Layers Of Abdominal Wall Research Articles

Abdominal Wall Masses: CT Findings and Clues to Differential Diagnosis

The abdominal wall does not comprise a distinct organ, and is often cursorily evaluated on CT. However, it is affected by many different pathological processes. These may be categorized according to their underlying etiology-trauma, infection or inflammation, iatrogenic and neoplastic process-or according to the abdominal wall layer they affect. We chose instead to group these lesions into 6 distinct categories based on their CT characteristic density: solid, infiltrative, hypervascular, fluid, fat, and bone density lesions. We highlight throughout the article the importance of integrating pertinent clinical history to narrow the differential diagnosis.

Hybrid repair of postoperative ventral hernia

To develop new technique of abdominal wall repair for postoperative ventral hernia without disadvantages which are intrinsic for open and laparoscopic surgery. Combined open and laparoscopic hernia repair was used in 18 patients with postoperative ventral hernia. Open stage provided safe dissection of abdominal adhesions and defect closure by autoplasty, laparoscopic procedure consisted of prosthesis deployment without separation of abdominal wall layers. Two types of composite endoprostheses with anti-adhesive coating were used for abdominal wall repair. There were no cases of recurrence or infectious complications in long-term period (from 3 to 106 months). Hybrid repair of postoperative ventral hernia is safe and effective procedure. Further studies are necessary to assess cost-effectiveness ratio of this method in view of expensive composite endoprostheses and laparoscopic supplies.

Probing into clinical anatomy teaching of abdominal surgery by organ procurement and back-table operation

The understanding of anatomical structures and their adjacent relationship is the foundation and key to the development of surgical skills and clinical thinking. In clinical teaching for residents and graduate students, we took the advantage of donor operations in organ transplantation and showed abdominal anal operations anatomical features and relationships through different view angles and compre-hensive ways. This new teaching approach was designed in accordance with processes of organ donation, procurement and back-table operation. The main contents included anatomy of abdominal wall layers, rela-tionships among abdominal organs, locations and courses of important structure, as well as medical humanistic education. In the context of organ donation becoming more and more popular and standardized after the cardiac death of Chinese citizens, this teaching approach is worth exploring. Key words: Abdominal surgery; Anatomy; Donation after cardiac death; Organ procurement and back-table operation

A Homemade Model that Helps Students Visualize Inguinal Canal Embryology, Anatomy, and Pathology

A simple, homemade anatomical model can be used as an active learning tool to engage students, encourage peer discussion, and enhance three‐dimensional visualization of inguinal canal anatomy, embryology, and pathology in a first year medical anatomy course. This model can be used by instructors when leading a classroom discussion and/or by groups of students engaged in peer teaching with some guiding instructions. The model is composed of 5 large pieces of construction paper of different colors (green, yellow, pink, light red, and dark red) each representing a layer of the anterior abdominal wall (parietal peritoneum, transversalis fascia, transversus abdominis muscle, internal oblique muscle, and external oblique muscle respectively). An inguinal canal is made by cutting holes through each paper layer, superior to the inguinal ligament (a line drawn on the red papers). Attached to each paper and emerging from the holes, are small “socks” of the same color as the paper they are emerging from. These “socks” represent the layers of the abdominal wall that form the fascial and muscular layers of the spermatic cord. The descent of the testes and formation of the spermatic cord, can then be demonstrated by putting a spherical object into the yellow sock and pushing it through the three red socks as it passes through the inguinal canal. The green sock, representing the parietal peritoneum, will be inside the yellow sock but the testes will not be inside the green sock – similar to the processus vaginalis. After the testes has emerged out of the superficial ring, it will be covered by multiple “sock” layers, each representing a layer of the spermatic cord. This poster outlines how to make and use this model to discuss the descent of the testes, the formation of the spermatic cord layers, and the pathology of inguinal hernias.

