Training in laparoscopic cholecystectomy. Quantifying the learning curve

The Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review

PURPOSE

To examine the effect of arthroscopic simulator training on technical performance in a human model.

METHODS

A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches of PubMed, Embase, and Cochrane Library were conducted using combinations of the terms virtual, digital, computer, reality, simulation, arthroscopy, training, learning, and education. Studies were considered for inclusion if they tested the effect of arthroscopic simulator training in a randomized controlled fashion, performed testing in a cadaver or live patient, and used explicit outcome measures of technical skill. Data from studies were extracted and study characteristics and outcomes were reviewed. The primary outcome measure was the number of studies in which the simulation trained group had significantly improved performance results relative to the control group in ≥50% of all measured outcomes. Risk of bias was assessed with Cochrane's Collaboration Tool.

RESULTS

Twelve studies, including 340 total study participants, were included for review. Eight studies showed improved performance of the simulation trained group relative to the control group in ≥50% of assessed outcomes. Six of ten studies reporting completion time, three of six studies reporting task checklist completion, 3 of 7 studies reporting global rating scales, and 1 of 4 studies reporting Arthroscopic Surgical Skill Evaluation Tool scores showed improved performance of the simulation group relative to the control group for the respective outcome measures.

CONCLUSIONS

The literature is limited due to heterogeneity, both in type and merit, of the outcome measures that have been used to assess the transfer validity of arthroscopic simulator training to clinical performance. Despite the limitations of the literature, this review demonstrates that arthroscopic simulator training has potential to improve clinical performance.

LEVEL OF EVIDENCE

II, systematic review of Level II studies.

Comparison of the learning curves for robotic left and right hemihepatectomy: A prospective cohort study

OBJECTIVE

Robotic hepatectomy has been continuously improving and shown to be safe and reliable. The learning curve of robotic hemihepatectomy is required which enable beginners to benefit from previous experience. The aim of this study was to assess the learning curve of robotic left (RLH) and right hemihepatectomy (RRH) in terms of operative time (OT) to determine which procedure has an easier learning curve for beginners.

METHODS

Data records for each 100 consecutive patients who underwent RLH and RRH between July 2012 and May 2019 were collected prospectively and analyzed retrospectively. The data included demographics, OT, estimated blood loss (EBL), postoperative hospital stay (PHS), and rates of morbidity and mortality. The cumulative sum method was used to evaluate the learning curve of OT.

RESULTS

All patients underwent the RRH and RLH procedure performed by the same surgical team. RRH and RLH learning curve consisted of two phases: the first and second phase. The first phase of RRH included 45 patients, while RLH outcomes were optimized after 35 cases were completed. Compared with the first phase, the mean OT and the median blood loss were decreased significantly in the second phase in both learning curves. No significant decrease in the rates of morbidity and conversion to laparotomy or PHS was observed.

CONCLUSIONS

This study demonstrated the safety and feasibility of RLH and RRH. The surgeons who previously lacked robotic experience are able to overcome the learning curve for RLH faster than RRH.

[Learning curves in acquisition of experience for new technologies]

OBJECTIVE

Analysis of national and foreign trials investigating accumulation of experience in innovative technologies using the learning curves.

MATERIAL AND METHODS. S

Earching for Russian-language manuscripts was carried out within the references of the articles and in the ELIBRARY database. Foreign trials were selected from the PubMed database according to the keywords «learning curves in surgical practice». The discovered publications were studied for accordance with the objectives of this study.

RESULTS

Accumulation of experience in new technologies by using of learning curves is valuable to improve the training, determine duration of development of new technology and the factors affecting its characteristics.

CONCLUSION

The method is high-quality for comprehensive analysis of experience accumulation in new surgical technologies.

Virtual reality hip arthroscopy simulator demonstrates sufficient face validity

PURPOSE

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

METHODS

A total of 25 orthopaedic surgeons, 7 faculty members and 18 orthopaedic residents, performed diagnostic supine hip arthroscopies of a healthy virtual reality hip joint using a 70° arthroscope. Twelve specific targets were visualised within the central compartment; six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. This task was immediately followed by a questionnaire regarding the realism and training capability of the system. This consisted of seven questions addressing the verisimilitude of the simulator and five questions addressing the training environment of the simulator. Each question consisted of a statement stem and 10-point Likert scale. Following similar work in surgical simulators, a rating of 7 or above was considered an acceptable level of realism.

