UROMET PCNL SIMULATION PROGRAM
The following SOP has been derived to give the student a good concept building in the field of PCNL. It is recommended that this concept be developed during the sim program and the concept extrapolated during performance of live surgeries.
1. VIRTUAL FLUOROSCOPY PCNL SIMULATOR
The following is the structured simulation protocol tobe followed on theVIRTUAL FLUOROSCOPY -RADIATION FREE SIMULATOR during the training program at the UROMET
SIMULATOR ORIENTATION INSTRUCTIONS - 5 mins
•Stand in front of the simulator station as we stand besides the patient while performing a PCNL.
•Now the your right side is the patients head end and the left is the foot end. So effectively you are proposing to operate the right side of the patient
•The provided needle and wire attached allow you to attempt calyceal puncture
•Pushing the foot-switch turns on the C-arm
•Disregard the haptics and any refraction that you may observe during the puncture exercises
•Once you hit the calyx, a sound indication would confirm a successful puncture
•If you feel lost - use the provided internal HD cameras to locate and learn your position and understand what went wrong !!!
•Do not use these cameras to puncture !!!
Introductory Tasks -RECOMMENDED MANDATORY MINUTES10
- Learn the C-arm
- Appreciate the difference between 3D vision anatomy & 2D C-arm image
- Learn object relativity using parallax- Two point , Three point relativity
- Holding the needle- Aiming stance (Thumb / Artery forceps), Puncture stance
EXERCISE 1 – RECOMMENDED MANDATORY MINUTES10
IDENTIFYING THE POSTERIOR CALYX– Learn to identify the anterior and posterior calyx using C-arm movements
- Open the puncture fascia and observe the coloured PC system placed in the cradle. The green colored calyces are the posterior calyces while the red are the anterior
- Note that the infundibular lengths have been deliberately elongated to help us with better orientation
- Now observe the calyces on the monitor
- Move the C arm in following directions and observe how the calyces move
- 300 towards you
- 300 away from you
- 30 0 towards the head end
- 300 towards the foot end
- Now observe what happens to the posterior green calyx as we move the C-arm in different directions
- Look at the posterior and the anterior calyces one final time and attach the translucent fascia back onto the simulator station
- Now you would see the image on the monitor when you press the foot switch
- Push the footswitch and repeat the C-arm movements.
- Observe the movements of the calyces and try to identify the anterior and posterior calyces
EXERCISE 2 - BULL’S EYE TECHNIQUE - RECOMMENDED MANDATORY MINUTES - 30
Tasks:
- Learn what is it ? Slow mo bullet theory/Concept of Parallax - 5 mins
- Learn steps - Expert demo - 4 mins
- Spiraling into Bulls Eye - 1 min
- Identify a cranial, caudal, Superficial and deep punctures. Under and overshooting - 5 mins
- Learn the concept and practice nuances and variations - 2mins
- Identify the needle tip position using the C-arm movement - Quiz - 3mins
- Perform Step by Step Bull's Eye (ANNEX I) - 10 mins per student
EXERCISE 3 – TRIANGULATION TECHNIQUE - RECOMMENDED MANDATORY MINUTES - 30
Tasks-
- What is it ? Where is the triangle ? - 5mins
- Learn concept of aiming and depth perception - 5 mins (Tasks 2,3,4)
- Learn the planar concept of needle manipulation
- Observe the plane movements (H and V needle planes) with 00 and 300 with of the C-arm
- Learn steps - Expert demo- 5 mins
- Identify a cranial, caudal, Superficial and deep punctures: under and overshooting of IPN - 2 mins
- Learn the concept and practice nuances and variations - 2 mins
- Identify the needle tip position using the C-arm movement - Quiz - 1 min
- Perform Step by Step Triangulation technique (ANNEX II) - 10 mins per student
LOGIC BENCH FOR PUNCTURE - OBSERVATION BENCH. RECOMMENDED MANDATORY MINUTES - 10
Tasks-
- Observe the relativity of the calyx to the skin entry point
- Learn the logic of Bull's and Triangulation
- Learn the planar concept of needle manipulation
- Observe the plane movements (H and V needle planes) with 00 and 300 with of the C-arm
FLUOROSCOPY SIMULATOR
OR ENVIRONMENT - RECOMMENDED MANDATORY MINUTES - 35
Tasks -
- Learn the functions of the C-arm - 1 min
- Learn to move and manipulate the C-arm - 1 min
- Respiratory movements on the simulator - 1 min
- Learn apnoea position - 1 min
