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ABSTRACT

In pediatric minimally invasive surgery (MIS), the

advantages of expert technique are demonstrable, but moving

from novice to expert often seems more the product of

fortunethanintent. Meanwhile, themodernresidencyis being

driven away from unlimited hours of direct experience and

towardformal curricula, more didactics, lessons on simulators,

and learning metrics. Advocates and critics of these changes

probablycanagree:WeneedtoteachmoreefEiciently.Thatis,

each trainee must make more progress toward expertise

(howeverdeEined)inlesstime.InpediatricMIS,thatneedseems

magniEied, but safe surgical methodology hinges less on

contrived core competencies than on sound principles andheuristics. Thisessaydescribesteachable principlesdesignedto

improve mechanicaladvantage inanyMIS procedure. Pediatric

surgical residents who learn these principles exhibit easier,

faster,andsaferminimallyinvasivetechnique.

KYWORDS: laparoscopy, thoracoscopy,minimallyinvasivesurgery,surgicaleducation,

residenttraining,heuristics

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INTRODUCTION

As tomethods theremaybeamillionandthensome,butprinciples

arefew.Themanwhograspsprinciplescansuccessfullyselecthisown

methods. Themanwho triesmethods, ignoring principles, is sure to

havetrouble.RalphWaldoEmerson

Minimally invasivesurgery(MIS)is hardto teach. To begin

with, it is hard tolearn(1). Theskills neededfor successfulMISare

groundedingoodopensurgicaltechnique,butexpertabilitytoperform

agivenoperationusingopentechniqueisonlytheFirstprerequisiteto

endoscopicexpertise. SuccessfulMISrequires a superset ofskills to

perform complex procedures in small spaces with long tillers via

remotevisualization.MISisnotareplacementforgoodsurgicalhabits

andtechniques,but is averypowerfulextensionofsurgicaltechnique.

DespitesomeskepticismofMISinpediatricsurgery(2,3),thepotentialbeneFits to patients are plain: smaller incisions create far less

morbidity.

Nevertheless,clumsylaparoscopictechniqueisnotminimally

invasive. Ad hoc practices and imprecise maneuvers lead to long

operating and anesthetic times, poor mechanical results, and return

tripstotheoperatingroom.TheserisksareampliFiedinchildren:

The variety ofcases isbroader, includingcasesin thechest,

abdomen, andpelvis associated with a very wide variety of

malformations and other problems. The scope of required

expertiseisverybroad.

Thepatientsaremuchmoredelicate,andhavemuchsmaller

structures.Therefore,precisemovementofinstrumentswithin

bodycavitiesisessentialforsafetissuemanipulationandgood

surgicalresults.

Scaling effects of biomechanical structures and essential

physiology createnewsurgicalconstraints. or example,the

abdominal wall of a baby is relatively similar in thickness

comparedto that ofa leanadult, but itsabsolutethickness is

muchsmaller,dramaticallyreducingitsabilitytoholdatrocar

in place. Technique must be speciFically adapted to

accommodate thethinabdomen. Similarly, round structures(such as esophagus, etc) must be perfectly approximated

duringrepair, lest nonlinear increases in resistance at small

diametersleadtopooroutcomes.

The patients are muchmore sensitive to hypothermia than

adults because of their diminished metabolic capacity,

diminished reserve, and physical characteristics allowing

greater heat loss. Poor endoscopic technique can actually

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placesmallpatientsatincreasedriskofhypothermiacompared

to open technique, as long operating times and poor

instrumentation choices force high insufFlation Flows to

maintain visualization. The energy required to heat and

humidify high-Flow insufFlation gas can easily be twice the

basalmetabolicrateofababy. The instruments are shorter, narrower, andmore delicate.

Relativelyfewtoolsarespeciallyadaptedforpediatricuse.

Thestakesfromamisadventure canbemuchhigher(e.g.In

anadult,90mLofbloodlossistrivial;ina3kgchilditis1/3of

the total blood volume), and complications seem to be

somehowmoretragicinchildrenthaninadults.

or all of these reasons, the margin for error in small patients is

disproportionatelysmall.

The objectiveofthis essay is to set outdiscreteprinciples of

good pediatric minimally invasive surgical techniquebeyond simple

exercises(4,5).Theheuristicslistedhereareintendedtomaximizethe

surgeons mechanical advantageat all times, inallcases. Maximum

mechanical advantage fosters precision and spares the surgeon

unnecessary fatigue,keepshimaway fromavoidableblunders,creates

optionsforrecoveringfrom slipsorunexpectedanatomicalchallenges,

increases,shortensoperatingtime,andprotectsthepatient.

Surgery is a physical art. Surgeryis theartofapplyingmechanicalsolutions tomedicalproblems.Assuch,surgicalinterventionsleadtothebestresultswhen

thosemedical problems have amechanical basis. Someexamples for

whichsurgeryisthebest interventioninclude: repairingthedamage

from a stab incision; removing a tumor; relieving an intestinal

blockage;reconnectingthe esophagus; restoring the insertion of the

ureter on the bladder;repairing ameniscal tear. These, andmany

other problems allhaveamechanicalproblemastheir source, anda

mechanicalsolutionisdemanded.However,surgerysometimesisused

for diseases that arenot strictlymechanical, but more physiological,

somedisorder at thecellularlevel.orexample,ulcerativecolitismaybe treated by colectomy, but this is morepalliationthan cure: the

surgeonhasnotrepairedabiomechanicalproblem,only removedan

organ afFlicted with an inFlammatory disease that we dont really

understand.Thesamemaybesaidforobesitysurgery.Observethatas

ageneralrule, theresultsformechanical interventions tomechanical

problems are superior to those for physiological ones: repairing a

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duodenum damaged by a handle-bar is better than removing the

antrumofthestomachtopreventulcersintheduodenum.

Inthis way, surgery is akind of engineering. Inorder to

achieve thebest results,surgeons must know about theirtools, their

materials, the raw substrate they are manipulating, and what the

mechanicalobjectiveisthattheyaretryingtoachieve.Trytostatethepurelymechanicalobjectivesof:

fundoplasty

diaphragmaticplication

appendectomy

gunshotwound

inguinalherniarepair

In diaphragmatic plication for example, there are two objectives:

increasefunctionalresidualcapacityoftheipsilaterallung,andprovide

alesscompliantmedialborderto thecontralateralhemidiaphragmso

to increaseitsdeFlectionforthesamemuscular contraction. Compare

mechanicalobjectiveslikethiswithpalliativeobjectivesin,forexample,

colectomyforulcerativecolitis,orpancreatectomyforhyperinsulinism.