RESULTS

The diagnostic hip arthroscopy module was found to have an acceptable level of realism in all domains apart from the tactile feedback received from the soft tissue. 23 out of 25 participants (92%) felt the simulator provided a non-threatening learning environment and 22 participants (88%) stated they enjoyed using the simulator. It was most frequently agreed that the level of trainees who would benefit most from the simulator were registrars and fellows (22 participants; 88%). Additionally, 21 of the participants (84%) agreed that this would be a beneficial training modality for foundation and core trainees, and 20 participants (80%) agreed that his would be beneficial for consultants.

CONCLUSIONS

This VR hip arthroscopy simulator was demonstrated to have a sufficient level of realism, thus establishing its face validity. These results suggest this simulator has sufficient realism for use in the acquisition of basic arthroscopic skills and supports its use in orthopaedics surgical training.

LEVEL OF EVIDENCE

I.

Naked-eye box trainer and training box games have similar training effect as conventional video-based box trainer for novices: A randomized controlled trial

BACKGROUND

Laparoscopic surgery has become a well-established technique for management of various surgical problems. A more efficient training methods are of upmost importance for current surgery residents.

METHODS

This is a prospective, randomized, 3-arm trial to compare the training efficient of the naked-eye box trainer, training box games and conventional video-based box trainer in training laparoscopic suturing skill.

RESULTS

The three training models were well acceptable and all could improve the acquisition of laparoscopic suturing and knotting skill in novices. The completion time was 604 ± 298 s in the box trainer games, 617 ± 335 s in the naked-eye training module, and 491 ± 334 s in the video-based box trainer (p = 0.322). Using the structured procedure-specific checklist, there was no significant difference in scores between these three groups (p = 0.977).

CONCLUSIONS

Naked-eye box trainer and training box games produce similar training effect as the conventional video-based box trainer. The naked-eye box trainer may serve as a convenient way for novice trainees to acquire laparoscopic suturing technique skills before video-based simulation.

Does virtual reality simulation have a role in training trauma and orthopaedic surgeons?

Aims

The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research.

Materials and Methods

A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results' titles, abstracts, and references were examined for relevance.

Results

A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training.

Conclusion

The demonstration of 'real-world' benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559-65.

Can Surgical Trainees Achieve Arthroscopic Competence at the End of Training Programs? A Cross-sectional Study Highlighting the Impact of Working Time Directives

PURPOSE

To provide training guidance on procedure numbers by assessing how the number of previously performed arthroscopic procedures relate to both competent and expert performance in simulated arthroscopic shoulder tasks.

METHODS

A cross-sectional study that assessed simulated shoulder arthroscopic performance was undertaken. A total of 45 participants of varying experience performed 2 validated tasks: a simple diagnostic task and a more complex Bankart labral repair task. All participants provided logbook numbers for previously performed arthroscopies. Performance was assessed with the Global Rating Scale and motion analysis. Receiver operating characteristic curve analyses were conducted to identify optimum cut points for task proficiency at both "competent" and "expert" levels.

RESULTS

Increasing surgical experience resulted in significantly better performance for both tasks as assessed by Global Rating Scale or motion analysis (P < .0001). Receiver operating characteristic curve analyses demonstrated 52 previous arthroscopies were needed to perform to a competent level at the diagnostic task and 248 to be competent at the complex task. To perform at an expert level, 290 and 476 previous arthroscopies, respectively, were needed.

CONCLUSIONS

This study provides quantified guidance for arthroscopic training and highlights the positive relationship between arthroscopic case load and arthroscopic competency. We have estimated that the number of arthroscopies required to achieve competency in a basic arthroscopic task exceed those recommended in some countries. These estimates provide useful guidance to those responsible for training program.

CLINICAL RELEVANCE

The numbers to achieve competent arthroscopic performance in the assessed simulated tasks exceed what is recommended and what is possible during surgical training programs in some countries.

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.

