Surgical Simulation: ERCP Module

The ERCP module accurately replicates the sight, sound, and feel of the endoscopic retrograde cholangiopancreatography (ERCP) procedure. Users view a realistic three-dimensional model that visibly responds to scope movement in real-time. The feel of performing the procedure is provided by Immersion's touch feedback (haptic) technology, which reproduces the tactile sensations of scope resistance, tissue stretching, and difficult cannulation. Six cases provide progressively difficult variations in anatomy and pathology.

Multimedia didactic materials provide an extensive background to help understand and visualize the procedure and its objectives. Videos demonstrate ERCP techniques, such as cannulation of the major and minor papilla. A comprehensive pathology atlas depicts both endoscopic and fluoroscopic pathologies. Interactive anatomy lessons include manipulating a 3D model to visualize anatomy at different angles. Information on use of the endoscopic elevator, radiation, contrast injection, and orientation for selective cannulization are also provided.

A thorough evaluation report is automatically generated every time a user proceeds through a case. All reports are stored in a password-protected database to provide user-specific documentation of training and competency. Items that are recorded include total procedure time, time to intubate pylorus, and time to cannulate the major papilla; the occurrence of complications such as perforation, oversedation, and overdilation of ducts by contrast; fluoroscopic metrics such as total fluoroscopy time, total amount of contrast injected, and amount of contrast injected into the pancreatic duct; use of pharmacological agents; patient discomfort metrics; and captured endoscopic images and radiographs.

Training Objectives

Upon completion of this module, users will be able to:

• Demonstrate techniques for orienting the duodenoscope and selective cannulating the respective ducts in a simulated environment.
• Understand why ERCP requires a side-viewing scope with an elevator.
• Identify pathology and understand why contrast and fluoroscopy are needed to visualize duct variations.
• Discuss the indications, contraindications and complications of ERCP.
• Describe the common anatomic and pathologic variations of the biliary and pancreatic ducts.
• Understand the safe use of fluoroscopy in ERCP and some of its potential complica tions.
• Discuss tips and techniques for overcoming common challenges specific to ERCP.

Realistic Educational Aids

The Endoscopy AccuTouch® System delivers realistic, procedure-
based content for cognitive and motor skills training. The system consists of a PC, an interface device with interchangeable anatomy, proxy endoscopes, and software modules for a wide range of training scenarios. The ERCP module provides several tools for learning how to navigate the duodenoscope through the upper GI tract, selectively cannulate the biliary and pancreatic ducts, and obtain cholangiopancreatograms:

• Complications occur such as perforation, over-sedation, and pancreatic duct injury.
• Each computerized patient audibly responds to the endoscopist's actions by expressing discomfort or pain.
• Force feedback replicates the feel of navigating the duodenoscope and manipulating the working channel tools.
• Realistic action allows practicing techniques for intubating the esophagus, passing through the pylorus, and obtaining the proper scope angle for successful cannulation.
• The scope allows injecting contrast under fluoroscopy and obtaining radiographs from a variety of angles.
• The patient responds in a physiologically realistic manner to the administration of pharmacologic agents.
• Transparent views through the duodenum show the orientation of the biliary and pancreatic ducts.
• Animations explain the short-scope and long-scope positions and the influence these positions have on cannulating the papilla.
• A Virtual Attending provides real-time instruction during the procedure.
• Textual tips provide information for overcoming difficult cannulations.