The effect of inspiratory and expiratory loads on abdominal muscle activity during breathing in subjects “at risk” for the development of chronic obstructive pulmonary disease and healthy

The abdominal muscle activity has been shown to be variable in subjects with chronic obstructive pulmonary disease (COPD) when respiratory demand increases and their recruitment pattern may change the mechanics, as well as the work and cost of breathing. The scientific evidence in subjects “at risk” for the development of COPD may be important to understand the natural history of this disease. This study aims to evaluate the effect of inspiratory and expiratory loads on the abdominal muscle activity during breathing in subjects “at risk” for the development of COPD and healthy. Thirty-one volunteers, divided in “At Risk” for COPD (n=17; 47.71±5.11years) and Healthy (n=14; 48.21±6.87years) groups, breathed at the same rhythm without load and with 10% of the maximal inspiratory or expiratory pressures, in standing. Surface electromyography was performed to assess the activation intensity of rectus abdominis (RA), external oblique and transversus abdominis/internal oblique (TrA/IO) muscles, during inspiration and expiration. During inspiration, in “At Risk” for COPD group, RA muscle activation was higher with loaded expiration (p=0.016); however, in Healthy group it was observed a higher activation of external oblique and TrA/IO muscles (p<0.050). During expiration, while in “At Risk” for COPD group, RA muscle activation was higher with loaded inspiration (p=0.009), in Healthy group TrA/IO muscle showed a higher activation (p=0.025). Subjects “at risk” for the development of COPD seemed to have a specific recruitment of the superficial layer of ventrolateral abdominal wall for the mechanics of breathing.

Abdominal muscle activity during breathing in different postures in COPD “Stage 0” and healthy subjects

This study aims to evaluate the effect of different postures on the abdominal muscle activity during breathing in subjects “at risk” for the development of chronic obstructive pulmonary disease (COPD) and healthy. Twenty-nine volunteers, divided in “At Risk” for COPD (n=16; 47.38±5.08years) and Healthy (n=13; 47.54±6.65years) groups, breathed at the same rhythm in supine, standing, tripod and 4-point-kneeling positions. Surface electromyography was performed to assess the activation intensity of rectus abdominis, external oblique and transversus abdominis/internal oblique (TrA/IO) muscles, during inspiration and expiration. From supine to standing, an increased activation of all abdominal muscles was observed in “At Risk” for COPD group; however, in Healthy group, TrA/IO muscle showed an increased activation. In both groups, the TrA/IO muscle activation in tripod and 4-point kneeling positions was higher than in supine and lower than in standing. Subjects “at risk” for the development of COPD seemed to have a specific recruitment of the superficial layer of ventrolateral abdominal wall for the synchronization of postural function and mechanics of breathing.

Ultrasound anatomy of the transversus abdominis plane region in pregnant women before and after cesarean delivery.

BackgroundAfter cesarean delivery, analgesia is often incomplete and a multimodal approach to analgesia is necessary. Transverse abdominal plane (TAP) block has been advocated in this setting, yet no systematic description of the ultrasound anatomy in pregnant women exists in the literature. Therefore, we aimed to describe the sonographical features of relevant structures in pregnant women before and after elective cesarean.MethodsSixty women at, or close to term scheduled for elective cesarean delivery underwent a standardized ultrasound examination before and after delivery. We assessed the visibility of the muscular layers and measured the distance from the skin to the layers of the abdominal wall muscles in the region for TAP block before and after cesarean section on both side.ResultsThe three muscular layers of the lateral abdominal wall (external oblique, internal oblique and transversus abdominis muscle) were visible in all examinations. Before cesarean section the median TAP distance was shorter: 2.9 cm (interquartile range 2.6–3.6) compared to 3.9 cm (3.1–4.5) after cesarean section (left side, p < 0.001). The external and internal oblique muscles were located closer to the skin surface before cesarean section. An increased body mass is associated with increased the TAP distance before and after birth (p < 0.001).ConclusionRelevant anatomical landmarks for a TAP block are sonographically well visible after cesarean delivery. Postoperatively, depth of the TAP as compared to before birth is increased significantly. Scanning the abdominal wall before CD will underestimate the target depth of the TAP after delivery. The obstetric anesthetist needs to be aware of these changes when planning a TAP block in the context of cesarean delivery.

Ultrasonic Reverberation Clutter Suppression Using Multiphase Apodization With Cross Correlation.

