Development of a virtual reality training curriculum for laparoscopic cholecystectomy

Can Computerized Simulation be Used to Assess Surgical Proficiency in Laparoscopic Colorectal Surgeries? A Systematic Review

INTRODUCTION

Computerized simulation (CS) of surgery in virtual reality (VR), augmented reality (AR) and mixed reality (MR) settings are used to teach foundational skills, but its applicability in advanced training is to be determined. This review aims to summarize the types of CS available for laparoscopic colorectal surgery (CRS) and its utility in assessment of proficiency.

METHODS

A systematic review of CS in laparoscopic CRS was done on PubMed, Embase, Scopus and Cochrane Library databases.

RESULTS

Eleven relevant observational studies were identified. The most common procedure simulated was laparoscopic colectomy. Assessment using performance metrics measured by the simulator such as path length moved by laparoscopic tools, procedure time and number of discrete movements had the most consistent differentiating ability between expert and non-expert cohorts. Surgeons fared similarly in proficiency scores in assessment with CS compared to assessment with traditional cadaveric or porcine models.

CONCLUSION

CS of laparoscopic CRS may be used in assessment of proficiency using performance metrics measuring economy of movement. CS may be a viable assessment tool in advanced surgical training, but further studies should assess utility of incorporating it as a formal assessment tool in training programs.

The bibliometric analysis of extended reality in surgical training: Global and Chinese perspective

Objectives

The prospect of extended reality (XR) being integrated with surgical training curriculum has attracted scholars. However, there is a lack of bibliometric analysis to help them better understand this field. Our aim is to analyze relevant literature focusing on development trajectory and research directions since the 21st century to provide valuable insights.

Methods

Papers were retrieved from the Web of Science Core Collection. Microsoft Excel, VOSviewer, and CiteSpace were used for bibliometric analysis.

Results

Of the 3337 papers published worldwide, China contributed 204, ranking fifth. The world's enthusiasm for this field has been growing since 2000, whereas China has been gradually entering since 2001. Although China had a late start, its growth has accelerated since around 2016 due to the reform of the medical postgraduate education system and the rapid development of Chinese information technology, despite no research explosive period has been yet noted. International institutions, notably the University of Toronto, worked closely with others, while Chinese institutions lacked of international and domestic cooperation. Sixteen stable cooperation clusters of international scholars were formed, while the collaboration between Chinese scholars was not yet stable. XR has been primarily applied in orthopedic surgery, cataract surgery, laparoscopic training and intraoperative use in neurosurgery worldwide.

Conclusions

There is strong enthusiasm and cooperation in the international research on the XR-based surgical training. Chinese scholars are making steady progress and have great potential in this area. There has not been noted an explosive research phase yet in the Chinese pace. The research on several surgical specialties has been summarized at the very first time. AR will gradually to be more involved and take important role of the research.

Scene-dependent, feedforward eye gaze metrics can differentiate technical skill levels of trainees in laparoscopic surgery

INTRODUCTION

In laparoscopic surgery, looking in the target areas is an indicator of proficiency. However, gaze behaviors revealing feedforward control (i.e., looking ahead) and their importance have been under-investigated in surgery. This study aims to establish the sensitivity and relative importance of different scene-dependent gaze and motion metrics for estimating trainee proficiency levels in surgical skills.

METHODS

Medical students performed the Fundamentals of Laparoscopic Surgery peg transfer task while recording their gaze on the monitor and tool activities inside the trainer box. Using computer vision and fixation algorithms, five scene-dependent gaze metrics and one tool speed metric were computed for 499 practice trials. Cluster analysis on the six metrics was used to group the trials into different clusters/proficiency levels, and ANOVAs were conducted to test differences between proficiency levels. A Random Forest model was trained to study metric importance at predicting proficiency levels.

RESULTS

Three clusters were identified, corresponding to three proficiency levels. The correspondence between the clusters and proficiency levels was confirmed by differences between completion times (F2,488 = 38.94, p < .001). Further, ANOVAs revealed significant differences between the three levels for all six metrics. The Random Forest model predicted proficiency level with 99% out-of-bag accuracy and revealed that scene-dependent gaze metrics reflecting feedforward behaviors were more important for prediction than the ones reflecting feedback behaviors.

CONCLUSION

Scene-dependent gaze metrics revealed skill levels of trainees more precisely than between experts and novices as suggested in the literature. Further, feedforward gaze metrics appeared to be more important than feedback ones at predicting proficiency.

Resident performance in simulation module is associated with operating room performance for laparoscopic cholecystectomy

BACKGROUND

Simulation is an important tool in surgical training. However, the transferability of skills obtained in the simulation setting to the operating room (OR) is uncertain. This study explores the association between resident simulation performance and OR performance in a laparoscopic cholecystectomy (LC) simulation module.

METHODS

A simulation module focused on LC utilizing a virtual reality simulator was completed by general surgery residents. Simulation performance was evaluated using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) and Objective Structured Assessment of Technical Skills (OSATS), as well as a LC-specific simulation assessment form (LC-SIM). Resident subsequent OR performances of LC were measured by the Surgical Training and Assessment Tool (STAT), an online mobile-based evaluation completed by attending surgeons.

RESULTS

Twenty-one residents who completed the simulation module and also with STAT data on LC from 2016 to 2020 were included. Higher scores on incision/port placement on LC-SIM is associated with better tissue handling (coefficient 0.20, p = 0.048) and better time & economy of motion on STAT (coefficient 0.22, p = 0.037). However, higher scores on time and motion on OSATS are associated with worse tissue handling (- 0.28, p = 0.046), worse time & economy of motion (- 0.37, p = 0.009), and worse overall grade (- 0.21, p = 0.044). Higher scores on overall performance on OSATS is associated with worse time & economy of motion (- 0.80, p = 0.008). Higher scores on depth perception on GOALS are associated with worse tissue handling (- 0.28, p = 0.044).

CONCLUSION

We found significant positive and negative associations between resident simulation performance and OR performance, particularly in tissue handling and economy of motion. This could suggest that simulation performance does not reliably predict OR performance. However, this could highlight the concept of excessive caution in the real OR environment and longer operative time which could be interpreted as worse time and economy of motion by the attending surgeons.

Stress in surgical educational environments: a systematic review

BACKGROUND

The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance.

METHODS

A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682).

RESULTS

Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance.

CONCLUSIONS

The impact of stress responses presents an important factor in surgical environments, affecting residents' training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons' stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Subjective vs. objective assessment of simulation performance on laparoscopic cholecystectomy: are we evaluating the right things?

BACKGROUND

Simulation using virtual reality (VR) simulators is an important tool in surgical training. VR laparoscopic simulators can provide immediate objective performance assessment without observer evaluation. This study aims to explore the correlation between subjective observer evaluation and VR laparoscopic simulator performance metrics in a laparoscopic cholecystectomy (LC) simulation module.

METHODS

A LC simulation module using a VR laparoscopic simulator was completed by PGY2-3 general surgery residents at a single institution. Simulation performance was recorded and evaluated by a trained evaluator using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) form, the Objective Structured Assessment of Technical Skills (OSATS) form, and a LC-specific simulation assessment form (LC-SIM). Objective performance metrics were also obtained from the simulator system. Performance before the curriculum (pre-test) and after the curriculum (post-test) were compared.

RESULTS

Fourteen residents were included in the study. There were significant improvements from pre-test to post-test on each component of GOALS, OSATS, and LC-SIM scores (all p values < 0.05). In terms of objective simulator metrics, significant improvements were noted in time to extract gallbladder (481 ± 221 vs 909 ± 366 min, p = 0.019), total number of movements (475 ± 264 vs 839 ± 324 min, p = 0.012), and total path length (955 ± 475 vs 1775 ± 632 cm, p = 0.012) from pre-test to post-test. While number of movements and total path lengths of both hands decreased, speed of right instrument also decreased from 4.1 + 2.7 to 3.0 ± 0.7 cm/sec (p = 0.007). Average speed of left instrument was associated with respect for tissue (r = 0.60, p < 0.05) and depth perception (r = 0.68, p < 0.05) on post-test evaluations.