In each of these later cases, the basis of the treatment isnt

biomechanical,butsimplytoremovethedysfunctionalorgan,tradinga

diseasedphysiologytosomelesserdysfunction.

In indirect inguinal hernia repair, the objective is to

permanently close the internal ring (while avoiding damage to the

spermatic cordstructures). What approachmostlikelyachieves this?

Laparoscopic repairs allowthesurgeontovisualizetheringataround

8xmagniFicationdecreasingtheprobabilityofdamagingthecord.But

early results showed a disappointingly high recurrence rate. This

problem vanished when permanent suture was used instead of the

moretraditionalabsorbablesutureusedinopentechnique.Itappears

that whilethemechanical objective (permanently close the internal

ring)ofopenandlaparoscopicrepairsisthesame,the methodmaybe

different--one technique disconnects the sac, one does not--and so

different materials must be used. Still, whatever the details of the

method,themechanicalobjectiveisthesame,andmustbeachievedfor

a successful repair regardless of whether the approach is open or

laparoscopic.The ten principles here increase the chances that the mechanical

objectivesofagivenprocedurewillbeachieved.

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#1 Perfect Operations Begin With Perfect Tools

IfIhad8hourstocutdownatree,Iwouldspend6hourssharpeningmy

axe.

AbeLincoln.

Therighttoolscamera,ports,instruments,scopesmakethe

difference between a safe operation performed smoothly under

conditionsofexcellentvisualizationandaFlail.Inthisway,patient

safety is seen to begin with (but not end with) well-chosen and

perfectlymaintainedtools.

MIS instrument maintenance and replacement is often

neglectedinhospitals eventhoughtheinstrumentshaveafar shorter

usable lifetimethanthoseusedinopenprocedures. Astainless steel

Kocher clamp will work reliably for generations; a Fine 3mm

endoscopic needle-driver will be sprung in a few years or less and

endoscopic scissors may not last more than a single operation.

OperatingroombudgetsmustreFlecttheseshorterusefullifetimesand

plan for constant replacement of defective instruments. Clever

operatingrooms partnerwithvendorstomaintaintheinstrumentson

a constant basis, vastly extending these tools working lives. An

operatingroom staffthatholdsoutastandardoflikenewoperation

for everyinstrument for everycase protectsbothitsownbottom line

andits patients. Put moresimply,toolsthat arenotgoodenoughfor

useonyourownchildarenot goodenough. It is thesurgeons job to

insistonthisstandard.

Perfectoperationsareperformedwithtoolsthathavesmooth,low-resistance working parts, precision approximation at the tip,

reproducibleandpredictableaction. Anexpertwieldsthesetools,the

long reach from hand to organ hardly noticed. In contrast, poorly

functioningtools canbedeadly.Whileanexperiencedsurgeonwillbe

irritated and slowed by sticky instruments, the novice will be

thoroughly Flummoxed, operatingwith jerkymoves andhaltingover-

corrections. The delicate infant liver, Fine sutures, and ephemeral

tissueplanes becomeinevitablecasualties. Then,disruptedanatomy

and bloody, obscured views makes the operation even harder,

producing a feed-forward spiral to sub-optimal results at least, and

disasteratworst.Wellchosen,wellfunctioningtoolsmustberegardedandbudgetedasindispensablecontributorstopatientsafety.

Animportant corollaryhereisthat theexpert knows howall

his toolswork. Heknowshowthetools Fit together, howfeedback is

measuredbytheinsufFlator,howFlowrelatestohypothermia,howthe

variousenergysourcesworkandwhattheirlimitsandliabilitiesare.A

noviceisbafFledbypoorinsufFlation;anexpertknowshowtotrackand

disposeofproblemsinstantly,fromtheCO2source,totheinsufFlator,to

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thetubing,to thetrocars,to theinstruments,tothelevelofanesthesia.

The expert chooses hook, or spatula, or hot scissors, or Harmonic

Scalpel (Ethicon, Endosurgery, Cincinnati, OH), or Ligasure

(ValleyLab,Boulder,CO)accordingtothewaytheydeliverenergy,how

the shape of the business end Fits his surgical Field, and what

problems areminimizedbychoosing oneover theother. Thenovicehasonetoolandtries touseiteverywhere. Anoviceblamesthetools;

theexpertstoolsservehistechnique.

In other words, MIS is not technology; it is technique.

Surgeons liketechnology. Thenumberandvarietyofinstrumentsand

devicesforuseintheoperatingroomrunsintothethousands.Withthe

spread of endoscopic methods, vendors have hugely expanded the

available tools. Certainly technological progress in charge-couple

devices, electronics,optics, andmaterials has helpedspur thebroad

applicationofMISmethods,andongoingadvances(especiallyinoptics)

willcontinuetoaidtechniqueandhelppatients.Butalargenumberof

theseare meregadgets, engineered solutions to non-problems. or

example, suture assist devices exist in order to bridge a deFicit of

sewingandtyingskill. Vendorshavemarketedallmannerof devices

thatholdincommononlythattheyarecomplex,expensive,andtotally

unnecessarytotheexpertendoscopicsurgeon.

The tools never do theoperation. or example, thesurgical

robot is really a telemanipulator (or a waldo), andcannot make a

novice endoscopic surgeon into an expert one. Even suture assist

devices that use ski-needlesarenotanasset but a liability inbabies:

Thelargesizeoftheseneedlesmakesthemclumsyinstruments,better

suited to inadvertently damaging the liver or spleen than allowing

accuratesutureplacement. Inanycase,endoscopic gadgetsarerarely

designedforverysmallpatients,andtryingtoforcethesedevices(e.g.

tryingtosqueezeevenasmallstaplerintoaninfantschest)isnoroute

tobetteroutcomes.Thewrongtoolsweakenthesurgeonandendanger

thepatient.

On the other hand, the expert surgeon has attended to

developing robust and general ski lls with basic endoscopic

instruments. He exhibits suture technique as precise as open

technique. Heunderstandsandcantroubleshoottheequipment. He

can safely and rapidlyperform averywidenumberofproceduresat

leastaswellas(andinmanycases betterthan)usingopentechnique.Use of gadgets fosters shortcuts and poor methods, compromising

outcomes and lending MIS an air of risk. In cases of trouble, the

surgeon,andhispatient,are betterservedby reliable technique than

bytechnology.