Simulation-Based Education for Cardiac, Thoracic, and Vascular Anesthesiology

Simulation has been used for medical teaching and testing for at least four decades in some form, such as that used for cardiopulmonary resuscitation training; however, new technology applied to medical and procedural training has recently led to a marked increase in the use of simulation-based instruction. Educational theory has further supported simulation for medical education and procedural training. Simulation-based testing to demonstrate competence with new procedures is already required by the US Food and Drug Administration for one angiographicallyplaced device, and it is likely that simulationbased credentialing for procedures will be increasingly prevalent. Anesthesiologists, like other physicians, may be credentialed or certified based on their performance in a simulated environment in the future. This review describes some of the current simulation-based education techniques related to cardiovascular and thoracic anesthesiology. Additional discussion covers some of the applicable educational theory and the expected future uses of simulation modalities in healthcare education, testing, and practice.

What is the Learning Curve for Laparoscopic Major Hepatectomy?

BACKGROUND

Laparoscopic liver resection is rapidly expanding with more than 9500 cases performed worldwide. While initial series reported non-anatomic resection of benign peripheral hepatic lesions, approximately 50-65 % of laparoscopic liver resections are now being done for malignant tumors, primarily hepatocellular carcinoma (HCC) or colorectal cancer liver metastases (mCRC).

METHODS

We performed a literature review of published studies evaluating outcomes of major laparoscopic liver resection, defined as three or more Couinaud segments.

RESULTS

Initial fears of adverse oncologic outcomes or tumor seeding have not been demonstrated, and dozens of studies have reported comparable 5-year disease-free and overall survival between laparoscopic and open resection of HCC or mCRC in case-cohort and propensity score-matched analyses. Increased experience has led to laparoscopic anatomic liver resections including laparoscopic major hepatectomy. A steep learning curve of 45-60 cases is evident for laparoscopic hepatic resection.

CONCLUSION

Laparoscopic major hepatectomy is safe and effective in the treatment of benign and malignant liver tumors when performed in specialized centers with dedicated teams. Comparable to other complex laparoscopic surgeries, laparoscopic major hepatectomy has a learning curve of 45-60 cases.

The acquisition and retention of urinary catheterisation skills using surgical simulator devices: teaching method or student traits

BACKGROUND

The acquisition of procedural skills is an essential component of learning for medical trainees. The objective of this study was to assess which teaching method of performing urinary catheterisation is associated with most efficient procedural skill acquisition and retention. We evaluated factors affecting acquisition and retention of skills when using simulators as adjuncts to medical training.

METHODS

Forty-two second year medical students were taught urinary catheter insertion using different teaching methods. The interactive group (n = 19) were taught using a lecture format presentation and a high fidelity human urinary catheter simulator. They were provided with the use of simulators prior to examination. The observer group (n = 12) were taught using the same method but without with simulator use prior to examination. The didactic group (n = 11) were taught using the presentation alone. Student characteristics such as hand dexterity and IQ were measured to assess for intrinsic differences. All students were examined at four weeks to measure skill retention.

RESULTS

Catheter scores were significantly higher in the interactive group (p < 0.005). Confidence scores with catheter insertion were similar at index exam however were significantly lower in the didactic group at the retention testing (p < 0.05). Retention scores were higher in the interactive group (p < 0.001). A significant positive correlation was observed between laparoscopy scores and time to completion with overall catheter score (p < 0.05). Teaching method, spatial awareness and time to completion of laparoscopy were significantly associated with higher catheter scores at index exam (p = 0.001). Retention scores at 4 weeks were significantly associated with teaching method and original catheter score (p = 0.001).

CONCLUSION

The importance of simulators in teaching a complex procedural skill has been highlighted. Didactic teaching method was associated with a significantly higher rate of learning decay at retention testing.

Structured training on box trainers for first year surgical residents: does it improve retention of laparoscopic skills? A randomized controlled study

BACKGROUND AND AIM

Structured training on box trainers in laparoscopic skills in the initial years of residency has been used and found to be effective. Although there are studies that confirm immediate improvement after training, there is a lack of well-designed trials addressing the crucial issue of retention of these skills over time. The purpose of this study is to assess improvement in laparoscopic skills of surgical trainees after structured training on box trainers, compared with traditional training (observing and assisting laparoscopic procedures in the operation rooms) immediately and after 5 months.