CONCLUSION

Our study demonstrated significant improvement in technical skills based on subjective evaluator assessment as well as objective simulator metrics after simulation. The few correlations identified between the subjective evaluator and the objective simulator assessments suggest the two evaluation modalities were measuring different aspects of the technical skills and should both be considered in the evaluation process.

Validation of a novel virtual reality simulation system with the focus on training for surgical dissection during laparoscopic sigmoid colectomy

Background

Mastery of technical skills is one of the fundamental goals of surgical training for novices. Meanwhile, performing laparoscopic procedures requires exceptional surgical skills compared to open surgery. However, it is often difficult for trainees to learn through observation and practice only. Virtual reality (VR)-based surgical simulation is expanding and rapidly advancing. A major obstacle for laparoscopic trainees is the difficulty of well-performed dissection. Therefore, we developed a new VR simulation system, Lap-PASS LP-100, which focuses on training to create proper tension on the tissue in laparoscopic sigmoid colectomy dissection. This study aimed to validate this new VR simulation system.

Methods

A total of 50 participants were asked to perform medial dissection of the meso-sigmoid colon on the VR simulator. Forty-four surgeons and six non-medical professionals working in the National Cancer Center Hospital East, Japan, were enrolled in this study. The surgeons were: laparoscopic surgery experts with > 100 laparoscopic surgeries (LS), 21 were novices with experience < 100 LS, and five without previous experience in LS. The participants’ surgical performance was evaluated by three blinded raters using Global Operative Assessment of Laparoscopic Skills (GOALS).

Results

There were significant differences (P-values < 0.044) in all GOALS items between the non-medical professionals and surgeons. The experts were significantly superior to the novices in one item of GOALS: efficiency ([4(4–5) vs. 4(3–4)], with a 95% confidence interval, p = 0.042). However, both bimanual dexterity and total score in the experts were not statistically different but tended to be higher than in the novices.

Conclusions

Our study demonstrated a full validation of our new system. This could detect the surgeons' ability to perform surgical dissection and suggest that this VR simulator could be an effective training tool. This surgical VR simulator might have tremendous potential to enhance training for surgeons.

Using Automated Continuous Instrument Tracking to Benchmark Simulated Laparoscopic Performance and Personalize Training

OBJECTIVE

Laparoscopic simulation is widely used in surgical training. However, the impact of training on performance is difficult to assess. Observation is time-intensive and subjective. SurgTrac laparoscopic box-trainer instrument tracking software provides continuous, automated, real-time, objective performance feedback. We used this data to assess the relationship between task attempts and performance. We assessed whether improvement in performance with repetition could be modeled in learning curves that might be used for benchmarking.

DESIGN

Anonymized SurgTrac data for performances undertaken between 10/2016 and 05/2019 were retrospectively extracted. The thread transfer task, a basic instrument handling task, was assessed. Task duration and instrument-based metrics were analyzed; total distance travelled by instrument tips, average speed, average acceleration, and the ratio of movements between the left and right hands. Curve estimation regression was used to assess the relationship between attempt number and metrics for pooled data across the entire cohort of users and amongst individual users with ≥50 attempts. Threshold for significance p = 0.05.

SETTING

SurgTrac has generated the largest available database of performances in box trainer simulated tasks with 64,000 activities performed by over 1450 users in 77 countries to date.

PARTICIPANTS

Data was derived from the unselected world-wide cohort of SurgTrac users. No participants were excluded.

RESULTS

Five hundred seventy-eight users performed 13,027 attempts in the thread transfer task. Across the entire cohort, SurgTrac performance metrics were significantly associated with attempt number. Task duration and total distance decreased with attempt number. This benefit persisted across 100 attempts. Ambidexterity increased with attempt number. Individual candidate performance improved in line with predicted learning curves for better performing candidates.

CONCLUSIONS

We analyzed the largest database of simulated laparoscopic task performances. Performance improves with practice. Using learning curves derived from peer-group performances as benchmarks, users may be regularly and objectively assessed to support personalization of training.

Development of a north-west London paracentesis simulation course for core medical trainees

We designed, implemented and evaluated a near-peer simulation training programme teaching diagnostic and therapeutic abdominal paracentesis to core medical trainees (CMTs). We taught diagnostic and therapeutic abdominal paracentesis to 77 north-west London CMTs over 8 training days over 4 years, 2015 to 2019. The programme was optimised by use of plan, do, study, act (PDSA) cycles and the content was evaluated by anonymous pre- and post-course questionnaires. There was a need for this training; 89% of participants reported inadequate training opportunities pre-course and only 28% felt 'confident' or 'very confident' to insert an ascitic drain. Simulation training appears effective when teaching these skills. Having been low in confidence before the course, all participants reported increased confidence after completing the course. Simulation training has been highlighted as a key aspect of the new internal medicine training programme, which replaces CMT. We would recommend using PDSA cycles to implement effective simulation programmes.

Evaluation of a Novel Laparoscopic Cholecystectomy Curriculum With the Use of Animal Models and Live Operating

BACKGROUND

Despite wide recognition of the benefits of simulation training, there is no established model for the teaching of laparoscopic cholecystectomy. The authors developed a replicable, intensive 2-day proficiency-based curriculum, to include simulation and live operating, designed to be practical to both attend and organize. The primary objective of this study was to evaluate this curriculum for improved procedural confidence, measured by participant self-evaluation. Secondary outcomes were objective improvement in technical skills in accordance with the Objective Structured Assessment of Technical Skills (OSATS) scale and trainee self-assessment scores.

METHODS

The course consisted of lectures, operating on a sheep hepatobiliary model through a laparoscopic box trainer, and live operating on female patient volunteers. It was attended by eight junior registrars. Precourse data collated included demographic information, experience, and procedural confidence scores using a visual analog scale. Performance on an animal model and live patient was assessed by experts using the OSATS score. Procedural confidence was re-evaluated after each task, as well as self-assessment of speed, accuracy, and overall performance.

RESULTS

Procedural confidence scores improved by a mean of 12% (P < 0.001). All trainees demonstrated sustained objective improvement in technical skills (P < 0.001). The overall mean OSATS score increased by 18%. Significant improvement was observed after performing the procedure on an animal model (P < 0.001); however, no further significant improvement was observed with live operating. No significant difference was found on trainee self-assessment scores, in any category.

CONCLUSIONS

The study describes a successful curriculum model for the teaching of laparoscopic cholecystectomy, to include procedural and technical skill acquisition, in addition to the refinement and development of procedural confidence. Importantly, this was carried out in a safe environment with direct transferability to the operating theater.

Implementation of a Surgical Simulation Care Pathway Approach to Training in Emergency Abdominal Surgery

BACKGROUND

Simulation-based care pathway approach (CPA) training is a novel approach in surgical education. The objective of the present study was to determine whether CPA was feasible for training surgical residents and could improve efficiency in patients' management. A common disease was chosen: acute appendicitis.

METHODS

All five junior residents of our department were trained in CPA: preoperative CPA consisted in virtual patients (VPs) presenting with acute right iliac fossa pain; intraoperative CPA involved a virtual competency-based curriculum for laparoscopic appendectomy (LAPP); finally, post-operative VP were reviewed after LAPP. Thirty-eight patients undergoing appendectomy were prospectively included before (n = 21) and after (n = 17) the training. All demographic and perioperative data were prospectively collected from their medical records, and time taken from admission to management was measured.

RESULTS

All residents had performed less than 10 LAPP as primary operator. Pre- and intraoperative data were comparable between pretraining and post-training patients. Times to liquid and solid diet were significantly reduced after training [7 h (2-20) vs. 4 (4-6); P = 0.004, and 17 h (4-48) vs. 6 (4-24); P = 0.005] without changing post-operative morbidity [4 (19%) vs. 0 (0); P = 0.11] and length of stay [48 h (30-264) vs. 44 (21-145); P = 0.22].