Oneproblemwithmedicalandsurgicaldevicesistheproblem

ofimplieduse,thecuesonthedeviceitselfthatimplyhowthethinkis

intendedtobeused. These cues aresometimes called affordances.

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Rarelyaresurgeonsgiveninstructionon theelements ofhowdevices

are designed, and user manuals are an early casualty of a busy

operatingroom,evenifthesurgeonwasinterested.Instead,surgeons

duringtheirtrainingtypicallyreceivesomelessons asmemesor lore,

oftenpassedfromaseniorresident,alessontheywillpasstotheirown

trainees. Often, those lessons are little more than someonesworkaroundwhentryingtousethedeviceforacertainpurpose(e.g.a

malecot drain repurposed as a gastrostomy tube, now virtually

standardofcareinpediatricsurgery).Othertimes,theuseissimply

amisunderstandingofa designthat implies,byitsshapeor structure,

thatitshouldbeusedaparticularway(e.g.thesutureholesonmany

gastrostomytubeswhicharein fact merelyventilationholes, andnot

designedorintendedforsecuringatube).

Sometimes,thesehintsforuseareaccurate,butoftennot,and

the novice may have no basis onwhich to tell the difference. or

example, novice operators very commonly pick up instruments and

holdthem inthumb and index Finger, a gripthat puts the userat a

disadvantageintermsoftorqueandprecision. Thesurgeonmustpay

attention to how devices were actually engineered to be used, but

hemustgofurther:hemustunderstandwhenthedesigndoesnotquite

servehis need,and bewareof how theseshortcomings canincrease

risks.orexample,it is commonforsurgicalstaplerstorequireavery

stronggripinorderto Fire. Asurgeonwithsmallerhandsmaybeata

mechanical disadvantage and struggle with the Firing, which can

translateto jarringorshakingatthebusiness endofthestapler. One

way around this is to turn the handle upside downwhich acts to

lengthen themoment arm, thereby decreasing the force required to

exertthesametorqueontheFiringmechanism.

Expert minimally invasive surgery is technology wielded

accordingtoproFicienttechnique.

#2 Face the Organ

Positioning the patient properly begins withpositioning thesurgeon.oranyendoscopicprocedure,thesurgeonmuststandfacing

the organ of interest. Too often, surgeons are seen operating

backwards,strickenbyparadoxicalactionoftheirtoolsonthescreen.

Precisionmotionis impossible when the surgeon cannot even intuitright andleft,upanddown. Ofcourse,itsnot funnyif thesurgeonis

you.

Meanwhile, operatinginpoor position is very tiring to the

surgeon. As the surgeon fatigues, the muscles responsible for Fine

movements fail First. In this way, fatigue hugely compromises

precision.orexample,asurgeonwhoattemptstooperateonaspleen

from the leftsideofthetablenot onlyhasa poorangleofattack and

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The wrong hold. It canseem like the right

way to grasp the instrument, but this hold

destroys control at the tip and leaves the

user unable to spin the shaft.

Stand up. No one can maintain precise

technique if hunched over, twisted, or

awkwardly positioned. The surgeon is the

first surgical instrument, and must be

used properly like all the others.

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someparadoxicalmotiontocontendwith,butawkwardbodyposition

that quickly leads to fatigue. If you are shaking and sore after an

endoscopicprocedure,yourset-upwasprobablysuboptimal.

Perfectpositionallowsthesurgeontooperatewithlittleeffort.

The most important principleforgoodpositionis for the surgeon to

facetheorgan heisoperatingon. Inotherwords,thesurgeonshouldplacethemonitor(ideallymountedontheceiling,butthepracticecan

bemaintainedwithtowers)inalinewithhimself, thecamera,andthe

organofinterest. Agoodmnemonic that somesurgeonsteachisS-C-

O-P, or surgeoncameraorganpicture(6). or example, with

appendectomy,thesurgeonstandstothepatientsleft,facingtheright

lowerquadrantwiththescreenonthepatientsright.Ifthesurgeonis

operatingontheGE junction, heshould standat the foot of the bed

(withbabies frog-leggedat the endofthebed, larger patients inlow

lithotomy position) facing the epigastrium, with the monitor hung

directlyoverthepatients chest. ThisistheFirstprinciplethatallows

thesurgeontouseallavailabledegreesoffreedom.

Implicitinthisruleisknowingwhattheorganis.orexample,

whenperformingathoracoscopiclobectomy,theorganisnotthelung

or the lobe, but themajor Fissure, the placewheremost of the Fine

dissectionoccurs(seeigure1,above),andthesurgeonshouldstandin

linewithit. Similarly, inlaparoscopic pullthroughforHirschprungs,

theareawheretheFinedissectionoccursistherectum,andthesurgeon

shouldstandatthebabyshead.

Onementalbarrier tofacethe organ istheimplicit rulethata

surgeonandhisassistantmustoperateoppositeeachother. Innearly

everyopenproceduresurgeonandassistant faceeachother,andany

other arrangement seems wrong, even taboo. But what brings

advantageinopencases may bringdisadvantagein endoscopic cases.

Itisabsurdforeithersurgeonorassistantto strugglewithparadoxical

motion,but this foolishpracticeistoleratedbecauseofthebeliefthat

anoperatormust standon each sideof thepatient regardlessof the

surgical objective. ace the organ goes for surgeonand assistant,

evenifbothstandonthesamesideofapatient(astheyoftenshould).

Only when facing the organ can the other aspect of good

positioningbeemployed,thePianistPosition. Virtuosopianistshold

theirarms loose at theshoulder,armsbent attheelbow,wristsloose

and Fingersonthekeys. Virtuosoendoscopic surgeons operatewiththebedatalevelthatallowsthemthesameposition:headuprightand

level with the screen, shoulders relaxed, elbows bent at 90

120degrees,wristsloose,andactionontheinstrumentscontrolledwith

Fingertips. The novicecan beseenwithback bent, arms abducted,

elbowsaskew,wristsstiff,instrumentsheldinadeathgrip.

The comfortable surgeon attends to surgical detail; the

uncomfortablesurgeonthinksabouthissoreback.

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In lobectomy, the organ is not the lobe

being removed, but the fissure. The

surgeon gets best advantage by aligning

tools and his body along its axis.

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#3 Triangulate the Ports Positioningtheportswellalsocontributestothesurgeonscomfortandprecision.Cameraandworkinghandsshouldforma

triangle,likethebroadendofakitewheretheorganofinterestisthepointedtail(igure2).Ingeneral,thecameraisinthecenter(butnot

always,seebelow).

