laparoscopic training involves many levels that the surgeon must master . practice in both the simulation laboratory and the animal operating room
these devices permit a safe haven for learning instrument handling maneuvers and mastery of basic surgical skills , such as dissecting , suturing , and knot tying .
the trainers are used both by novice surgeons just starting out and experienced ones wanting to refine a particular skill .
, cuts of chicken , organ meats , or molded plastic or sponge models have been used for this purpose .
the resemblance to human tissue is closer and should better prepare surgeons for the operating room .
the technique described below permits salvage of the rabbit carcasses after sacrifice and allows their use as training material for laparoscopic pelvic trainers .
figure 1 shows an illustration of the rabbit tissue model ( rtm ) and the anatomy used during practice sessions .
the stomach can be filled and used to practice dissecting techniques with both the laparoscopic scissors and cautery . interrupted , running , or purse - string suturing can be practiced on the different organs .
( a ) inner right abdominal wall flap(b ) posterior abdominal muscles(c ) right kidney(d ) right renal vessels(e ) spine and retroperitoneal structures(f ) tie anchoring esophagus to spine(g ) catheter through esophagus into stomach(h ) stomach distended with saline(i ) site for an electrocautery incision(j ) sigmoid remnant embedded in stomach(k ) interrupted sutures(l ) site for purse - string sutures(m ) segment of left uterine horn removed prior to anastomosis(n ) opening in broad ligament(o ) inner left abdominal wall flap(p ) urinary bladder(q ) left thigh with intact femoral vessels(r ) site of disarticulation of leg(s ) circumferential incision in body of uterus for end - to - end anastomosis(t ) incision site in body of uterus for running anastomosis(u ) right horn of uterus(v ) right ovary(w ) right ureter(x ) clamp across pylorus ( a ) inner right abdominal wall flap ( b ) posterior abdominal muscles ( d ) right renal vessels ( e ) spine and retroperitoneal structures ( f ) tie anchoring esophagus to spine ( g ) catheter through esophagus into stomach ( h ) stomach distended with saline ( i ) site for an electrocautery incision ( j ) sigmoid remnant embedded in stomach ( k ) interrupted sutures ( l ) site for purse - string sutures ( m ) segment of left uterine horn removed prior to anastomosis ( n ) opening in broad ligament ( o ) inner left abdominal wall flap ( q ) left thigh with intact femoral vessels ( r ) site of disarticulation of leg ( s ) circumferential incision in body of uterus for end - to - end anastomosis ( t ) incision site in body of uterus for running anastomosis ( u ) right horn of uterus ( x ) clamp across pylorus
mature female rabbits are preferred because of their large bicornate uterus . the larger the animal , the better the specimen . after sacrificing the animals in a humane fashion ,
they are immediately skinned , and a laparotomy is performed by a midline longitudinal incision extending from the xiphoid to the pubis .
a segment of rectosigmoid measuring approximately 6 inches is cleaned free of stool and preserved .
care is taken to tie off the vascular pedicle to the bowel without injuring the renal vessels .
the remaining large and small bowel is then excised to the level of the pylorus , followed by removal of the liver .
the opening into the stomach through the pylorus is then gently stretched and the contents within the lumen extracted and the cavity irrigated copiously with normal saline .
an entry is made into the diaphragm and dissection of the esophagus carried out to the upper - most portion of the thorax , at which point the organ is transected .
a tie is then placed at the end of the esophagus and the stump sutured to the top of the remaining spinal musculature to hold it in place .
the legs are removed at the knee joint leaving the thighs attached to the pelvis .
the upper half of the animal carcass is then removed below the costal margins and the spine transected an inch above the level of the diaphragmatic insertion .
ideally , this is the point at which the animal carcass is also bled , if prior entry into the vasculature has not already accomplished this .
however , on farm animals traditional slaughtering and bleeding techniques at the neck are done before proceeding with the above dissections .
clearly seen are the triangular muscle flaps , kidneys , esophagus , stomach , ovaries , and the bicornate uterus .
the specimen is then rinsed a final time with saline and the abdominal flaps approximated with large safety pins as illustrated in figure 3 .
prior to freezing , the specimen is placed in an airtight plastic bag to preserve the tissue architecture and prevent drying and hardening . when needed , the specimen can be defrosted and kept moist with frequent applications of saltwater during the exercises .
this model can be used repeatedly and frozen between use . when finished , simply discard as any other meat product .
rabbit tissue model with open abdominal flaps and visualization of the remaining internal organs , after disembowelment .
the kidneys , renal vessels , ureters , the bicornate uterus , and ovaries can be used to practice laparoscopic dissecting techniques .
simple , running , interrupted suturing , and stapling practice can be performed on the inner and outer muscle flaps of the rtm .
the esophagus and the bicornate uterus can be used to practice catheterization of tubular structures .
the stomach can be filled with saline through a catheter in the esophagus and the pylorus closed off with an atraumatic clamp to hold the liquid in place . while the stomach is distended , an electrocautery incision can be placed and 2 muscular flaps raised . to leave the underlying mucosa intact during this exercise , careful dissection is required .
the sigmoid remnant can be used to represent a ureter . approximating the raised stomach muscular flaps over this remnant
end - to - end anastomoses can be performed on both the horns and body of the rabbit uterus , as well as on the esophagus .
surgeons at different levels of competency in laparoscopic surgery can benefit from the rtm . to obtain maximum flexibility during the exercises , a pelvic trainer large enough to accommodate the carcass is needed .
it easily accommodates specimens of different sizes and provides a greater number of options in instrument positioning above the selected specimens .
although mature female rabbits provide ample practice material , the harvesting techniques described above can also be used , with minor alterations , to create tissue models of larger animals like dogs or pigs . when using a pig ,
this allows the practice of a laparoscopic simulation cholecystectomy . in the case of the pig , the entire bowel must be removed because the soft stool does not allow a sigmoid remnant to be preserved .
this permits surgeons to perform laparoscopic manual or stapler anastomoses in preparation for similar bowel anastomosis in humans .
this is an inexpensive model to produce and the animals are not alive during the practice sessions .
laboratory animals designated for sacrifice , after termination of research protocols , can be recycled for this purpose . in the absence of laboratory - designated animals ,
 a method for creating a tissue model using a female rabbit for laparoscopic simulation exercises is described . 
 the specimen is called a rabbit tissue model ( rtm ) . 
 dissection techniques are described for transforming the rabbit carcass into a small , compact unit that can be used for multiple training sessions . 
 preservation is accomplished by using saline and refrigeration . 
 only the animal trunk is used , with the rest of the animal carcass being discarded . 
 practice exercises are provided for using the preserved organs . 
 basic surgical skills , such as dissection , suturing , and knot tying , can be practiced on this model . 
 in addition , the rtm can be used with any pelvic trainer that permits placement of larger practice specimens within its confines . 
INTRODUCTION
METHODS
DISCUSSION
CONCLUSIONS