Despite numerous recent advances in medical ultrasound imaging, reverberation clutter from near-field anatomical structures, such as the abdominal wall, ribs, and tissue layers, is one of the major sources of ultrasound image quality degradation. Reverberation clutter signals are undesirable echoes, which arise as a result of multiple reflections of acoustic waves between the boundaries of these structures, and cause fill-in to lower image contrast. In order to mitigate the undesirable reverberation clutter effects, we present, in this paper, a new beamforming technique called multiphase apodization with cross correlation (MPAX), which is an improved version of our previous technique, dual apodization with cross correlation (DAX). While DAX uses a single pair of complementary amplitude apodizations, MPAX utilizes multiple pairs of complementary sinusoidal phase apodizations to intentionally introduce grating lobes from which an improved weighting matrix can be produced to effectively suppress reverberation clutter. Our experimental sponge phantom and preliminary in vivo results from human subjects presented in this paper suggest that MPAX is a highly effective technique in suppressing reverberation clutter and has great potential for producing high contrast ultrasound images for more accurate diagnosis in clinics.

Ectopic Penile Prosthesis Reservoir Placement: An Anatomic Cadaver Model of the High Submuscular Technique

IntroductionHigh submuscular ectopic placement of inflatable penile prosthesis (IPP) reservoirs via the inguinal canal has been popularized as an alternative to the retropubic (orthotopic) location, particularly among men with prior pelvic surgery. Published results suggest minimal complications and high patient satisfaction. However, in our practice, we identified several patients presenting for IPP revision after high submuscular placement who were found to have reservoirs within the peritoneal cavity. AimGiven the potential for complications, we performed a cadaveric study to define the anatomic location of reservoirs placed using this technique. MethodsWe utilized 10 fresh male cadavers without embalming. Bilateral ectopic reservoir placement (10 AMS Conceal [Boston Scientific, Marlborough, MA] and 10 Coloplast Cloverleaf [Coloplast Corp, Humlebaek, Denmark]) was performed using the high submuscular technique via a penoscrotal incision. Strict adherence to published reports detailing the technique was emphasized to assure reliability of findings. Main Outcome MeasuresAnatomic dissection was performed to identify reservoir location within the abdominal wall layers. ResultsTwenty IPP reservoirs were placed without difficulty or concern for inadvertent malpositioning. Sixteen reservoirs (80%) were found anterior to the transversalis fascia, including 7 (35%) deep to the rectus muscle and 9 (45%) deep to the external oblique fascia and lateral to the rectus muscle belly. Two reservoirs (10%) were identified in the retroperitoneal space, while 1 (5%) was preperitoneal (deep to transversalis fascia) and 1 (5%) was intraperitoneal. ConclusionPlacement of IPP reservoirs using the high submuscular technique results in variable anatomic locations, including within or immediately superficial to the peritoneal cavity. Given the lack of immediate recognition and risk of delayed complications with suboptimal reservoir placement, further studies are mandated to assess the long-term safety of the technique.

008 Submuscular Ectopic Inflatable Penile Prosthesis Reservoir Placement: A Cadaveric Study of Anatomic Location

Ectopic submuscular placement of the inflatable penile prosthesis (IPP) reservoir via the inguinal canal has become popularized as an alternative to the traditional retropubic space of Retzius. Published results suggest minimal complications and high patient satisfaction. However, in our practice, we identified several patients presenting for IPP revision after submuscular ectopic placement who were found to have reservoirs within the peritoneal cavity. Given the potential for associated complications, we performed a cadaveric study to define the anatomic location of reservoirs placed in the high submuscular position via the inguinal canal. We secured 10 fresh male cadavers (prior to the embalming process) without history of prior intra-abdominal surgery. Bilateral submuscular ectopic reservoir placement was performed using published techniques via the inguinal canal. After placement, an anatomic dissection was performed to identify the location within the abdominal wall layers. Cadaver specific data, surgical technique, and anatomic reservoir location were recorded.

Thickness estimation of the subcutaneous fat using coaxial probe.

In this Letter, a non-invasive method for thickness estimation of the subcutaneous fat layer of abdominal wall is presented by using a coaxial probe. Fat layer has the highest impact on the averaged attenuation parameter of the abdominal wall due to its high thickness and low permittivity. The abdominal wall is modelled as a multi-layer medium and an analytical model for the probe is derived by calculation of its aperture admittance facing to this multi-layer medium. The performance of this model is then validated by a numerical simulation using finite-difference-time-domain (FDTD) analysis. Simulation results show the high impact of the probe dimension and fat layer thickness on the sensitivity of the measured permittivity. The authors further investigate this sensitivity by statistical analysis of the permittivity variations. Finally, measuring in different locations relative to the body surface is presented as a solution to estimate the fat layer thickness in the presence of uncertainty of model parameters.