Eveninsmallpatientsthekiteallowswideenoughseparation

between ports that the operator will not cross the streams and

impedehisownwork. Equalspacingallows bothhands tocontribute

similarly(seePrinciple#6).Noticethattriangulationallowsmaximum

motionthrough all available degrees of freedom (DO). Degrees of

freedom in mechanics are the parameters required to specify an

objectspositioninspace.InMIS,thereare6:

(1) Sidetoside

(2) Upanddown

(3) Inandoutthroughthetrocar

(4) Rotationoftheinstrument

(5) Opening/Closing the instrument (e.g. a marylands working

tip)

(6) Translationofthebodywall(whatCO2insufFlationgives)

Evenif fourormoreportsare needed,thepositionofall theports is

determinedbytheworkingtriangle,andthe prinicipleofmaximizing

allavailabledegreesoffreedom.

Noticethat poor triangulationdestroys aDO. or example,trocars positioned too close together, or too far from the organwill

maketheinstrumentsworknearlyinparallel,constrainingthe#1.Itis

nearlyimpossibletotiesuturesinthiscircumstance.Similarly,putting

trocars too lateral (where the bodywall begins to curveback down

towardthebed),orbumpingthepatients legsupbothcanimpede#2,

makinganterior anatomyimpossible toreach,or awkwardto handle.

Morefamiliarly,whenCO2insufFlationisinadequatefromleaksorpoor

settings or a bucking patient, #6 is constrained, destroying the

surgeonsviewandmakingprogress impossible. But anyreductionof

DO(suchasforgettingtheavailableinstrumentrotation,#4)seriously

degradesthesurgeonsabilitytomovefreelyandwithprecision.Goodmechanicalresultscannotbeattainedthisway.

Centering the cameraalsokeeps paradoxical motion to the

minimum.Paradoxicalmotionisattemptingtooperatewhentheimage

isreversed, fromthesurgeonsperspective. It istheoppositeofface

the organ. or example if the camera was looking toward the

appendix,butthesurgeonwasstandingonthepatientsright,hewould

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In general, trocars should be placed so

that right and left hand instruments

approach the organ of interest separated

by approximately 90 degrees. Meanwhile,

the camera port should (usually) be offset

from the two main working ports such that

the three ports form a triangle, not a line.

These four pointsthe three main ports

and the organform a kite shape, a

configuration that generally allows the

best view, comfort, and maneuverability.

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be working paradoxically. All moves would feel backwards, and

unintuitive.Noonecanoperatewithprecisionthisway.

But rigidly keeping the camera in a center port is

disadvantageous. Occasionally, operations are better performed (at

least in part) by placing the camera to one side, as an outrigger

camera. orexample,inappendectomy, itmaybeeasiertoplacethecameraattheumbilicus andworkthroughsuprapubicand left-lower-

quadrantports.Inthoracoscopicdiaphragmaticherniarepairwiththe

patient in decubitus position, it may be advantageous to have the

camera(andthecameraoperator)intheportnearestthepatientsback

andtheoperatorusingtheports inthemidandanterioraxillarylines.

In other cases, the peculiarities of the anatomy (e.g. some thoracic

masses) may require the camera to occupy any of the ports as the

procedureprogresses.Observethatwhenusingtheoutriggercamera

technique, advantagecan be gainedby using anangledscopewhich

allows the viewing angle to approach (if not perfectly achieve) a

centeredview.Triangulatingtheportsallowsthefreedomtomovethe

camera whenever needed, without creating distortions in working

mechanicaladvantage.

#4 Do The Same Operation

Somehavetheimpressionthatendoscopicmethodsarenotasreliable, safe,oreffectiveas opentechnique,thatsomehowtheresults

arelessrobustandthepatientswellbeinglesswellinhand.Certainly

the novice feels unnaturally constrained by the tools and the

visualization, andoftenisconfusedby theorientation. Struggleswiththeanatomyandwithbasicskillssuchasendoscopicsuturingcanlead

somesurgeons into doingan operationthatis prettyclose,nearlyas

good, a fair approximation, etc. Stitches are placed, workaround

methodswithclipsorothergadgetsareemployed,anddissectionsare

fudgedin ways that thesamesurgeonwouldnever accept were the

casebeingdoneinstandardopenfashion.Whocouldbesurprisedthen

when outcomes are not as good, especially early in a surgeons

experience?

Dothesameoperationmeans:Performanoperationwithat

leastasgoodamechanicalresult aswouldbeachievedwithclassic

opentechnique. This does notmeanthat everystepusedinanopenprocedureshouldbereplicatedendoscopically. Instead,oneis aiming

atthesameFinalmechanicalproduct:

Use thesame suture. If youare repairingduodenalatresia,

and youwould perform the duodenoduodenostomy with a

series of Fine interruptedmonoFilament sutures ina double-

d iamond ana s tomos is , d o t he s ame ana s tomosi s

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Surgeryistheapplicationofmechanicalsolutionstomedicalproblems.

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laparoscopically. Alternatively, if you would never use a

braided2-0ona skineedle for this anastomosis, dontuse it

laparoscopicallysimplybecausethatistheonlysutureyoucan

usewiththescope.

Dothesamedissection. orexample, ifyoucarefullyisolate

andvisualizethesplenicvesselsandclearlyvisualizethetailofthe pancreas during splenectomy, you should do the same

laparoscopically rather than Firing a stapler semi-blindly

acrossthesplenichilum.

Completeatleastthesamemechanicalrepair. Ifyoustick-

tie the appendiceal base during open appendectomy, you

should do this (or amechanical equivalent, like staples) ina

laparoscopicappendectomy.Ifyouwouldplaceastitchinthat

serosal tear inanopencase,put a suturein laparoscopically

too. Ifyouwouldmobilizethecolonmoretodecreasetension

duringanopenpull-through,youshouldmobilizeitprecisely

the same amount when per forming the procedure

laparoscopically.

The ideais toperformatleastasgoodanoperation.Inskilled

handsofcourse,endoscopicproceduresmayproducesuperiorresults:

alaparoscopicNissendonewellwillhaveaffordedabetterviewof the

vagusnervesandabetter,saferwrap;alaparoscopicpyloromyotomyis

faster; a laparoscopicduodenoduodenostomyallows theanastomosis

dobedonelargely insitu,decreasingtheamountofdissectionneeded

and possibly leading to faster resolution of gastric i leus; a

thoracoscopic esophageal atresia repairallows less dissection of the

distalsegmentanddissectionunderveryhighmagniFicationapparently

leading to measurably lower stricture and leak rate(7). Better

visualizationcancertainlyallowtheendoscopicexperttodoasuperior

procedure. But theessentialprinciple is a cognitive commitment to

doingthesameexcellentoperationonewoulddousingopentechnique.