CONCLUSIONS

CPA training is feasible in abdominal surgery. In the current study, it improved patients' management in terms of earlier oral intake.

Video-based self-assessment enhances laparoscopic skills on a virtual reality simulator: a randomized controlled trial

BACKGROUND

Hysterectomy rates are decreasing in many countries, and virtual reality (VR) simulators bring new training opportunities for residents. As coaching interventions while training on a simulated complex procedure represents a resource challenge, alternative strategies to improve surgical skills must be investigated. We sought to determine whether self-guided learning using a video-based self-assessment (SA) leads to improved surgical skills in laparoscopic hysterectomy (LH) on a VR simulator.

METHODS

Twenty-four gynecology residents from two university hospitals were randomized into an SA group (n = 12) and a Control group (n = 12). Each participant's baseline performance on a validated VR basic task was assessed. Both groups then performed three virtually simulated LHs during which the participants received no guidance nor feedback. Following each LH, the SA group participants rated the video of their own performance using a generic and a procedure-specific rating scale, while the Control group participants watched an LH video demonstration. The LH videos of both groups' participants were blindly reviewed and rated by expert surgeons, using modified Objective Structured Assessment of Technical Skills scores (OSATS). Objective metrics recorded by the VR simulator were also compared.

RESULTS

There was no difference between the groups' baseline performances on the VR basic task. For the first LH, the OSATS-derived scores did not differ between SA and Control groups (9 [7-13] versus 9 [8-14]; p = 0.728). For the third LH, the OSATS-derived scores were higher for the SA group than for the Control group (17 [15-21] versus 15 [11-17], p = 0.039). Between the two groups, the objective metrics did not differ from the first to the third LH.

CONCLUSIONS

The use of a structured video-based SA leads to improved procedural skills in LH on a VR simulator compared to watching benchmark expert performance, in a population of residents with moderate experience in the operating room.

Development and validation of non-guided bladder-neck and neurovascular-bundle dissection modules of the RobotiX-Mentor® full-procedure robotic-assisted radical prostatectomy virtual reality simulation

Background

Full‐procedure virtual reality (VR) simulator training in robotic‐assisted radical prostatectomy (RARP) is a new tool in surgical education.

Methods

Description of the development of a VR RARP simulation model, (RobotiX‐Mentor®) including non‐guided bladder neck (ngBND) and neurovascular bundle dissection (ngNVBD) modules, and assessment of face, content, and construct validation of the ngBND and ngNVBD modules by robotic surgeons with different experience levels.

Results

Simulator and ngBND/ngNVBD modules were rated highly by all surgeons for realism and usability as training tool. In the ngBND‐task construct, validation was not achieved in task‐specific performance metrics. In the ngNVBD, task‐specific performance of the expert/intermediately experienced surgeons was significantly better than that of novices.

Conclusions

We proved face and content validity of simulator and both modules, and construct validity for generic metrics of the ngBND module and for generic and task‐specific metrics of the ngNVBD module.

Comparison of manual versus robot-assisted contralateral gate cannulation in patients undergoing endovascular aneurysm repair

PURPOSE

Robotic endovascular technology may offer advantages over conventional manual catheter techniques. Our aim was to compare the endovascular catheter path-length (PL) for robotic versus manual contralateral gate cannulation during endovascular aneurysm repair (EVAR), using video motion analysis (VMA).

METHODS

This was a multicentre retrospective cohort study with fluoroscopic video recordings of 24 EVAR cases (14 robotic, 10 manual) performed by experienced operators (> 50 procedures), obtained from four leading European centres. Groups were comparable with no statistically significant differences in aneurysm size (p = 0.47) or vessel tortuosity (p = 0.68). Two trained assessors used VMA to calculate the catheter PL during contralateral gate cannulation for robotic versus manual approaches.

RESULTS

There was a high degree of inter-observer reliability (Cronbach's α > 0.99) for VMA. Median robotic PL was 35.7 cm [interquartile range, IQR (30.8-51.0)] versus 74.1 cm [IQR (44.3-170.4)] for manual cannulation, p = 0.019. Robotic cases had a median cannulation time of 5.33 min [IQR (4.58-6.49)] versus 1.24 min [IQR (1.13-1.35)] in manual cases (p = 0.0083). Generated efficiency ratios (PL/aorto-iliac centrelines) was 1.6 (1.2-2.1) in robotic cases versus 2.6 (1.7-7.0) in manual, p = 0.031.

CONCLUSION

Robot-assisted contralateral gate cannulation in EVAR leads to decreased navigation path lengths and increased economy of movement compared with manual catheter techniques. The benefit could be maximised by prioritising robotic catheter shaping over habituated reliance on guidewire manipulation. Robotic technology has the potential to reduce the endovascular footprint during manipulations even for experienced operators with the added advantage of zero radiation exposure.

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial

Background

Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH.

Methods

Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants.

Results

Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047).

Conclusions

Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice.

Trial registration

ISRCTN 83733979

Assessment of training and selected factors on speed and quality of performing different tasks on the endoscopic simulator

Introduction

One of the most significant challenges nowadays is to educate and predict the predispositions of young surgeons taking into consideration that every ability has its own learning curve.

Aim

To determine the influence of selected factors and examine the shape and the length of the learning curve in performing simple tasks on an endoscopic simulator.

Material and methods

Twenty students took part in 4 training sessions with a one-week break between sessions. They were training 12 min and performed three tasks at every session on the endoscopic simulator. To identify whether selected factors influence the time of completing tasks, the participants were asked to fill in questionnaires. All participants also completed the Minnesota Manual Dexterity Test (MMDT) to assess hand-eye coordination.

Results

Our research reveals that regardless of activities performed in free time, the shape of the learning curve was logarithmic. Improvement after the fourth session ranged from 50% to 75%. Performing specific activities in the free time did not influence the results achieved on the simulator. No statistically significant correlation between MMDT results and the time to accomplish each task was found.

Conclusions

This study has shown that the length of the learning curve of performing simple tasks is quite short and the shape is logarithmic. It suggests that more complex exercises should be included in the training programme.

Development of a program for teaching practical skills in visceral and digestive surgery by simulation

Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.

Validation of a cost-effective appendicectomy model for surgical training

BACKGROUND

Appendicitis is a commonly occurring condition worldwide. The gold standard treatment is appendicectomy. Although training models are commercially available for this procedure, they are often associated with high cost. Here we present a cost-effective model.

AIM

To establish construct validity of a cost-effective laparoscopic appendicectomy simulation model.

METHODS

Three groups of surgeons were recruited; novices (n = 31), of intermediate expertise (n = 13) and experts (n = 5) and asked to perform a simulated laparoscopic appendicectomy using the new model. Their performance was assessed by a faculty member and compared between the three groups using a validated scoring system (Global Operative Assessment of Laparoscopic Skills [GOALS] score).

RESULTS

One-way ANOVA test showed a significant difference in task performance between groups (p < 0.0001). Post-hoc comparisons after the application of Bonferroni correction (statistically significant p value <0.017) demonstrate a significant difference in performance between all groups for all GOALS categories as well as the total score. Effect size calculations showed that experience level had moderate (Eta-squared >0.5 and <0.8) and significant (>0.8) impact on the performance of the simulated procedure.

CONCLUSION

The model described in this study is cost-effective, valid and can adequately simulate appendicectomy. The authors recommend inclusion of this model to postgraduate surgical training.

Validity assessment of the laparoscopic radical nephrectomy module of the LapVision virtual reality simulator

BACKGROUND

Virtual reality simulators allow trainees to perform repeated practice and provide objective dexterity metrics regarding their performance, which means that virtual reality-based surgical training is becoming a vital part of initial learning of basic laparoscopic surgical skills. However, its educational role in learning advanced procedures remains undetermined. We evaluated the validity of the laparoscopic radical nephrectomy module of the LapVision virtual reality simulator.