METHODS

Forty surgical residents in their first 2 months of residency training were randomized to either structured training on box trainers, in addition to traditional training, or to traditional training alone. Groups were equivalent with regards to demographics, previous operative experience, and baseline skills. Structured training consisted of 4 sessions with 6 tasks on box trainers under supervision and self practice. Task-based objective structured practical examinations (OSPE) were completed before and after each task. At the end of the training, residents were assessed by a blinded faculty member with the global operative assessment of laparoscopic skills (GOALS) rating scale. Residents also completed a satisfaction questionnaire. Focus group discussions were conducted for both groups. The GOALS were repeated for both the groups at the end of 5 months to assess retention of skills.

RESULTS

The mean GOALS score was significantly higher for the structured training group (mean/SD 20.35 + 0.74) compared with the traditional training group (mean/SD 16.35 + 1.75, p < 0.01) at the end of 5 months. The mean global rating scale (GRS) score was significantly higher (Pre 7.55 + 0.99 vs. Post 16.4 + 0.68, p < 0.01) for the structured training group at the end of course. Residents in the structured training group had significantly improved skills immediately after the training and had better retention of skills at the end of five months.

CONCLUSIONS

Structured training on box trainers, in addition to traditional training, compared with traditional training alone, leads to better skills and improved confidence of residents. There is significant retention of skills at the end of 5 months. These results provide support for incorporation of structured training with box trainers for laparoscopic skills into surgical training programs.

Effectiveness of box trainers in laparoscopic training

RATIONALE AND OBJECTIVES

Various devices are used to aid in the education of laparoscopic skills ranging from simple box trainers to sophisticated virtual reality trainers. Virtual reality system is an advanced and effective training method, however it is yet to be adopted in India due to its cost and the advanced technology required for it. Therefore, box trainers are being used to train laparoscopic skills. Hence this study was undertaken to assess the overall effectiveness of the box-training course. STUDY PROCEDURE: The study was conducted during six-day laparoscopic skills training workshops held during 2006. Twenty five surgeons; age range of 26 to 45 years, of either sex, who had not performed laparoscopic surgery before; attending the workshop were evaluated. Each participant was given a list of tasks to perform before beginning the box-training course on day one and was evaluated quantitatively by rating the successful completion of each test. Evaluation began when the subject placed the first tool into the cannula and ended with task completion. Two evaluation methods used to score the subject, including a global rating scale and a task-specific checklist. After the subject completed all sessions of the workshop, they were asked to perform the same tasks and were evaluated in the same manner. For each task completed by the subjects, the difference in the scores between the second and first runs were calculated and interpreted as an improvement as a percentage of the initial score.

STATISTICAL ANALYSIS

Wilcoxon matched-paired signed-ranks test was applied to find out the statistical significance of the results obtained.

RESULTS

The mean percentage improvement in scores for both the tasks, using global rating scale, was 44.5% ± 6.930 (Mean ± SD). For task 1, using the global rating scale mean percentage improvement was 49.4% ± 7.948 (Mean ± SD). For task 2, mean percentage improvement using global rating scale was 39.6% ± 10.4 (Mean ± SD). Using Wilcoxon matched-paired signed-ranks test, 2-tailed P-value<0.0001 which is extremely significant.

CONCLUSION

This study confirms that a short-term, intensive, focused course does improve laparoscopic skills of trainees. Box-trainers can be used to change the present day didactic training into objective and competency-based. Global rating scale and checklist provide an inexpensive and effective way of objective assessment of performance of laparoscopic skills.

Adoption of surgical innovations: factors influencing use of sentinel lymph node biopsy for breast cancer

PURPOSE

Sentinel lymph node biopsy (SLNB) has been unevenly adopted into practice in Canada. In this qualitative study, the authors explored individual, institutional, and policy factors that may have influenced SLNB adoption. This information will guide interventions to improve SLNB implementation.

METHODS

Qualitative methodology was used to examine factors influencing SLNB adoption. Grounded theory guided data collection and analysis. Semistructured interviews were based on Roger's diffusion of innovation theory. Purposive and snowball sampling was used to identify participants. Semistructured telephone interviews were conducted with urban, rural, academic, and community health care providers and administrators to ensure all perspectives and motivations were explored. Two individuals independently analyzed data and achieved consensus on emerging themes and their relationship.

