used for this purpose .
the animals are first sacrificed in a humane fashion , and then an immediate laparotomy is performed to remove the large and small intestines .
once these stool- and bacteria - containing organs are removed , the bladder is emptied by exerting pressure on the dome .
the stomach can be emptied through the opening in the pylorus and irrigated with saline .
the entire specimen is then washed down with saline to enhance preservation . a rabbit tissue model ( rtm )
the rabbit stomach has been filled with salt water that was introduced through a catheter in the esophagus .
once full , the rabbit stomach can be used to perform different exercises . in this figure ,
the reimplantation of a ureter is simulated by using a segment of the rabbit rectosigmoid .
tunnel was developed by dividing and dissecting free the stomach muscle for approximately 6 cm and then approximating the muscle over the  ureter  with interrupted sutures .
due to rabbit pellet stools , this portion of the bowel can be retained during the initial preparation of the rtm by simply removing the pellets and irrigating the lumen . rabbit tissue model ( rtm ) .
fine dissection technique can also be practiced using the rtm as seen in figure 10 . here
the left kidney , renal vessels , and ureter down to the bladder were dissected free of their adhering fibrous tissue .
female rabbits are preferable because end - to - end anastomosis can be performed on the bicornate uterus . practicing on these structures should allow transfer of skills later to human ureters or fallopian tubes ( m.m .
renal vessels , ( c ) left ureter , ( d ) bladder , ( e ) empty stomach , ( f ) sigmoid remnant .
even larger animal carcasses can be placed under the lap - ring simulation trainer . in figure 11
the pig was sacrificed , after its parts were no longer needed in an independent laboratory research protocol .
five stands and poles are then placed around the ptm , 4 to hold brs and 1 between the legs to suspend a laparoscopic camera .
pig tissue model ( ptm ) with surrounding stands and vertical poles , prior to setup of lap - ring simulation trainer .
the exercise taking place at this time is a cholecystectomy . using this arrangement , the maneuvers practiced to remove the gall - bladder are almost exactly the same as if performed on a live animal or human .
the major difference is the minimal cost of this method of training , vis -  - vis maintaining a live animal operating room .
covered ptm with equipment set up and simulation cholecystectomy performed . instead of a camcorder , a laparoscopic camera without the telescope
the kidneys , great vessels , genitalia , and bladder are clearly delineated prior to their dissection . because the bowels have to be removed as part of preparing the animal carcasses for practice sessions , female pigs are the prefered choice for the ptm . in this case
, the bicornate uterus and fallopian tubes can be used as bowel substitutes . on the pig uterus , surgeons can practice laparoscopic manual and mechanical anastomoses , mastering techniques that can then be transferred to bowel surgery .
the ability of laparoscopic surgery to shorten hospital stays and lessen patient morbidity has been well established over the past decade . some specialty areas , such as general surgery and gynecology , embraced the new technology with a passion and created multiple new laparoscopic operations .
success in this area is attributed to the existence of initial  easy  operations , such as laparoscopy , fallopian tubal ligation , and laparoscopic cholecystectomies . by means of these frequently performed operations ,
 operations , these specialty surgeons went on to undertake more technically difficult and challenging operations .
general urologists , on the other hand , have been less successful in incorporating the advantages of the laparoscopic surgery into their practices .
although brilliant advances to replace traditional retroperitoneal surgery have been achieved by a few shining stars in university urology departments , these have not filtered down to the general nonacademic urologist .
the major difficulty urologists have encountered in taking an aggressive leap into laparoscopic surgery has been the lack of an  easy 
laparoscopic urologic operation , one that can be performed frequently enough to develop and maintain basic laparoscopic skills .
urologists who initially started by performing laparoscopic pelvic lymph node dissections soon realized they needed more practice to perform these difficult operations . due to lack of adequate training programs ,
many urologists became discouraged and gave up on laparoscopic surgery . unless performed frequently , laparoscopic skills are difficult to maintain
it then secondly requires periodic practice of basic skills , such as instrument handling , suturing , knot tying , and dissecting .
although best ac - complished by frequent operating room experience , it can also be achieved by working in a simulated laparoscopic environment .
to encourage the return of the general urologist to the laparoscopic arena , more  user friendly  operations and training techniques must be made available .
the recent description of laparoscopic hands - assisted nephrectomy may be a step in that direction .
it offers a system that allows easy reference back to the open field during training exercises .
this ability enhances skills by allowing surgeons who are experiencing difficulty to look down away from the monitor to study instrument and tissue angle relationships .
they are then able to compare the monitor display field with what is actually happening at the specimen site in 3 dimensions .
this facilitates making timely corrections . when using the lap - ring simulation trainer , the natural tendency is always to look at the monitor because of its magnification , not the open practice field as one might suspect seeing the trainer initially .
it also allows use of diversified tissue specimens and permits variations in angles between the laparoscopic instruments and target tissues .
this training system is in its infancy and is presented here to encourage its use by surgeons interested in continued laparoscopic training .
its final success will be determined after training protocols are set up to analyze how easily surgeons using it are able to acquire new skills and refine old ones .
 regardless of the level of experience , surgeons need convenient times and locations to practice laparoscopic skills . 
 although attendance at formal courses is essential for continuing surgical education , reinforcement is still needed by other means to allow surgeons to learn new operations as they advance . 
 a method is presented here that allows surgeons to practice laparoscopic skills while following their own time schedules . 
 novice surgeons can also benefit from this method by practicing basic laparoscopic skills in a cost - effective simulated operative environment.the borinquen ring pelvic trainer was originally described in 1993 . 
 it is now reintroduced along with an additional device called a tissue suspender to create a new laparoscopic simulation training system . 
 instruction is provided for the use of these 2 devices in practicing basic surgical skills . 
 different simulation models are used to substitute for human organs and vessels . these consist of both artificial and animal tissue specimens . 
INTRODUCTION
MATERIALS AND METHODS
DISCUSSION
CONCLUSION