#5 Operate with Two Hands

Humansalmostalwaysdotaskswithadominanthand. Whenlearninganew task, thenaturaltendencyis tofocuson thedominanthand,unconsciouslyneglectingthenon-dominant hand. If thetask is

very new andvery difFicult, this unilateral neglect almost seems to

approachthat ofstrokepatients. Eventhedexterityof thedominant

handsuffers(8). Whendoctors attemptlaparoscopy fortheFirst time,

nearly all exhibit unilateral neglect (and it is not conFined to

laparoscopicsurgery;everyonetendstoignorethenon-dominanthand

whenFirst learningopensuturing). Allattentionseemsto befocused

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on the unusual tiller-action-at-a-distance that is laparoscopic

manipulation, channelingandtruncatingattentionintonarrowtunnel

vision. Novice operators struggle to manipulate aneedleor cautery

one-handedly,whentheycouldeasilyhelpthemselveswiththeirnon-

dominanthand.Instead,theinstrumentheld inthenon-dominanthand

driftsoutofview,islost,beginsgraspingwithawhite-knuckleddeathgrip,etc.Nearbyorgansandstructuresareatgreat,butunrecognized,

riskfrominstrumentclutchedintheneglectedhand.

Good teachers will stress non-dominant hand awareness,

boringtheirstudentswiththerefrainWhatisyourotherhanddoing?

Onlybyrepeatedlyredirectingattentiontobothhandscanonelearnto

usebothhandseffectively,andautomatically. Evenseasonedsurgeon

needtoexplicitlyremindthemselves.

Non-dominanthandawarenessisimportantnotonlyforspeed

andefFiciency,butbecausehumansaremorecoordinatedinFinemotor

taskswhenbothhandsappearintheirvisualField,evenifonehandis

not participating in the action(9). You can verify this yourself; try

cuttingsuturewithonehandonyourchestversuswithbothhands in

theField. Withbothhands inview,thecuttinghandwillbesmoother

andmoreprecise.ThesameeffectholdsinMIS.

Endoscopic methods always impose constraints on

manipulation, since thenumber ofhands inthe Fieldare always one

fewer than the number of trocars (unless one has an experimental

camera/manipulatorcombinationinstrument).So,onemustmaximize

what hecandowithwhathehas. Neglectingthenon-dominanthand

halvesanalready-restricteddexterity(byremovingdegreesoffreedom

grantedbythathand).Somemayboastthattheycanoperatewithone

hand tied behind their back, but this is no road to precision and

accuracyfor the rest of us. Precisionendoscopyis a two-handed

proposition.

Thisdiscussionbringsuponecommonbut verypoorpractice.

In general surgery, training cases (l ike cholecystectomy,

appendectomy,or evensplenectomy)arecommonlyset upin sucha

waythat theattendingmanipulatesorganswithone instrument, and

has the trainee try to operate with the dominant while the non-

dominanthandmoves thecamera. Therearenaturalreasonsforthis:

Attending surgeonstire of (andare notoriouslyunskilledat) running

thecamera(see#8,below),theyarenervousaboutthedexterityofthetrainee, feel the need to have a hand in the action as ameans of

exertingcontrol,andtheyworry that thetraineeisnotskillfulenough

tousebothhands.

However,this practicealways puts the trainee(and thus the

patient) at a disadvantage since he is forced to divide attention

between two very different tasks, camerawork and Fine dissection.

Meanwhile,removing thenon-dominant handfromviewdegradesthe

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coordination of theoperatinghand as described above. inally, no

degree of simpatico between teacher and student will allow good

coordination between two different operators single hands. This

attempted coordination almost always resembles fencing more than

operating. Instead, the teacher is always better having the learner

operatewithtwohands fromtheirFirst case, just aswe teachinopencases. Iftheteacherfeelsheneedsmorecontrol,thesolutionistoadd

aport(see#7below)andaninstrument,nottotakeoneawayfromthe

learningoperator.

But there is moreto theskillful use of two-handed surgery

thanmerely remembering to use two hands. The skillful operator

moves his instruments the way a geisha walks, with small, even

mincing, but highly-controlled steps. The tips of the instruments

remaininviewofthecamera(reducingtheneedtorelyon#9,below),

and eachmove is slow,smooth,controlled. urthermore, the skilled

endoscopicsurgeonis ambidextrous. Therewillbetimeswhenit is

bettertohavetheenergysourceenterfroma left-handedport, anda

retractor from the right. One should be able to readily switch

instruments fromhand tohand, always keeping thehighest possible

mechanicaladvantage.

Those Fine, measured movements also apply to the use of

energysources likemonopolarelectrosurgery(thebovie). Energy

sources in babies not only require lower power settings, but the

mannerofapplyingtheseinstrumentsisdifferent. Inparticular,when

using the hook cautery, energy should never be engaged unless in

contact with the tissue to be divided or fulgurated (Swinging the

activatedhookaroundlikealightsaberriskscauteryinjury). Also,it

is bad practice to work in a hole; keeping a wide working front

maximizes visualizationandminimizescollateraldamage. Allenergy

sourcescertainlyperformbetteriftheoperatoravoidsgettinggreedy,

e.g.takinglargebites oftissuetodivide,apracticethat leadstoexcess

char, incompletehemostasis,andbroadcollateral burns. inally,and

mostimportantly,precisiontechniquebeneFitsfromalight footon the

pedal.MostdivisionandcoagulationcanbeachievedwithFinetapsof

thepedal,whereas long continuous burns produce char anda wide

penumbraofthermaldamage.

Ofcourse,nocuttingcanoccurwithout propertensiononthe

tissue. Perhapsthemostimportant roleofthenon-dominanthandiscreationoftensiononwhateverareaistobecut.Withoutgoodtension

applied to it,the tissuewillmerelycontract andcharwhenenergy is

applied. It willnot separate, butthermalspreadwilltakeoverasthe

operator vainlyappliesmoreelectricity. Insmallspaces, unintended

tissuedamagebecomesinevitable.Novicesoftencannotseethatwhile

theymaybe creatingtensioninthetissue,thefocus ofthetensionis

away from where it is that they want to be cutting. But careful

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Puttensionwhereyouarecutting;

cutwherethetensionis.