METHODS

Urologists, medical students, and a junior resident voluntarily participated in the present study, and they performed training with a laparoscopic left radical nephrectomy module. For construct validation, dexterity metrics calculated in the simulator and the mean score of Global Operative Assessment of Laparoscopic Skills evaluated by 2 experts' video review were compared according to the certification of Japanese Endoscopic Surgical Skill Qualification or previous surgical experience.

RESULTS

Ten experts (≥ 50 laparoscopic surgeries), 9 intermediates (11-49), and 14 novices (0-10) voluntarily participated in the present study. Regarding the construct validity, there was a significant difference in the total number of errors, blood loss, and Global Operative Assessment of Laparoscopic Skills score among the groups for both the Endoscopic Surgical Skill Qualification status and previous surgical experience.

CONCLUSION

The present study demonstrated good construct validity for the LapVision nephrectomy module. Furthermore, global skill assessment was possible by experts' reviews, which indicates the usefulness of the virtual reality procedural module as a skill assessment tool. Virtual reality-based procedural simulation has marked potential to become a vital part of integrated laparoscopic training programs.

Perfect Registration Leads to Imperfect Performance: A Randomized Trial of Multimodal Intraoperative Image Guidance

OBJECTIVE

To compare surgical safety and efficiency of 2 image guidance modalities, perfect augmented reality (AR) and side-by-side unregistered image guidance (IG), against a no guidance control (NG), when performing a simulated laparoscopic cholecystectomy (LC).

BACKGROUND

Image guidance using AR offers the potential to improve understanding of subsurface anatomy, with positive ramifications for surgical safety and efficiency. No intra-abdominal study has demonstrated any advantage for the technology. Perfect AR cannot be provided in the operative setting in a patient; however, it can be generated in the simulated setting.

METHODS

Thirty-six experienced surgeons performed a baseline LC using the LapMentor simulator before randomization to 1 of 3 study arms: AR, IG, or NG. Each performed 3 further LC. Safety and efficiency-related simulator metrics, and task workload (SURG-TLX) were collected.

RESULTS

The IG group had a shorter total instrument path length and fewer movements than NG and AR groups. Both IG and NG took a significantly shorter time than AR to complete dissection of Calot triangle. Use of IG and AR resulted in significantly fewer perforations and serious complications than the NG group. IG had significantly fewer perforations and serious complications than the AR group. Compared with IG, AR guidance was found to be significantly more distracting.

CONCLUSION

Side-by-side unregistered image guidance (IG) improved safety and surgical efficiency in a simulated setting when compared with AR or NG. IG provides a more tangible opportunity for integrating image guidance into existing surgical workflow as well as delivering the safety and efficiency benefits desired.

Emotional Intelligence Predicts Accurate Self-Assessment of Surgical Quality: A Pilot Study

BACKGROUND

Self-assessment is fundamental in surgical training. Accuracy of self-assessment is superior with greater age, experience, and the use of video playback. Presently, there is scarce evidence in the literature regarding predictors for a surgical trainee's aptitude for self-assessment. The objective of this study was to investigate whether emotional intelligence or visual-spatial aptitude can predict effective self-assessment among novice surgeons performing laparoscopic appendectomy (LA).

MATERIALS AND METHODS

Eighteen novice trainees performed a simulated LA, and two aptitude measures were evaluated: (1) emotional intelligence questionnaire and (2) visual spatial ability test. Self-assessment of their performance was conducted using the Objective Assessment of Surgical and Technical Skills global rating scale and ranking five subtasks of the procedure in order of quality of performance after watching a playback of their LA. Two blinded experts (senior consultant surgeons, performed >100 LAs) assessed surgical quality using the same scoring system. Candidates were ranked into higher and lower aptitude groups for the two aptitude measures. Spearman's rank correlation coefficient was calculated to identify if either of the two groups demonstrated greater agreement between self and expert assessment in relation to the two aptitude measures.

RESULTS

Participants with a higher degree of emotional intelligence demonstrated significant agreement with expert assessment (r = 0.73, P = 0.031).

CONCLUSIONS

Emotional intelligence can predict better self-assessment of surgical quality after performing a simulated LA. This may facilitate early identification of individuals who might require mentoring or guidance with self-assessment as well as contribute to selection criteria.

Challenges of training in adrenal surgery

While adrenal tumors are common, adrenalectomy is rather uncommon. This is one reason for the many challenges regarding the training of adrenal surgery. Here we focus on issues that are most pertinent regarding training of the young surgeons performing adrenalectomy. Due to the very limited literature, what is presented is mainly based on personal experience and/or from the literature published for other surgical operations and subspecialties. The discussed challenges include indications for surgery, surgical approaches and extent, and intraoperative complications. With advances in adrenal surgery, we expect some old challenges to be resolved, and some new challenges to arise. These challenges will be faced in order to continue to help our younger trainee acquire the knowledge and skills to best care for our patients with adrenal diseases.

Development of a structured virtual reality curriculum for laparoscopic appendicectomy

BACKGROUND

Laparoscopic appendicectomy (LA) is a common surgical emergency procedure mainly performed by trainees. The aim was to develop a step-wise structured virtual reality (VR) curriculum for LA to allow junior surgeons to hone their skills in a safe and controlled environment.

METHODS

A prospective randomized study was designed using a high-fidelity VR simulator. Thirty-five novices and 25 experts participated in the assessment and their performances were compared to assess construct validity. Learning curve analysis was performed.

RESULTS

Five of the psychomotor tasks and all appendicectomy tasks showed construct validity. Learning was demonstrated in the majority of construct-valid tasks. A novel goal-directed VR curriculum for LA was constructed.

CONCLUSIONS

A step-wise structured VR curriculum for LA is proposed with a framework which includes computer generated metrics and supports deliberate practice, spacing intervals, human instruction/feedback and assessment. Future study should test the feasibility of its implementation and transferability of acquired skill.

CAN VIRTUAL REALITY BE AS GOOD AS OPERATING ROOM TRAINING? EXPERIENCE FROM A RESIDENCY PROGRAM IN GENERAL SURGERY

Background:

The increasingly intense usage of technology applied to videosurgery and the advent of robotic platforms accelerated the use of virtual models in training surgical skills.

Aim:

To evaluate the performance of a general surgery department’s residents in a video-simulated laparoscopic cholecystectomy in order to understand whether training with virtual reality is sufficient to provide the skills that are normally acquired in hands-on experience at the operating room.

Methods:

An observational study with twenty-five first- and second-year general surgery residents. Each subject performed three video-laparoscopic cholecystectomies under supervision in a simulator. Only the best performance was evaluated in the study. Total number of complications and total procedure time were evaluated independently. The groups were defined according to total practice time (G1 and G2) and the year of residency (R1 and R2), each being analysed separately.

Results:

Twenty-one residents finished the three practices, with four follow-up losses. Mean practice time was 33.5 hours. Lowering of the rate of lesions in important structures could be identified after a level of proficiency of 60%, which all participants obtained regardless of previous in vivo experience. No significant difference between the R1 and R2 groups was observed.

Conclusion:

Learning in groups R1 and R2 was equal, regardless of whether previous practice was predominantly in vivo (R2) or with virtual reality (R1). Therefore, it is possible to consider that skills obtained in virtual reality training are capable of equalising the proficiency of first- and second-year residents, being invaluable to increase patient safety and homogenise learning of basic surgical procedures.

The Heidelberg VR Score: development and validation of a composite score for laparoscopic virtual reality training

INTRODUCTION

Virtual reality (VR-)trainers are well integrated in laparoscopic surgical training. However, objective feedback is often provided in the form of single parameters, e.g., time or number of movements, making comparisons and evaluation of trainees' overall performance difficult. Therefore, a new standard for reporting outcome data is highly needed. The aim of this study was to create a weighted, expert-based composite score, to offer simple and direct evaluation of laparoscopic performance on common VR-trainers.