Umbilical hernia in patients with liver cirrhosis: A surgical challenge.

Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.

Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in children

Laparoscopic hernia repairs have been proven to be efficient and safe for children, despite the slightly higher recurrence rate compared with the classic surgical repair. They have the advantage of easy and precise identification of the type of defect and its correction, both in ipsilateral and contralateral sides. The objectives of this study were to evaluate the efficacy, safety and outcome of the laparoscopically assisted piecemeal high ligation of a patent processus vaginalis (PPV) in children. A total of 40 children were enrolled into this prospective study; they were aged ≥ 6 months and had an inguinal hernia. The peritoneal cavity, including the contralateral side, was inspected for the possibility of bilateral hernias using a 3-mm 30° telescope. Another 3-mm port was introduced through the same infra-umbilical incision. The hernia was manually reduced or with the aid of a working infra-umbilical grasper. A prolene or vicryl 2/0 or 3/0 suture on a curved semicircle round-bodied taper-ended 25-30 mm needle was introduced through a very small inguinal skin-crease incision. It was passed through the abdominal wall layers to the peritoneum and was manipulated by the laparoscopic grasper to pick up the peritoneum in piecemeal all around the internal ring. The needle was then pushed to the outside near to the entrance site, thus forming a semicircle around the internal ring. The suture was then tied and the knot was subcutaneously buried. The primary outcome of the procedure was the incidence of intraoperative diagnosis and surgical repair of contralateral hernias in pre-operatively diagnosed unilateral cases. The secondary outcomes were defined as the incidence of complications and hernia recurrence. The exploratory laparoscopy found contralateral patent processus vaginalis (CPPV) with a detection rate of 28.1%. Chan et al., Esposito et al., Toufique et al. and Niyogi et al. reported similar figures for laparoscopic contralateral hernia detection rates of 28%, 39%, 39.7% and 29.2%, respectively. The limitations of this study were the small sample size, plus the risk factors and clinical significance for CPPV. Laparascopically assisted piecemeal closure of the internal inguinal ring in children is a safe and effective procedure. It helps in detecting a contralateral hernia without prolonging the operative time.

TEP and Lichtenstein anatomy: does simulation accelerate acquisition among interns?

The anatomy of the inguinal region is notoriously challenging to master. We sought to teach open inguinal hernia (OIH) and totally extraperitoneal (TEP) anatomy with simulation models among general surgery (GS) interns. Low-fidelity OIH and TEP models were constructed out of cardboard, plastic bins, fabric, and yarn. GS interns (n=30) participated in a 3-h hernia session including a pretest, anatomy lecture, simulated OIH and TEP hernia repair, and posttest. Pre- and posttest scores were based on a difficult 30-point exam which included didactic questions (10 points), drawing relevant TEP (10 points), and OIH (10 points) anatomy. Participants were surveyed following the session. Median pretest scores were 13% (range 0-60%). Median posttest scores improved to 47% (range 20-93%, p<0.001). Median number of structures drawn in the TEP image improved from 2 (range 0-14) to 11 (range 1-21, p<0.001). Median number of structures drawn in the OIH image improved from 3 (range 0-15) to 7 (range 1-19, p<0.001). 67% (12/18) demonstrated improvement in knowledge of abdominal wall layers. 23% (7/30) knew the triangles of pain/doom on the pretest vs. 77% (23/30) on the posttest. Mean Likert scores favored session enjoyability (4.5), not a waste of training time (4.4), and improved understanding of OIH and TEP anatomy (4.4, 4.2). Low-fidelity simulators can be used to teach and assess knowledge of TEP and OIH anatomy. While enjoyable and useful, one 3-h session does not create master hernia surgeons or expert anatomists out of novice trainees.