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attentionto tensionlinescombinedwithanunconstraineduseof the

non-dominant hand will allow the operator to recognize where the

tissue tension lies within the tissueplain. Moreover, the non-

dominant handmust continue to adjust tobring newtension to the

working plane as attachments are cut and tension is released. In

general, theprincipleis: Put tensionwhereyouarecutting, and cutwhere the tension is. This sounds hilariously obvious, but is

notoriouslydifFiculttoapplyinpracticewithoutanexpliciteffort.

SuchdaintyuseofenergyusuallyseemsoddatFirst,butthese

habits lower energy settings, no lightsabers, no holes, no

greediness,no Bovie pedalleadfoot, andattentionto tension

translateinto Fine, efFicient dissectionwithless smoke, less char, less

bleeding,andlessriskofunintentionaldamage.

The surgeon who always operates with two hands has the

fullestpossiblecontroloverthesurgicalField.

#6 Gravity is the Third Hand

Gravity can be a tremendous hindrance if ignored. On theotherhand,usinggravitytoones advantagecandramaticallyimprove

visibility, decrease the need for manipulating the organs, and cut

anesthetictime. orexample,whenoperatinginthepelvis, theworst

possible position would be reverse-Trendelenberg; all of the small

bowel would slide to the pelvis, hopelessly obscuring all other

structures.Ontheotherhand,whenoperatingintheupperquadrants,

especially, for example, during a fundoplasty or a gastric bypass,

reverse-Trendelenberg is crucial topullthe colonand fatty omentumoutoftheway. Even routine cases such as appendectomy beneFit

from simple positioning changes: rolling thepatient to the left, and

placinghiminslightTrendelenbergelevates thececum andallowsthe

ileumtofalldownandbackfromtheFieldofview.Inallofthesecases,

gravity is like a third hand holding a retractor for the surgeon,

keepingother organsout ofthe Fieldofview. Thisisalwaysa better

methodthanconstantlytryingtosweeptheboweloromentumawayso

onecanseetheoperativeField.

But tousegravity effectively, one must planthepositioning

carefully.Inparticular,onehastokeepinmindtwostrategies:

Set up thetrocarandpatientpositionssothat gravitycanbe used. or

example,onewouldnotwanttoapproachtheposteriorleftlower lobe

witha patient supinesinceno amountofturningthe tablewillallow

thelungto fallawayfrom the chestwall. Ontheotherhand,anterior

mediastinalmassesarebestapproachedwiththepatientsupinesince

inthis position the lung is already pulleddown and away from the

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operativetargetbygravity. Obviously,partof thisset-updependson

Principle#2:acetheorgan.

Secureand pad thepatientproperly to restrain gravity. orexample,

oneofthemostcommonpositionswhenoperatingonbabiesistoplace

themat the foot of the table,with legs frog-legged, andthemonitorhanging above the patients head or chest (lower picture). This

position is excellent for Nissen, Ladds, duodenal atresia repair,

abdominal approach to CDH/eventration, Morgagni hernia repair,

choledochal cyst excision, etc. But the samegravity that pulls the

omentumdowncanpullthewholepatientdownaswell. Indeed,ina

baby, even a short slide downthe table, say 1-2 cm, is enough to

dislodge the endotracheal tube, creatingunintended extubation. To

avoidthiskindofproblem,carefulpaddingandtapingareessential.In

addition,theuseofasmallbumpundertheabdomenactsasakindof

skid-stoptoretardsliding.

The pictures show two well-positioned patients, top, for

laparoscopic right nephrectomy, and, bottom, for laparoscopic

fundoplasty (or duodenal atresia, or choledochal cyst, or others).

Observethatthereisnostretchontheextremities that couldproduce

nerve injuries, and that good padding is placed everywhere. No

undercrossinglinesor tubes snakebeneaththebodyor limbs(these

couldquicklycreatepressureinjuriesinchildren).Also,notethattape

with adequate tensile strength is used; it is a common blunder in

pediatricsurgerytorelyonclearplasticorpapertapeinanattemptto

begentle. But there isnothinggentleabout fallingofftheoperating

table.

#7 Add a Port

It is anerrortosacriFiceprecision,mechanicaladvantage,andspeed in the nameof making fewer port incisions. Occasionally, a

perverse sort of macho ethic sneaks

intoa surgeonsmentalhabits,likethe

s u r ge o n w h o r a c es t h r ou g h

laparoscopiccholecystectomies aiming

for personal best skin-to-skin times.Here the error is to replace effect as

cause: It is from precision and

efFiciency that a speedy operation

results. ocusing on speed will not

improve precision, but precision

always bringsspeed. Astitchintime

reallydoessavenine.Similarly,adding

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Using gravity well also means protecting

from gravity. These patients are properly

padded and secured.

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a port in a casewhere exposure or counter-tension is difFicult can

dramatically improve theoverall precisionof thecase, andallowits

completionspeedily.Regardingtheadditionofatrocarassomesortof

failing,as a loss insomekindofNameThat Tunetypeof numerical

contest(Icantakeout thatspleenwithonlythreetrocarsWellIcan

doitwithonlytwo!)doesnotservethepatient. One of the worries about adding trocars is that the addition

couldaddsigniFicantly tothemorbidity oftheoperation. However,a

fourthorFifth3or5mmtrocarwill not contribute substantially to a

patientspainorscarring.Experienceshowsthattheextratrocarsite

adds trivially to the patients pain. But if the operative time is

shortenedfrom3hours ofstrugglewithgrasping andregrasping the

bowel toa smooth1 hour casewiththeleastamountofmanipulation

necessary,thepatientisplainlywellserved.

Considerationoftrocarincisionlengthsbringsustooneofthe

primefallacies inendoscopic surgery. It isinevitable that onehears

the argument that surgical technique is not improved if an open

operationcanbedonethroughalinearincisionwhoselengthissimilar

to thesum lengthofall trocarsiteincisions. orexample,itisargued

thata2.5cmincisionisnodifferentthanFive5mm incisions,withthe

implication that the endoscopic method is somehow a fancy waste.