MATERIALS AND METHODS

An integrated analytic hierarchy process-Delphi survey was conducted with 14 international experts to achieve a consensus on the importance of different skill categories and parameters in evaluation of laparoscopic performance. A scoring algorithm was established to allow comparability between tasks and VR-trainers. A weighted composite score was calculated for basic skills tasks and peg transfer on the LapMentor™ II and III and validated for both VR-trainers.

RESULTS

Five major skill categories (time, efficiency, safety, dexterity, and outcome) were identified and weighted in two Delphi rounds. Safety, with a weight of 67%, was determined the most important category, followed by efficiency with 17%. The LapMentor™-specific score was validated using 15 (14) novices and 9 experts; the score was able to differentiate between both groups for basic skills tasks and peg transfer (LapMentor™ II: Exp: 86.5 ± 12.7, Nov. 52.8 ± 18.3; p < 0.001; LapMentor™ III: Exp: 80.8 ± 7.1, Nov: 50.6 ± 16.9; p < 0.001).

CONCLUSION

An effective and simple performance measurement was established to propose a new standard in analyzing and reporting VR outcome data-the Heidelberg virtual reality (VR) score. The scoring algorithm and the consensus results on the importance of different skill aspects in laparoscopic surgery are universally applicable and can be transferred to any simulator or task. By incorporating specific expert baseline data for the respective task, comparability between tasks, studies, and simulators can be achieved.

A Randomized Controlled Trial of Skills Transfer: From Touch Surgery to Laparoscopic Cholecystectomy

BACKGROUND

Surgical training has traditionally involved teaching trainees in the operating room. However, intraoperative training is time-intensive and exposes patients to greater risks. Touch Surgery (TS) is an application that uses animation to provide simulation training via cognitive task analysis as an adjunct to intraoperative training.

METHODS

Forty students were recruited and randomly allocated to either a control or intervention group. Each group received the same preparation before intervention, including a 10-min introduction to laparoscopic equipment and a 15-min educational tutorial on laparoscopic cholecystectomies. The participants then received training via either TS (intervention) or written information (control). Their performance was compared using a validated scoring tool on a porcine laparoscopic cholecystectomy model. Significance was defined as P < 0.050.

RESULTS

In total, n = 22 and n = 18 participants were randomly assigned to intervention and control groups, respectively. There was no significant difference between age (P = 0.320), year of medical school (P = 0.322), handedness (P = 1.000), or gender (P = 0.360) of the groups. The overall mean performance score was higher for intervention (mean ± SD = 41.9 ± 22.5) than control (mean ± SD = 24.7 ± 19.6; P = 0.016). There was no significant difference between scores for each intraoperative segment between the intervention and control group (P > 0.050).

CONCLUSIONS

This study demonstrates that TS is effective for providing cognitive training in laparoscopic cholecystectomies to medical students. It is likely that this effect will be seen across modules and other platforms that use cognitive task analysis alongside high-fidelity animation. Further work is necessary to extend this to other surgical procedures for evaluating its longitudinal effectiveness.

Does Personal Learning Style Predict the Ability to Learn Laparoscopic Surgery? A Pilot Study

PURPOSE

Acquiring laparoscopic skills occurs at different rates among trainees. We conducted a pilot study to determine whether variation in laparoscopic skill acquisition was associated with subject's learning styles.

MATERIALS AND METHODS

Nineteen medical students performed 10 repetitions of the object transfer task over a period of 4 weeks using a validated laparoscopic simulator. The main exposure was participants' learning style categorized according to the Fleming VARK-learning style inventory. VARK (V = visual, A = aural, R = read/write, K = kinesthetic) is a validated learning style model that identifies four different learning styles. The main outcome measures that reflected laparoscopic skill acquisition were task completion time (<107 seconds) and total instrument distance (<2.03 m) obtained from SurgTrac^® motion analysis software. To determine whether participants' laparoscopic proficiency was associated with learning style we used chi-square tests for categorical variables and t-tests for continuous variables.

RESULTS

Nineteen participants completed the inventory, 37% (7) were classified as kinesthetic and/or visual style learners, while 63% (12) were considered multimodal or reading/writing style learners. Participants classified as visual/kinesthetic were ∼4 years older than participants classified as multimodal or reading/writing style learners. No gender differences were observed between the groups. Eighty-five percent (6) of participants with a kinesthetic and/or visual learning style reached the proficiency level for task completion time while only 17% (2) of participants with multimodal or read/write learning style performed the task in <107 seconds (χ² = 8.7; P = .003). Regarding total instrument distance, 85% (6) of participants classified as kinesthetic and/or visual learners and 67% (8) of participants classified as multimodal or read/write learners performed the task in <2.03 m (P = .36).

CONCLUSIONS

This is the first study to investigate the correlation between trainees' VARK-learning style and their ability to acquire laparoscopic skills. This pilot study suggests that trainees' learning style may affect the ability to acquire laparoscopic skill proficiency. Larger studies are needed to confirm these preliminary observations.

Twelve tips for efficient procedural simulation

Procedural simulation (PS) is increasingly being used worldwide in healthcare for training caregivers in psychomotor competencies. It has been demonstrated to improve learners' confidence and competence in technical procedures, with consequent positive impacts on patient outcomes and safety. Several frameworks can guide healthcare educators in using PS as an educational tool. However, no theory-informed practical framework exists to guide them in including PS in their training programs. We present 12 practical tips for efficient PS training that translates educational concepts from theory to practice, based on the existing literature. In doing this, we aim to help healthcare educators to adequately incorporate and use PS both for optimal learning and for transfer into professional practice.

Face and Construct Validity of a Novel Virtual Reality-Based Bimanual Laparoscopic Force-Skills Trainer With Haptics Feedback

BACKGROUND

The purpose of this study was to examine the face and construct validity of a custom-developed bimanual laparoscopic force-skills trainer with haptics feedback. The study also examined the effect of handedness on fundamental and complex tasks.

METHODS

Residents (n = 25) and surgeons (n = 25) performed virtual reality-based bimanual fundamental and complex tasks. Tool-tissue reaction forces were summed, recorded, and analysed. Seven different force-based measures and a 1-time measure were used as metrics. Subsequently, participants filled out face validity and demographic questionnaires.

RESULTS

Residents and surgeons were positive on the design, workspace, and usefulness of the simulator. Construct validity results showed significant differences between residents and experts during the execution of fundamental and complex tasks. In both tasks, residents applied large forces with higher coefficient of variation and force jerks (P < .001). Experts, with their dominant hand, applied lower forces in complex tasks and higher forces in fundamental tasks (P < .001). The coefficients of force variation (CoV) of residents and experts were higher in complex tasks (P < .001). Strong correlations were observed between CoV and task time for fundamental (r = 0.70) and complex tasks (r = 0.85). Range of smoothness of force was higher for the non-dominant hand in both fundamental and complex tasks.

CONCLUSIONS

The simulator was able to differentiate the force-skills of residents and surgeons, and objectively evaluate the effects of handedness on laparoscopic force-skills. Competency-based laparoscopic skills assessment curriculum should be updated to meet the requirements of bimanual force-based training.

Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis

BACKGROUND

Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures, remains associated with significant major morbidity including bile leak and bile duct injury (BDI). The effect of changes in practice over time, and of interventions to improve patient safety, on morbidity rates is not well understood. The aim of this review was to describe current incidence rates and trends for BDI and other complications during and after LC, and to identify risk factors and preventative measures associated with morbidity and BDI.

METHODS

PubMed, MEDLINE, and Web of Science database searches and data extraction were conducted for studies which reported individual complications and complication rates following laparoscopic cholecystectomy in a representative population. Outcomes data were pooled. Meta-regression analysis was performed to assess factors associated with conversion, morbidity, and BDI rates.