Abdominal Wall Prosthetic Repair in Ventral and Incisional Hernia Treatment: Classification, Terminology and Technical Aspects (Review)

DOI: 10.17691/stm2015.7.2.19 Received August 26, 2014V.V. Parshikov, MD, DSc, Professor, Department of Hospital Surgery named after B.А. Korolev;А.А. Fedaev, PhD, Associate Professor, Department of Hospital Surgery named after B.А. KorolevNizhny Novgorod State Medical Academy, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russian federationThe review considers in detail the most important aspects of open abdominal wall prosthetic repair techniques applied in surgical treatment of ventral and incisional hernias according to contemporary foreign and domestic experience. we have presented the views of leading researchers on the use of synthetic endoprostheses. The authors have suggested a modern classification of primary ventral and incisional hernias indicating its variation from the previous classification SwR (Chevrel and Rath) and others. we have assessed and interpreted the English terms compared to those used in Russia. The review has traced the change of the term “tension-free plasty” in its historical perspective.The work has presented the main up-to-date techniques for mesh endoprostheses implantation, their advantages and drawbacks. There have been estimated the key points of prosthetic repair surgeries in median abdominal wall closure. we have considered correct names of variants of surgeries depending on mesh placement in relation to hernia orifices, anatomical layers of abdominal wall, and self-tissue displacement.we have clarified some peculiarities of operative techniques relying on intra-abdominal pressure control, and estimated the advantages and disadvantages of these techniques.The review has specified the most urgent problems of modern herniology, and presented one of promising directions of surgical technique improvement in the treatment of patients with large ventral and incisional hernias. we have shown the necessity of proper usage and understanding of the implication of terms standing for operative interventions, as well as correct use of corresponding classifications and terminology for adequate comparison of our research results with those of our colleges.Key words: incisional hernias; ventral hernias; prosthetic repair; tension-free plasty; abdominal wall reconstruction; mesh; intra-abdominal pressure.For contacts: Parshikov Vladimir Vyacheslavovich, e-mail: pv1610@mail.ruV.V. Parshikov, А.А. fedaev

AN ADAPTIVE PATH LOSS CHANNEL MODEL FOR WAVE PROPAGATION IN MULTILAYER TRANSMISSION MEDIUM

Advances in micro robots in non-invasive medicine have enabled physicians to perform diagnostic and therapeutic procedures with higher resolution and lower risk than before. However, navigation and precise localisation of such micro robots inside human body still remains a challenge. This is mostly due to the 1) lack of precise communication channel models, 2) inhomogeneity of the propagation medium and 3) non-geometric boundaries of the tissues morphometric parameters. In this study, we derive novel intra-body path loss channel models for wave propagation in wireless capsule endoscopy, i.e., propagation through the gastrointestinal tract and the abdominal wall. We formulate an adaptive attenuation parameter as a function of permittivity, conductivity and the thickness of various layers between the transmitter and the receiver. The standard deviation of modelling error of the path loss using our adaptive channel model is smaller than 50% of that of existing channel models. We further analyse the sensitivity of the path loss model to the variations of thickness of different abdominal wall layers. We finally show that the thickness of the fat layer has the greatest influence on the total attenuation parameter of the path loss model and therefore, we modify our adaptive model accordingly.

Abdominal wall hydrocele: A rare late postoperative complication of drain site wound incisional hernia

Late postoperative abdominal wall hydrocele is a rare complication following surgery. It may be form from a small untreated incisional hernia that passed through the musculo-aponeurotic layer of the abdominal wall. Diagnosis is easily made by clinical history of prolonged non-tender, non-reducible cystic mass below an incisional scar. Hydrocele should always be suspected when CT scan showed a fluid containing mass in the subcutaneous layer of abdominal wall with the presence of musculo-aponeurotic defect and absence incarcerate viscera in patient with chronic hypoalbuminemia. Surgical treatment should include total excision of hydrocele, facial repair and closure of hernia sac, preferably invertedly close into the abdominal cavity in order that the fluid secreting portion of the sac drained directly into in the abdominal cavity.

POST LAPAROSCOPIC PAIN CONTROL USING LOCAL ANESTHESIA THROUGH LAPAROSCOPIC PORT SITES

Background: Severe abdominal pain is not common after laparoscopic surgeries, but acute or chronic pain after operation is considerable in some patients. Post-operative Pain control after laparoscopic surgeries, is conventionally achieved using analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and narcotics, but their administration has a lot of side effects. This study compares the efficacy and side effects of local anesthetic drugs versus conventional analgesics in post-operative pain control. Materials and Methods: This prospective investigation was conducted into two groups of patients (n=93). Group 1, as control group, was given conventional analgesics such as narcotics and NSAIDs. In investigational group, at the end of laparoscopic surgery, prior to port withdrawal, a local anesthetic mixture, a short acting (Lidocaine 2%) plus a long acting (Bupivacaine 0.5%) is instilled through the port lumen between the abdominal wall layers. The efficacy of both types of medications was compared to their efficacy and side effects. Results: 85% of the control group, received 5 to 20 ml Morphine for pain control while the others were controlled with trans-rectal NSAIDs. In the treatment group, the pain of 65% of the patients was controlled only by local anesthetic drugs, 30% required NSAIDs and the other 5% required narcotics administration for pain control. Conclusion: The administration of local anesthetic drugs after laparoscopic surgery is an effective method for pain control with a low complications rate and side effects of narcotics.