However, it is not true that the lengths of trocar incisions sum to

similaropenincisionlengthsintermsofpain,scar,disability,etc. or

example,itisintuitivelyobviousthat5incisionsdistributedaroundthe

abdomen have a very lowor zero risk of dehiscence, but a 2.5-3cm

linear incision is vulnerable to this complication. urthermore, the

mathematics of woundtensionshow that thetotal tension across an

incision varies as a function of the square of its length, so the total

tensionof a longincisionis greaterthan thesummedtensionsacross

several very smallincisions ofthe sameaggregate length(10). Pain

and scarring plainly depend on tension(11). The smaller tensions

across trocar incisions are the origin of the minimally invasive

moniker,butthereisno reasonfor thesurgeonto endurea minimal

accessdisadvantage.

Dontstruggle.Addaport.

#8 Tai Chi Camera Ironically, camerawork, one of the tougher tasks, is oftendelegated to the least experienced person around the table. The

cameraoperatormust keepanupright imagecenteredon theaction

withtherightzoom andleastmovementatalltimes.Often,theintern

ormedicalstudentisaskedtorunthecameraandhasno ideahowthe

operation is done, what needs tobe seen, or evenexactlywhathe is

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A TROCAR OF DIAMETER D...

...REQUIRES AN INCISION

OF LENGTH

L=r2D

OR ONE HALF THE

CIRCUMFERENCE!

L

D

Good trocar placement requires making

precisely sized trocar incision. The oute

diameter of a 5mm trocar is usually just ove

7 mm, but the incision needs to be a little

larger. This formula suggests an incision o

11mm for a 7mm OD trocar, but because th

skin has a small amount of elasticity, the rea

value is the formula, minus a little bit, o

closer to 9mm. If it is too small, the troca

will crush the skin edges, and the surgeon

may damage underlying structures while h

struggles to insert it. Conversely, a trocar i

too large an incision will slide in and out wit

the instruments, easily falling out, etc.

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seeing. Whensternorders are barked(Look left! NO! Left! And

DOWN!)theresultisadizzyingjumpypicturelikeabad1980smusic

video.

Buteveryonemustlearncameraworksometime.ortunately,

afewsimpleideascanvastlyhelpthelearnermentallypicturewhatit

is heneeds to do. irst, takeone minuteto show(or to learn) thecameracontrols,lensconnection,andlighthookup.Explaintheuseof

theextradegreeof freedom one gains withanangled telescope, and

howtouseittoadvantage(forexample,twistthescopesotheobjective

pointsupwardwhenplacingtrocars,etc.). Demystify it,so that the

cameraoperatorwillnotbedistractedbyapprehension.

Next,thelearnermustunderstandthattheimagemustalways

becenteredontheaction,andkeptupright. Novices tendtoallowthe

camerato drift away from center, andoff kilter. Ifyou Findyourself

tryingtolookaroundthecornerofthescreen,oraretiltingyourhead,

check your cameraman. Most learners need to be reminded of this

multiple times. Even seasoned surgeons can be pulled into this

tendency to look aroundcorners of a two-dimensional image, but a

goodcameraoperatorwillnottempttheoperator.

Notonlyshouldthecamerabecenteredontheaction,butthe

picturemust bekept upright. It is amatterof simple demonstration

that task precisionradicallydegrades iftheimagetilts relativeto the

surgeonssenseofupanddown.Itispossible(althoughnotoptimal)to

worksemi-paradoxically,that iswithonesbodyorienteduptonearly

90degreesoffthelinebetweencameraandorganofinterest (that is,

partiallyviolatingtheruleto facetheorganbeingoperateon). This

positionallows anassistanttoworkwellfromthepatients sidewhen

theoperator is at thefoot,forexample. It also make theoutrigger

cameraaviablestrategy. But evenaslightchangeintiltdestroysthe

surgeonsabilitytomovebecauseofhumanrelianceonanabsolutez-

axis. orbothsurgeonandassistant,theupanddownmustremaina

consistentreferenceframeinwhichtowork.

Novices also tendto jerk the camera around,makingsmall,

briskmovementswithmultipleovercorrections.Humansareknownto

performbetteratnewskillsiftheycanmentallylinkthenewactionto

animaginedactionorimagethattheyknow.Martialartsteachershave

knownthisforcenturies: Bendlikethereed inthewindorStand

likeanironhorse. Theimagesdo not needto beanactionthat thenovice has alreadydone(althoughthatis helpful), but evocativeina

waythat pre-Fires the cerebellum ina particularway. Inthis spirit,

teachthenewcameraoperatortomovethecameraasifsheweredoing

TaiChi. Everyonecanpicturetheslow,graceful,highlycontrolledand

FluidmotionofsomeoldmasterpracticingTaiChi.Holdingthisimage

inmindpredisposesthenovicetorelax,breathe,andmovethecamera

slowly, precisely. The imagewillbe better thanin response to the

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order Move slower! The novicelearns faster when primed than

whenbullied.

TheTaiChicameraisalwayscentered,upright,anddeliberate.

#9 Use Bifocals for Spatial and Situational Awareness.

It isveryeasytoloseoneselfduringanendoscopicprocedure.Theperspectiveisdifferent,theanatomydisorienting,andtheangleof

approach of ones instruments to the surgical objective may be

awkward. Instrumentsleavethevisualframewheneveronedoesnot

practice Geisha walkmovements, when the non-dominant hand is

neglected, or whenever an instrument must be changed or cleaned.

Onehandcaneasily get lost, leavingtheoperatorFlailingaroundin

anattemptto bringtheinstrumentbackintoviewofthecamera. Ina

baby,thesegross,blindmovescandamagebowel,liveror lung. Even

withoutdamage,thesestruggleswastetime.

ortunately,onecanseemorethanjustwhatisonthescreen.

Onecanseethepatientaswell.Alostinstrumentcaneasilybefound

if one looks at the patient to seewhere the camera is pointingand

simplyaims theinstrumentfor that region. Inessence,one triesto

focus alternately between the virtual image on the screen, and the

realimageof theactualField. Callingthismethodbifocalsgivesthe

techniqueaname,makingthemethodeasiertoremember.

Bifocals also improve situational awareness. It means that

not onlymust thesurgeon be able to focus onthe imagesinside theoperatingcavity,butmustbeattunedtowhatishappeningoutsidethe

operatingFieldaswell. Istheanesthesiologistactingworried? Isthe

pulseoxdrifting? Istheend-tidalCO2 oddly high? Didsomeonejust

callfor blood? Haveyouprimedthescrub nurseortechtohavethe

right stitchorcriticalendomechanicaldevicereadyforthenextmove,

andthemoveafter that? Awarenessofthesethingshelpsyousmooth

theprocedureandprotectthepatient.