RESULTS

One hundred and fifty-one studies reporting outcomes for 505,292 patients were included in the final quantitative synthesis. Overall morbidity, BDI, and mortality rates were 1.6-5.3%, 0.32-0.52%, and 0.08-0.14%, respectively. Reported BDI rates reduced over time (1994-1999: 0.69(0.52-0.84)% versus 2010-2015 0.22(0.02-0.40)%, p = 0.011). Meta-regression analysis suggested higher conversion rates in developed versus developing countries (4.7 vs. 3.4%), though a greater degree of reporting bias was present in these studies, with no other significant associations identified.

CONCLUSIONS

Overall, trends suggest a reduction in BDI over time with unchanged morbidity and mortality rates. However, data and reporting are heterogenous. Establishment of international outcomes registries should be considered.

Effect of Continuous Motion Parameter Feedback on Laparoscopic Simulation Training: A Prospective Randomized Controlled Trial on Skill Acquisition and Retention

OBJECTIVE

To investigate the effect of motion parameter feedback on laparoscopic basic skill acquisition and retention during a standardized box training curriculum.

DESIGN

A Lap-X Hybrid laparoscopic simulator was designed to provide individual and continuous motion parameter feedback in a dry box trainer setting. In a prospective controlled trial, surgical novices were randomized into 2 groups (regular box group, n = 18, and Hybrid group, n = 18) to undergo an identical 5-day training program. In each group, 7 standardized tasks on laparoscopic basic skills were completed twice a day on 4 consecutive days in fixed pairs. Additionally, each participant performed a simulated standard laparoscopic cholecystectomy before (day 1) and after training (day 5) on a LAP Mentor II virtual reality (VR) trainer, allowing an independent control of skill progress in both groups. A follow-up assessment of skill retention was performed after 6 weeks with repetition of both the box tasks and VR cholecystectomy.

SETTING

Muenster University Hospital Training Center, Muenster, Germany.

PARTICIPANTS

Medical students without previous surgical experience.

RESULTS

Laparoscopic skills in both groups improved significantly during the training period, measured by the overall task performance time. The 6 week follow-up showed comparable skill retention in both groups. Evaluation of the VR cholecystectomies demonstrated significant decrease of operation time (p < 0.01), path length of the left and right instrument, and the number of movements of the left and right instruments for the Hybrid group (all p < 0.001), compared to the box group. Similar results were found at the assessment of skill retention.

CONCLUSION

Simulation training on both trainers enables reliable acquisition of laparoscopic basic skills. Furthermore, individual and continuous motion feedback improves laparoscopic skill enhancement significantly in several aspects. Thus, training systems with feedback of motion parameters should be considered to achieve long-term improvement of motion economy among surgical trainees.

Development and implementation of a virtual reality laparoscopic colorectal training curriculum

BACKGROUND

Contemporary surgical training can be compromised by fewer practical opportunities. Simulation can fill this gap to optimize skills' development and progress monitoring. A structured virtual reality (VR) laparoscopic sigmoid colectomy curriculum is constructed and its validity and outcomes assessed.

METHODS

Parameters and thresholds were defined by analysing the performance of six expert surgeons completing the relevant module on the LAP Mentor simulator. Fourteen surgical trainees followed the curriculum, performance being recorded and analysed. Evidence of validity was assessed.

RESULTS

Time to complete procedure, number of movements of right and left instrument, and total path length of right and left instrument movements demonstrated evidence of validity and clear learning curves, with a median of 14 attempts needed to complete the curriculum.

CONCLUSIONS

A structured curriculum is proposed for training in laparoscopic sigmoid colectomy in a VR environment based on objective metrics in addition to expert consensus. Validity has been demonstrated for some key metrics.

Integration of Hands-On Team Training into Existing Curriculum Improves Both Technical and Nontechnical Skills in Laparoscopic Cholecystectomy

OBJECTIVE

Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery.

DESIGN

9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training.

SETTING

Tertiary care, university based teaching institution.

PARTICIPANTS

A total of 9 general surgery residents at the intern level.

RESULTS

The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001).

CONCLUSION

Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

Background

Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.

Methods

Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.

Results

The participants performed equally well when presented with a “straight-forward” anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 p = 0.64—NOM: 437 vs. 413 p = 0.88—PL cm: 1317 vs. 1059 p = 0.32—per: 0.5 vs. 0 p = 0.22—NCB: 0 vs. 0 p = 0.71—DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η² = 0.32—Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η² = 0.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 p = 0.03 η²=0.34, DA: 0 vs. 1 p = 0.02 η² = 0.22). in the cases with more challenging anatomies.

Conclusion

These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

Development of a proficiency-based virtual reality simulation training curriculum for laparoscopic appendicectomy

BACKGROUND

Proficiency-based virtual reality (VR) training curricula improve intraoperative performance, but have not been developed for laparoscopic appendicectomy (LA). This study aimed to develop an evidence-based training curriculum for LA.

METHODS

A total of 10 experienced (>50 LAs), eight intermediate (10-30 LAs) and 20 inexperienced (<10 LAs) operators performed guided and unguided LA tasks on a high-fidelity VR simulator using internationally relevant techniques. The ability to differentiate levels of experience (construct validity) was measured using simulator-derived metrics. Learning curves were analysed. Proficiency benchmarks were defined by the performance of the experienced group. Intermediate and experienced participants completed a questionnaire to evaluate the realism (face validity) and relevance (content validity).

RESULTS

Of 18 surgeons, 16 (89%) considered the VR model to be visually realistic and 17 (95%) believed that it was representative of actual practice. All 'guided' modules demonstrated construct validity (P < 0.05), with learning curves that plateaued between sessions 6 and 9 (P < 0.01). When comparing inexperienced to intermediates to experienced, the 'unguided' LA module demonstrated construct validity for economy of motion (5.00 versus 7.17 versus 7.84, respectively; P < 0.01) and task time (864.5 s versus 477.2 s versus 352.1 s, respectively, P < 0.01). Construct validity was also confirmed for number of movements, path length and idle time. Validated modules were used for curriculum construction, with proficiency benchmarks used as performance goals.

CONCLUSION

A VR LA model was realistic and representative of actual practice and was validated as a training and assessment tool. Consequently, the first evidence-based internationally applicable training curriculum for LA was constructed, which facilitates skill acquisition to proficiency.

Box- or Virtual-Reality Trainer: Which Tool Results in Better Transfer of Laparoscopic Basic Skills?-A Prospective Randomized Trial

OBJECTIVE

Simulation training improves laparoscopic performance. Laparoscopic basic skills can be learned in simulators as box- or virtual-reality (VR) trainers. However, there is no clear recommendation for either box or VR trainers as the most appropriate tool for the transfer of acquired laparoscopic basic skills into a surgical procedure.

DESIGN

Both training tools were compared, using validated and well-established curricula in the acquirement of basic skills, in a prospective randomized trial in a 5-day structured laparoscopic training course. Participants completed either a box- or VR-trainer curriculum and then applied the learned skills performing an ex situ laparoscopic cholecystectomy on a pig liver. The performance was recorded on video and evaluated offline by 4 blinded observers using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. Learning curves of the various exercises included in the training course were compared and the improvement in each exercise was analyzed.

SETTING

Surgical Skills Lab of the Department of General and Visceral Surgery, University Hospital Muenster.

PARTICIPANTS

Surgical novices without prior surgical experience (medical students, n = 36).

RESULTS

Posttraining evaluation showed significant improvement compared with baseline in both groups, indicating acquisition of laparoscopic basic skills. Learning curves showed almost the same progression with no significant differences. In simulated laparoscopic cholecystectomy, total GOALS score was significantly higher for the box-trained group than the VR-trained group (box: 15.31 ± 3.61 vs. VR: 12.92 ± 3.06; p = 0.039; Hedge׳s g* = 0.699), indicating higher technical skill levels.

CONCLUSIONS

Despite both systems having advantages and disadvantages, they can both be used for simulation training for laparoscopic skills. In the setting with 2 structured, validated and almost identical curricula, the box-trained group appears to be superior in the better transfer of basic skills into an experimental but structured surgical procedure.

Bile Duct Injury after Cholecystectomy: Surgical Therapy

BACKGROUND

Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries.