Component separation technique for closure of burst abdomen

Background: Burst abdomenis a continuing problem for thegeneral surgeon as theincidence of such complication may reach 3% with a mortality rate exceeding 25%. Methods: Component separation of all layers of anterior abdominal wall would give an extra length on each side towards medial advancement. 20 patients, 12 men and 8 women aged 35-65 {mean, 48.6) years, with burst abdomen after major gastrointestinal and hepatobiliary surgery whose abdomen could not be closed primarily were managed using this technique. Long term follow up of patients was done for development of complications. Results: One patient died on the fourth postoperative day from pulmonary embolism {mortality 5%), and 2 patients developed subincisional abscesses (10.5%). Skin necrosis occurred in 1 patient (5%). No single case of reburst occurred Only one patient showed few symptoms of abdominal compartment syndrome. The mean hospital stay was 18.5 days. Long term follow up showed only one case ofincisional hernia (5.5%) in a patient with biliary fistula. Conclusion: The component separation technique is a suitable, straightforward and tension free method with a comparable mortality and morbidity to other conventional methods for closure of burst abdomen.

A Cheaper Simulator for Learning Percutaneous Renal Access: A Latex Glove Model

Introduction: The most difficult step of percutaneous renal surgery is to obtain an appropriate access to the renal cavities, which reduces the risk of vascular injury and leads to a better stone-free rate.1–3 Model-based training that provides experience in percutaneous renal access may reduce the learning curve associated with the procedure and increase the safety profile for beginners as they gain experience on patients.2,3 Thus, many biological models with porcine kidney and virtual reality simulator have been developed, to facilitate the learning and training of percutaneous renal surgery.3,4–7 We present a video of a cheaper and easily available model using a latex glove for percutaneous calyx puncture. Materials and Methods: Two or three foam layers are used to simulate the abdominal wall layers. A ureteral catheter is inserted in a latex glove, which is closed using a few ligations. The glove is filled with saline solution and contrast media. It is placed on the distal half of the foams with the fingers looking toward the middle. The fingers are fixed to the foam using medical tapes. The foams are folded to cover the glove. The puncture, guidewire insertion, and small dilation are performed under fluoroscopic guidance, with the X-ray beam perpendicular to the tract. Thus, the operator's hands are outside the fluoroscopic field, similar to the technique we use in percutaneous renal access.8 Urologist and residents were taught needle access and the beginning of tract dilation. Results: The glove model is simple and quick to set up, with a preparation time of a few minutes. It is economical, by using widely available material. It can be performed in the operating room; since it is a nonbiological model, there is no risk of biologic contamination nor any hygiene or sterilization issue. Percutaneous puncture and limited dilation were possible in all the fingers and with the same techniques used in our real percutaneous access.8,9 The needle mobilization and puncture of the glove's fingertip are similar to the feeling of the calyx puncture. Beside a good fixation to the foam, the fingers have to be tightly filled to be firm to the needle puncture. Otherwise, if the finger is flaccid, the needle will push the fingertip without puncturing it. Moreover, dilation and Amplatz sheath insertion are difficult or impossible; the finger is pushed by the dilator. It is a nonbiological model, so there is a limitation in terms of tissue feeling and for anatomic relations. In addition, ultrasound-imaging guidance cannot be used. Evaluations submitted by training session participants revealed a high degree of satisfaction with model effectiveness in the application of percutaneous calyx puncture. Conclusions: This glove model seems to be an effective means of skills acquisition for percutaneous calyx puncture. Moreover, it is cheap, simple, and quick to set up, with no risks of biologic contamination. However, further technical experience and comparative studies with biologic and virtual reality simulators are necessary to evaluate this technique. No competing financial interests exist. Run time of video: 5 mins 20 secs