RESULTS

A total of 43 interviews were completed with 21 surgeons, 5 pathologists, 7 nuclear medicine physicians, and 10 administrators. Generated themes included awareness of SLNB with the exception of some administrators, acknowledged advantage of SLNB, SLNB compatibility with beliefs regarding axillary staging, acknowledgment that SLNB was a complex innovation to adopt, extensive trialing of SLNB prior to adoption, observable benefits with SLNB, acknowledgment that hospital-level administrative support enabled adoption, desire for a provincial policy supporting SLNB to assist in hospital-level adoption, requirement of a local high-volume breast surgery champion who communicated extensively with team to facilitate local adoption, and need for credentialing of SLNB to ensure quality.

CONCLUSIONS

SLNB is a complex innovation to adopt. Successful adoption was assisted by a high-volume breast cancer surgical champion, interprofessional communication, and administrative support.

Bile duct injury and use of cholangiography during laparoscopic cholecystectomy

BACKGROUND

Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). A Swiss database was used to identify risk factors for BDI and to assess the effect of intraoperative cholangiography (IOC).

METHODS

Data for patients from 114 Swiss institutions who underwent LC for acute or chronic cholecystitis between 1995 and 2005 were used in univariable and logistic regression analyses.

RESULTS

In total 31 838 patients, mean(s.d.) age 54·4(15·9) years, were analysed. The incidence of BDI was 0·3 per cent (101 patients), which did not change over time (P = 0·560). Univariable analysis revealed that male patients had a higher risk of BDI (0·5 per cent versus 0·2 per cent in female patients; P = 0·001), as did patients whose operation lasted at least 150 min (1·1 per cent versus 0·1 per cent for operating time of less than 150 min; P < 0·001). Logistic regression confirmed male sex (odds ratio (OR) 1·89, 95 per cent confidence interval 1·27 to 2·81) and prolonged surgery (OR 12·60, 10·87 to 23·81) as independent risk factors. Comparison of groups with and without intraoperative cholangiography showed no difference in the incidence of BDI (both 0·3 per cent; P = 0·755) and BDIs missed during surgery (10 versus 8 per cent; P = 0·737).

CONCLUSION

Male sex and prolonged laparoscopic surgery are independent risk factors for BDI during LC. Frequent use of IOC does not seem to reduce BDI or the number of injuries missed during surgery.

Patient safety, competency, and the future of surgical simulation

Despite its relatively short track record, simulation has been successfully introduced into the surgical arena in an effort to augment training. Initially a fringe endeavor at isolated centers, simulation has now become a mainstream component of surgical education. The surgical community is now aware that the old adage, "see one, do one, and teach one" is no longer acceptable from the ethical standpoint of practicing procedures on patients. Moreover, financial and time constraints have made teaching outside of the operating room an attractive proposition. Coupled with the growing body of validation, new procedures can now be practiced and proficiency can be acquired on a multitude of simulation platforms. Importantly, simulation standards are being established and there is an unprecedented national acceptance and endorsement of simulation as an invaluable educational tool; in fact, simulation is being mandated for surgical residency programs. Team training will likely expand the impact of surgical simulation considerably and help assure multidimensional competency verification. For both surgery residents and surgeons in practice, simulation holds great promise as a safe, effective, and efficient means of acquiring new skills.

Lessons learned from long-term university training in minimally invasive surgery in Spain

PURPOSE

Starting from our prolonged experience in university minimally invasive surgery training (1993 to 2005), we aim to analyze the most important differences in participants' requirements from these courses along this time span.

METHODS

Surveys' answers from the 6 first course editions (from 1993 to 1999, group 1) are compared with the last 6 ones (from 1999 to 2005, group 2), for a number of items including reasons to choose these courses, opinion about duration of training minimally invasive surgery (MIS) courses, responsibility of training MIS, and opinion about experimental training with animals.

RESULTS

Total number (N) of participants was 341, with 177 in group 1 and 164 in group 2. The most important feature was the number of hours of animal training (61% from group 1 vs. 75% from group 2, P<0.05). There was a trend to consider hospitals as more responsible (68.3% from group 1 vs. 83.5% from group 2, P=0.06) and the University as less responsible for MIS training (36.7% from group 1 and 18.2% from group 2, P=0.01). Laparoscopic training courses should last at least 1 year (76.7% from group 1 vs. 78.2% from group 2, not significant).