METHODS

This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view.

RESULTS AND CONCLUSION

In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.

Mental practice with interactive 3D visual aids enhances surgical performance

BACKGROUND

Evidence suggests that Mental Practice (MP) could be used to finesse surgical skills. However, MP is cognitively demanding and may be dependent on the ability of individuals to produce mental images. In this study, we hypothesised that the provision of interactive 3D visual aids during MP could facilitate surgical skill performance.

METHODS

20 surgical trainees were case-matched to one of three different preparation methods prior to performing a simulated Laparoscopic Cholecystectomy (LC). Two intervention groups underwent a 25-minute MP session; one with interactive 3D visual aids depicting the relevant surgical anatomy (3D-MP group, n = 5) and one without (MP-Only, n = 5). A control group (n = 10) watched a didactic video of a real LC. Scores relating to technical performance and safety were recorded by a surgical simulator.

RESULTS

The Control group took longer to complete the procedure relative to the 3D&MP condition (p = .002). The number of movements was also statistically different across groups (p = .001), with the 3D&MP group making fewer movements relative to controls (p = .001). Likewise, the control group moved further in comparison to the 3D&MP condition and the MP-Only condition (p = .004). No reliable differences were observed for safety metrics.

CONCLUSION

These data provide evidence for the potential value of MP in improving performance. Furthermore, they suggest that 3D interactive visual aids during MP could potentially enhance performance, beyond the benefits of MP alone. These findings pave the way for future RCTs on surgical preparation and performance.

Testing the Construct Validity of a Virtual Reality Hip Arthroscopy Simulator

PURPOSE

To test the construct validity of the hip diagnostics module of a virtual reality hip arthroscopy simulator.

METHODS

Nineteen orthopaedic surgeons performed a simulated arthroscopic examination of a healthy hip joint using a 70° arthroscope in the supine position. Surgeons were categorized as either expert (those who had performed 250 hip arthroscopies or more) or novice (those who had performed fewer than this). Twenty-one specific targets were visualized within the central and peripheral compartments; 9 via the anterior portal, 9 via the anterolateral portal, and 3 via the posterolateral portal. This was immediately followed by a task testing basic probe examination of the joint in which a series of 8 targets were probed via the anterolateral portal. During the tasks, the surgeon's performance was evaluated by the simulator using a set of predefined metrics including task duration, number of soft tissue and bone collisions, and distance travelled by instruments. No repeat attempts at the tasks were permitted. Construct validity was then evaluated by comparing novice and expert group performance metrics over the 2 tasks using the Mann-Whitney test, with a P value of less than .05 considered significant.

RESULTS

On the visualization task, the expert group outperformed the novice group on time taken (P = .0003), number of collisions with soft tissue (P = .001), number of collisions with bone (P = .002), and distance travelled by the arthroscope (P = .02). On the probe examination, the 2 groups differed only in the time taken to complete the task (P = .025) with no significant difference in other metrics.

CONCLUSIONS

Increased experience in hip arthroscopy was reflected by significantly better performance on the virtual reality simulator across 2 tasks, supporting its construct validity.

CLINICAL RELEVANCE

This study validates a virtual reality hip arthroscopy simulator and supports its potential for developing basic arthroscopic skills.

LEVEL OF EVIDENCE

Level III.

"Take-home" box trainers are an effective alternative to virtual reality simulators

BACKGROUND

Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS.

METHODS

After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared.

RESULTS

The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups.

CONCLUSIONS

This study suggests that a basic "take-home" BT is a suitable alternative to VRS.

Surgeon-Authored Virtual Laparoscopic Adrenalectomy Module Is Judged Effective and Preferred Over Traditional Teaching Tools

OBJECTIVE

The study assesses user acceptance and effectiveness of a surgeon-authored virtual reality (VR) training module authored by surgeons using the Toolkit for Illustration of Procedures in Surgery (TIPS).

METHODS

Laparoscopic adrenalectomy was selected to test the TIPS framework on an unusual and complex procedure. No commercial simulation module exists to teach this procedure. A specialist surgeon authored the module, including force-feedback interactive simulation, and designed a quiz to test knowledge of the key procedural steps. Five practicing surgeons, with 15 to 24 years of experience, peer reviewed and tested the module. In all, 14 residents and 9 fellows trained with the module and answered the quiz, preuse and postuse. Participants received an overview during Surgical Grand Rounds session and a 20-minute one-on-one tutorial followed by 30 minutes of instruction in addition to a force-feedback interactive simulation session. Additionally, in answering questionnaires, the trainees reflected on their learning experience and their experience with the TIPS framework.

RESULTS

Correct quiz response rates on procedural steps improved significantly postuse over preuse. In the questionnaire, 96% of the respondents stated that the TIPS module prepares them well or very well for the adrenalectomy, and 87% indicated that the module successfully teaches the steps of the procedure. All participants indicated that they preferred the module compared to training using purely physical props, one-on-one teaching, medical atlases, and video recordings.

CONCLUSIONS

Improved quiz scores and endorsement by the participants of the TIPS adrenalectomy module establish the viability of surgeons authoring VR training.

Changing the Learning Curve in Novice Laparoscopists: Incorporating Direct Visualization into the Simulation Training Program

OBJECTIVE

A major challenge in laparoscopic surgery is the lack of depth perception. With the development and continued improvement of 3D video technology, the potential benefit of restoring 3D vision to laparoscopy has received substantial attention from the surgical community. Despite this, procedures conducted under 2D vision remain the standard of care, and trainees must become proficient in 2D laparoscopy. This study aims to determine whether incorporating 3D vision into a 2D laparoscopic simulation curriculum accelerates skill acquisition in novices.

DESIGN

Postgraduate year-1 surgical specialty residents (n = 15) at the Schulich School of Medicine and Dentistry, at Western University were randomized into 1 of 2 groups. The control group practiced the Fundamentals of Laparoscopic Surgery peg-transfer task to proficiency exclusively under standard 2D laparoscopy conditions. The experimental group first practiced peg transfer under 3D direct visualization, with direct visualization of the working field. Upon reaching proficiency, this group underwent a perceptual switch, changing to standard 2D laparoscopy conditions, and once again trained to proficiency.

RESULTS

Incorporating 3D direct visualization before training under standard 2D conditions significantly (p < 0.0.5) reduced the total training time to proficiency by 10.9 minutes or 32.4%. There was no difference in total number of repetitions to proficiency. Data were also used to generate learning curves for each respective training protocol.

CONCLUSIONS

An adaptive learning approach, which incorporates 3D direct visualization into a 2D laparoscopic simulation curriculum, accelerates skill acquisition. This is in contrast to previous work, possibly owing to the proficiency-based methodology employed, and has implications for resource savings in surgical training.

Comprehensive simulation-enhanced training curriculum for an advanced minimally invasive procedure: a randomized controlled trial

BACKGROUND

There is no comprehensive simulation-enhanced training curriculum to address cognitive, psychomotor, and nontechnical skills for an advanced minimally invasive procedure.

OBJECTIVES

1) To develop and provide evidence of validity for a comprehensive simulation-enhanced training (SET) curriculum for an advanced minimally invasive procedure; (2) to demonstrate transfer of acquired psychomotor skills from a simulation laboratory to live porcine model; and (3) to compare training outcomes of SET curriculum group and chief resident group.

SETTING

University.

METHODS

This prospective single-blinded, randomized, controlled trial allocated 20 intermediate-level surgery residents to receive either conventional training (control) or SET curriculum training (intervention). The SET curriculum consisted of cognitive, psychomotor, and nontechnical training modules. Psychomotor skills in a live anesthetized porcine model in the OR was the primary outcome. Knowledge of advanced minimally invasive and bariatric surgery and nontechnical skills in a simulated OR crisis scenario were the secondary outcomes. Residents in the SET curriculum group went on to perform a laparoscopic jejunojejunostomy in the OR. Cognitive, psychomotor, and nontechnical skills of SET curriculum group were also compared to a group of 12 chief surgery residents.