Humanscannotreallymultitask. Truemultitaskingisamyth;

humans that attempt to do two jobs at once end updoing two jobs

poorly.Instead,apparentmultitaskingdependsonatleasttwoskills.

irst,theappearanceofmultitaskingisreallythequickFlitofattentionamongdifferentobjects,justthewaysomeonewearingbifocalsquickly

adjusts his focal lengthby peering through different portions of the

glasses. orexample, the aware surgeonmay quickly sample the

sounds around him periodically--thepulseox, theheart monitor, the

conversations.ThisFlittingsampletakesmilliseconds,butyieldslots

ofinformation.

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The second skill is the ability to ignore details. This skill is

familiar to anyone who has learned the automatic, unconscious

movements of driving a car. At First, every single move requires

deliberatethought--clutch,signal,turn,gas,clutch,brake,gas....Thenew

drivermustpaysomuchattentiontothemechanics ofthecarthat he

will not see that truck, that pedestrian, or that pothole. But withpractice, thedriver, andthesurgeon,movesautomatically,freeingthe

mindforotherfocus. Inthisway,practiceisreallyawayofremoving

distractions.Somewhatparadoxically,beingmoremindfulistheartof

attendingto less. Expertiseisnottheabilityto attendtomorethings,

but the ability to be more selective in attention. The expert

automatically pays attention to the important stuff andneglects the

unimportant.Beinganexpertmeansbeingabletotellthedifference.

#10 Build Versatility by Analogy

Innovativenewproceduresarecreatedthesamewaythatthelearneraddstohisrepertoire. Theskills andlessons fromothercases

arecarriedover to newapplications. orexample,whenconsidering

the repair of duodenal atresia, one can reuse the setup for

pyloromyotomy. Later, familiarity with the right upper quadrant

allows better exposure and understanding of the twisted duodenum

seen in correction of malrotation. Similarly, when confronting the

biopsy of a pelvic mass, one can re-use the set-up for laparoscopicrectalpullthrough. Or,ifoneneedstorepairaMorgagniorBochdalek

herniafrom theabdomen, familiaritywiththesetupandmanipulation

oftheupperabdomenanddiaphragmasinaNissencanbebrought to

bear. Eachsurgeonbecomesmoreversatileby reusingdiscreteskills

fromotheroperationstobuildanewone(evenifmerelynewtohim).

Anotherway to saythis isIfyoucanmakea pizza, you canmakea

calzone.

Versatility allows the surgeon to operate better in several

ways. Theability to adapt analogousmethodstonew circumstances

allows thesurgeontogetoutoftrouble (possiblyavoidingconversion

to opentechnique). Italsoallows thesurgeontoapplyoldtechniquestonewproblems. inally,movementanalogyhelpsreinforcetheskills

heusesforwhateverprocedureheisdoingrightthen:movesarewell-

practiced and less dangerous when used in many contexts. or

example, easy facility with an endo-loop type device for common

procedures like appendectomy extends that facility to unfamiliar

contextswithrarecaseslikecholedochalcyst.

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Explicitly noting the reused movement objects (the small

movesfromwhichmore complexactionsarebuilt) indifferent cases

allows thesurgeon to move up learning curves much more quickly.

Everyendoscopic case reinforces theothers,eventhe easy onesif

good principles are always followed. or example, safe trocar

placement,non-dominant handattention, cameramovement,and useofgravityforretractionareusedineverylaparoscopicorthoracoscopic

case, andthe lessons andskillsbuilthereareactuallymorecriticalin

hardercases. Inthis way,as casesarebuiltfrom skillblocks (like

classes in object-oriented computer programming), the learner

discovers thattherearenohard cases,only caseswith a greater

numberofeasymoves.

Conclusion

The principles describedherecanbeappliedinany pediatric

MIS case. They are intended to help maximize the surgeons

mechanicaladvantageanywhereminimallyinvasivemethodsareused.

Each of these is intendedto dealwith thescaling problemsof small

patients,tohelpthesurgeonwieldratherthansimplyusethedevices,

topromoteprecisionbymaximizingavailabledegreesoffreedom,orto

workwith(orovercome)inherenthumanstrengths(andweaknesses):

1. Perfect tools are perfectly maintained...and understood

2. Face the organ

3. Triangulate the ports

4. Do the same operation

5. Operate with two hands

6. Gravity is the third hand

7. Add a port

8. Tai Chi Camera

9. Bifocals for Spatial and Situational Awareness

10. Analogy builds versatility

Maximizingmechanicaladvantageaidsprecision, speed,andsafetyin

MIS, a technological extension of surgery that, perhaps ironically,

presents severalmechanical disadvantages (andsomeadvantages, of

course)to thesurgeon. Strugglingwiththesedisadvantages putsthe

patient at unnecessary risk, risk that is magniFied in babies and

children. ortunately,practicedapplicationof theheuristicsherecan

help the surgeon create the superset of skills needed to obviate

commonhazards.

But principles can go too far. Regarding the principles

presented here as rigid or exhaustive misses the principle behind

principles:Principlesaretobeused,notblindlyobeyed.TAB

Page 21 of 22

The learning curve: proficiency with any sk

requires practice. But it is not true that each ne

operation starts the surgeon at the bottom of th

curve. Instead, specific abilities--good set-u

two handed action, small moves, comfortab

facility with electrosurgical devices, etc--are a

objects that port easily to new procedures. Bthe surgeon must see the analogies to apply o

methods to new circumstances!

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4. Madan, A. K., and Frantzides, C. T. Prospective randomized

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6. Najmaldin, A. (Ed.) Operative Endoscopy and Endoscopic Surgery

in Infants and Children. New York: Oxford University Press, 2005.

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Ferro, M., Albanese, C. T., Ostlie, D. J., van Der Zee, D. C., and Yeung, C. K.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula:

a multi-institutional analysis. Annals of surgery 242: 422-428; discussion

428-430, 2005.

8. Desrosiers, J., Bourbonnais, D., Bravo, G., Roy, P. M., and Guay,

M. Performance of the 'unaffected' upper extremity of elderly stroke

patients. Stroke; a journal of cerebral circulation27: 1564-1570, 1996.

9. Georgopoulos, A. P., and Grillner, S. Visuomotor coordination in

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10. Blinman T Incisions do not simply sum. Surg Endosc. 2010 Jul;24(7):

1746-51. Epub 2010 Jan 7.

11. Burgess, L. P., Morin, G. V., Rand, M., Vossoughi, J., and Hollinger,

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rats.Archives of otolaryngology--head & neck surgery116: 798-802, 1990.

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