CONCLUSIONS

The time dedicated to practical training is highly appreciated by participants in training courses. Furthermore, we have not found many changes in trainees' requirements from MIS training courses over the last 12 years.

The learning curve in laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most adrenal tumors. LA learning curve (LC) varies among surgeons and may be influenced by factors depending on surgeon, patient, and lesion peculiarities. The aim of this study was to evaluate the LC by multi-dimensional analysis.

METHODS

Between August 1994 and August 2005, 241 LA were performed in our department. Data were prospectively collected. The pre-operative variables evaluated were patient-related (age, gender, body mass index, co-morbidities) and disease-related (histology, size, and side of lesion). Level of experience of surgical team and surgical approach (anterior, flank, submesocolic routes) were evaluated as well. Flank approached and bilateral procedures were excluded, while submesocolic LA, were collected separately. Operating time (OpT), conversion rate (CR), intra-operative and post-operative complications were evaluated. Patient, surgeon, and procedure-related factors involved in LC were investigated by a multi-factorial logistic regression analysis.

RESULTS

Body mass index, side, size, histology, technology improvement, and experience of surgical team, evaluated through the progressive series of surgical procedures, were independent predictors of CR and OpT. The CR for right adrenalectomy was 3% (3 cases) compared to 4.2% for left side (6 cases). The submesocolic approach significantly influenced OpT, but not CR. Mean OpT for right and left LA was 83 and 109 min, respectively. Based on surgical experience increase, the OpT and CR flattened their curves, roughly at 30 and 40 procedures for right and left LA, respectively. Post-operative complications did not change considerably throughout the series. Readmission rate within 30 days was negligible.

CONCLUSIONS

Manifold factors may affect LC and outcome in LA. Their knowledge may support teaching activities as well as reducing conversion and complication rates.

Surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy

BACKGROUND

The traditional process of surgical education is being increasingly challenged by economic constraints and concerns about patient safety. Sophisticated computer-based devices have become available to simulate the surgical experience in a protected environment. As with any new educational tool, these devices have generated controversy about the validity of the training experience.

HYPOTHESIS

Performance on a virtual reality simulator correlates with actual surgical experience.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-three test subjects of various experience levels in shoulder arthroscopy were tested on an arthroscopy simulator according to a standardized protocol. Subjects were evaluated for time to completion, distance traveled with the tip of the simulated probe compared with a computer-determined optimal distance, average probe velocity, and number of probe collisions with the tissues.

RESULTS

Subjects were grouped according to prior experience with shoulder arthroscopy. Comparing the least experienced with most experienced groups, the average time to completion decreased by 62% from 128.8 seconds to 49.2 seconds; path length and hook collisions were more than halved from 8.2 to 3.8 and 34.1 to 16.8, respectively; and average probe velocity more than doubled from 0.18 to 0.4 cm/second. There were no significant differences for any parameter tested between subjects with video game experience compared to those without.

CONCLUSIONS

The study demonstrated a close and statistically significant correlation between simulator results and surgical experience, thus confirming the hypothesis. Conversely, experience with video games was not associated with improved simulator performance. This indicates that the skill set tested may be similar to the one developed in the operating room, thus suggesting its use as a potential tool for future evaluation of surgical trainees.

CLINICAL RELEVANCE

The results have implications for the future of orthopaedic surgical training programs, the majority of which have not embraced virtual reality technology for physician education.

A needs-assessment study for continuing professional development in advanced minimally invasive surgery

BACKGROUND

The ideal continuing professional development (CPD) model to transfer advanced minimally invasive surgical (MIS) skills to surgeons in practice has not yet been determined.

METHODS

A survey of general surgeons practicing in Alberta was conducted to determine attitudes toward CPD with a focus on MIS colon surgery. Two separate mailings of the survey were conducted in both hard copy and e-mail format. Data were collected and analyzed.