- Learn the haptics of puncture - 1 min
- Expert Demo Bulls Eye -5 mins
- Expert demo Triangulation technique - 5 mins
- Practice Bulls Eye -10 mins per student
- Practice Triangulation technique- 10 mins per student
- Confirm puncture by 1. Aspiration and 2. Saline through ureter
- Park wires
STONE MANIPULATION BENCH - RECOMMENDED MANDATORY MINUTES - 25
Tasks -
- Learn parts of the scope and endocamera concept- 5 mins
- Learn the pneumatic lithotripsy and laser - 5 mins
- Handling the scope - 5 mins (Tasks 2,3,4)
- Learning tract haptics and scope manipulation fulcrii
- Look into as many calyces
- Learn to target, manipulate and pulverise the stone - 5 mins
- Forcep out stone pieces - 5 mins
ULTRASOUND SIMULATOR
RECOMMENDED MANDATORY MINUTES - 25
Tasks - USG GUIDED PUNCTURE
- USG machine - functions - 10 mins (Tasks 1,2,3,4,5,6,7)
- Caliberate the image
- Correlate the probe to the screen image
- Understanding probe windows and planes
- Learn the planar concept of needle visualization
- Learn the needle guide
- Identify the posterior calyx
- Planning target approach- 2 mins
- Expert demo USG guided puncture with needle guide - 4mins
- Expert demo USG guided puncture without needle guide - 4mins
- Practice - 10 mins per student
Tasks - USG GUIDED RENAL BIOPSYRECOMMENDED MANDATORY MINUTES - 20
- Identify the kidney and area of biopsy - 5mins
- Expert demo - Step by Step biopsy retrieval - 5 mins
- Expert demo - Biopsy examination and transport -5 mins
- Practice - 5mins per student
ANNEX 1:
STEP BY STEP: BULL’S EYE TECHNIQUE
1.Inspect the Pelvicalyceal system with contrast in 0 degree using the fluoroscopy unit
2.Rotate the fluoroscopy 30 degrees toward you keeping fluoroscopy on and observe the movements of the calyx
3.Calyx which moves towards the spine (relatively) is the posterior calyx
4.Select the desired posterior calyx.
5.C-arm can additionally be rotated caudad to bring it in line with the axis of the infundibulum of the calyx
6.Ask for apnoea in expiration
7.Mark a skin point over the desired calyx with the C-arm in 30 degrees
8.Make a skin stab - skin deep with a 11 number knife
9.Insert IPN in line with the direction of the C-arm
10.Penetrate the parieties
11.Rotate the IPN in a spiral fashion under fluoroscopy to turn it into a point (Bull’s Eye)
12.Inserted IPN maintaining the Bulls eye direction
13.Rotate the C-arm back to zero degree
14.Use00 fluoroscopy to assess the depth of puncture
15.Confirm puncture after reaching the desired depth
ANNEX II -STEP BY STEP: TRIANGULATION TECHNIQUE
1.Do an RGP and study the PC systemin 0 degree using the fluoroscopy
2.Rotate the fluoroscopy 30 degrees toward you keeping fluoroscopy on and observe the movements of the calyx
3.Calyx which moves towards the spine is the posterior calyx
4.Select the desired posterior calyx.
5.Rotate the C-arm to 0 degrees
6.Place needle tip on the selected calyx on the skin
8.Move/rotatethe needle in the horizontal plane (Plane parallel to the ground) to get the needle in line with the calyx and the infundibulum
9.Withdraw the needle laterally (around 4 cms) along its axis; so that the needle tip is lateral to the erector spinae and in the proposed puncture area. Confirm that the tip of the needle is still pointing towards the desired calyx.
10.Move the needle hub in a vertical plane keeping the tip fixed to the skin point (pivoted at the tip). Observe the fluroscopy image of the the needle. On moving the needle in the vertical plane, (with the C-arm in 00) the direction of the needle does not change but only the length of the needle increases or decreases. Memorise this plane
11. Take a skin deep stab and enter the parieties and confirm the horizontal plane direction of the needle
12. Turn the C-arm into 30 degrees in any direction
13. You will find that the needle may no longer point towards the calyx
14. Move the IPN hub in memorized vertical plane till it repoints towards the calyx. Do not move the hub in the horizontal plane.
15. Insert the needle in the set direction
16. Confirm the needle direction by shuttling the C-arm in between the two positions
17.Make minor directional adjustments if required
Note: In 00 C-arm position - Only horizontal plane movements are allowed
andIn non 00 C-arm position - Only vertical plane movements are allowed
18. Confirm the IPN having reached the desired calyx on fluoroscopy and confirm the puncture