RESULTS

SET curriculum group demonstrated superior psychomotor skills in a live porcine model (56 [47-62] versus 44 [38-53], P<.05) and superior nontechnical skills (41 [38-45] versus 31 [24-40], P<.01) compared with conventional training group. SET curriculum group and conventional training group demonstrated equivalent knowledge (14 [12-15] versus 13 [11-15], P = 0.47). SET curriculum group demonstrated equivalent psychomotor skills in the live porcine model and in the OR in a human patient (56 [47-62] versus 63 [61-68]; P = .21). SET curriculum group demonstrated inferior knowledge (13 [11-15] versus 16 [14-16]; P<.05), equivalent psychomotor skill (63 [61-68] versus 68 [62-74]; P = .50), and superior nontechnical skills (41 [38-45] versus 34 [27-35], P<.01) compared with chief resident group.

CONCLUSION

Completion of the SET curriculum resulted in superior training outcomes, compared with conventional surgery training. Implementation of the SET curriculum can standardize training for an advanced minimally invasive procedure and can ensure that comprehensive proficiency milestones are met before exposure to patient care.

A Virtual Reality Training Curriculum for Laparoscopic Colorectal Surgery

OBJECTIVE

Training within a competency-based curriculum (CBC) outside the operating room enhances performance during real basic surgical procedures. This study aimed to design and validate a virtual reality CBC for an advanced laparoscopic procedure: sigmoid colectomy.

DESIGN

This was a multicenter randomized study. Novice (surgeons who had performed <5 laparoscopic colorectal resections as primary operator), intermediate (between 10 and 20), and experienced surgeons (>50) were enrolled. Validity evidence for the metrics given by the virtual reality simulator, the LAP Mentor, was based on the second attempt of each task in between groups. The tasks assessed were 3 modules of a laparoscopic sigmoid colectomy (medial dissection [MD], lateral dissection [LD], and anastomosis) and a full procedure (FP). Novice surgeons were randomized to 1 of 2 groups to perform 8 further attempts of all 3 modules or FP, for learning curve analysis.

SETTING

Two academic tertiary care centers-division of surgery of St. Mary's campus, Imperial College Healthcare NHS Trust, London and Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, were involved.

PARTICIPANTS

Novice surgeons were residents in digestive surgery at St. Mary's and Nord Hospitals. Intermediate and experienced surgeons were board-certified academic surgeons.

RESULTS

A total of 20 novice surgeons, 7 intermediate surgeons, and 6 experienced surgeons were enrolled. Evidence for validity based on experience was identified in MD, LD, and FP for time (p = 0.005, p = 0.003, and p = 0.001, respectively), number of movements (p = 0.013, p = 0.005, and p = 0.001, respectively), and path length (p = 0.03, p = 0.017, and p = 0.001, respectively), and only for time (p = 0.03) and path length (p = 0.013) in the anastomosis module. Novice surgeons' performance significantly improved through repetition for time, movements, and path length in MD, LD, and FP. Experienced surgeons' benchmark criteria were defined for all construct metrics showing validity evidence.

CONCLUSIONS

A CBC in laparoscopic colorectal surgery has been designed. Such training may reduce the learning curve during real colorectal resections in the operating room.

Development of an evidence-based training program for laparoscopic hysterectomy on a virtual reality simulator

BACKGROUND

Substantial evidence in the scientific literature supports the use of simulation for surgical education. However, curricula lack for complex laparoscopic procedures in gynecology. The objective was to evaluate the validity of a program that reproduces key specific components of a laparoscopic hysterectomy (LH) procedure until colpotomy on a virtual reality (VR) simulator and to develop an evidence-based and stepwise training curriculum.

METHODS

This prospective cohort study was conducted in a Marseille teaching hospital. Forty participants were enrolled and were divided into experienced (senior surgeons who had performed more than 100 LH; n = 8), intermediate (surgical trainees who had performed 2-10 LH; n = 8) and inexperienced (n = 24) groups. Baselines were assessed on a validated basic task. Participants were tested for the LH procedure on a high-fidelity VR simulator. Validity evidence was proposed as the ability to differentiate between the three levels of experience. Inexperienced subjects performed ten repetitions for learning curve analysis. Proficiency measures were based on experienced surgeons' performances. Outcome measures were simulator-derived metrics and Objective Structured Assessment of Technical Skills (OSATS) scores.

RESULTS

Quantitative analysis found significant inter-group differences between experienced intermediate and inexperienced groups for time (1369, 2385 and 3370 s; p < 0.001), number of movements (2033, 3195 and 4056; p = 0.001), path length (3390, 4526 and 5749 cm; p = 0.002), idle time (357, 654 and 747 s; p = 0.001), respect for tissue (24, 40 and 84; p = 0.01) and number of bladder injuries (0.13, 0 and 4.27; p < 0.001). Learning curves plateaued at the 2nd to 6th repetition. Further qualitative analysis found significant inter-group OSATS score differences at first repetition (22, 15 and 8, respectively; p < 0.001) and second repetition (25.5, 19.5 and 14; p < 0.001).

CONCLUSIONS

The VR program for LH accrued validity evidence and allowed the development of a training curriculum using a structured scientific methodology.

Initial validation of a training program focused on laparoscopic radical nephrectomy

OBJECTIVE

To assess a training model focused on laparoscopic nephrectomy.

MATERIAL AND METHODS

16 residents participated in the study, who attended a training program with a theoretical session (1hour) and a dry (7hours) and a wet lab (13hours). During animal training, the first and last nephrectomies were assessed through the completion time and the global rating scale "Objective and Structured Assessment of Technical Skills" (OSATS). Before and after the course, they performed 3 tasks on the virtual reality simulator LAPMentor (1) eye-hand coordination; 2) hand-hand coordination; and 3) transference of objects), registering time and movement metrics. All participants completed a questionnaire related to the training components on a 5-point rating scale.

RESULTS

The participants performed the last nephrectomy faster (P<.001) and with higher OSATS scores (P<.001). After the course, they completed the LAPMentor tasks faster (P<.05). The number of movements decreased in all tasks (1) P<.001, 2) P<.05, and 3) P<.05), and the path length in tasks 1 (P<.05) and 2 (P<.05). The movement speeds increased in tasks 2 (P<.001) and 3 (P<.001). With regards to the questionnaire, the usefulness of the animal training and the necessity of training on them prior to their laparoscopic clinical practice were the questions with the highest score (4.92±.28).

CONCLUSIONS

The combination of physical simulation and animal training constitute an effective training model for improving basic and advanced skills for laparoscopic nephrectomy. The component preferred by the urology residents was the animal training.

Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis

INTRODUCTION

Laparoscopic surgery requires a different and sometimes more complex skill set than does open surgery. Shortened working hours, less training times, and patient safety issues necessitates that these skills need to be acquired outside the operating room. Virtual reality simulation in laparoscopic surgery is a growing field, and many studies have been published to determine its effectiveness.

AIMS

This systematic review and meta-analysis aims to evaluate virtual reality simulation in laparoscopic abdominal surgery in comparison to other simulation models and to no training.

METHODS

A systematic literature search was carried out until January 2014 in full adherence to PRISMA guidelines. All randomised controlled studies comparing virtual reality training to other models of training or to no training were included. Only studies utilizing objective and validated assessment tools were included.

RESULTS

Thirty one randomised controlled trials that compare virtual reality training to other models of training or to no training were included. The results of the meta-analysis showed that virtual reality simulation is significantly more effective than video trainers, and at least as good as box trainers.

CONCLUSION

The use of Proficiency-based VR training, under supervision with prompt instructions and feedback, and the use of haptic feedback, has proven to be the most effective way of delivering the virtual reality training. The incorporation of virtual reality training into surgical training curricula is now necessary. A unified platform of training needs to be established. Further studies to assess the impact on patient outcomes and on hospital costs are necessary. (PROSPERO Registration number: CRD42014010030).