RESULTS

Seventy-one of 92 surveys were returned, yielding a response rate of 77%. The majority (62%) of surgeons had received their training while in practice. The most prevalent form of CPD was short courses, with 82% of surgeons having attended at least 1 short course in MIS. When directly comparing short courses with mentorship, 69% of respondents rated courses as less helpful, whereas 21% thought they were equivalent to mentorship. Sixty-one percent of surgeons are interested in a comprehensive approach, such as a mini-fellowship, to learning laparoscopic colorectal surgery.

CONCLUSIONS

General surgeons want access to different modalities of training, including both mentorship experiences and short courses. They are willing to take time away from their practices to learn new MIS skills. The best way to provide CPD to practicing surgeons is likely through a combination of teaching interventions, including courses, mentoring relationships, and the application of new technologies.

The learning curve in pancreatic surgery

BACKGROUND

Pancreatic surgery is technically complex. We hypothesized that a learning curve existed for pancreaticoduodenectomy even for surgeons who had completed their training.

METHODS

During 1990 to 2004, we studied 650 consecutive patients who underwent pancreaticoduodenectomy by 3 surgeons who began their attending careers at 1 center. Operative time, estimated blood loss (EBL), length of hospital stay (LOS), and the status of resection margins (for pancreatic adenocarcinoma) were analyzed. The chi2, independent t test and Mann-Whitney U test were used to evaluate differences in categorical, normally distributed continuous, and non-normally distributed continuous variables, respectively. Using serial groups of 30 cases, median operative time, EBL, and LOS were calculated and the trend over time modeled using third-order polynomial equations. Trends in retroperitoneal margin positivity (R0/R1) were assessed.

RESULTS

From the first 60 cases per surgeon to the second 60 cases per surgeon, the median EBL dropped (1100 vs 725 mL, P < .001), operative time decreased (589 vs 513 minutes, P < .001), and LOS decreased (15 vs 13 days, P = .004). The proportion of microscopically positive or suspicious margins also decreased from the surgeons' first 60 cases each to the second 60 cases (30% vs 8%, P < .001). Extended analysis of a single surgeon's cases suggested that additional experience provided further incremental improvement (P < .001).

CONCLUSIONS

Pancreaticoduodenectomy has an inherent learning curve. After 60 cases, surgeons achieved significantly decreased EBL, operative time, and LOS, and carried out more margin-negative resections. Improvement in measured outcomes continues during the operative career.

The learning curve in pancreatic surgery

BACKGROUND

Pancreatic operation is technically complex. We hypothesized that a learning curve existed for pancreaticoduodenectomy even for surgeons who had completed their training.

METHODS

During 1990 to 2004, we studied 650 consecutive patients who underwent pancreaticoduodenectomy by 3 surgeons who began their attending careers at 1 center. Operative time, estimated blood loss (EBL), length of hospital stay (LOS), and the status of resection margins (for pancreatic adenocarcinoma) were analyzed. The chi(2), independent t test and Mann-Whitney U test were used to evaluate differences in categoric, normally distributed continuous, and non-normally distributed continuous variables, respectively. Using serial groups of 30 cases, median operative time, EBL, and LOS were calculated and the trend over time modeled using third-order polynomial equations. Trends in retroperitoneal margin positivity (R0/R1) were assessed.

RESULTS

From the first 60 cases per surgeon to the second 60 cases per surgeon, the median EBL dropped (1100 vs 725 mL, P < .001), operative time decreased (589 vs 513 minutes, P < .001), and LOS decreased (15 vs 13 days, P = .004). The proportion of microscopically positive or suspicious margins also decreased from the surgeons' first 60 cases each to the second 60 cases (30% vs 8%, P < .001). Extended analysis of a single surgeon's cases suggested that additional experience provided further incremental improvement (P < .001).

CONCLUSIONS

Pancreaticoduodenectomy has an inherent learning curve. After 60 cases, surgeons achieved significantly decreased EBL, operative time, and LOS, and carried out more margin-negative resections. Improvement in measured outcomes continues during the operative career.

Telementoring: an important enabling tool for the community surgeon

This study evaluated the efficacy of telementoring as an enabling tool for community general surgeons to perform advanced laparoscopic surgical procedures. We present a series of 19 patients who underwent advanced laparoscopic surgical procedures in two community hospitals, between November 2002 and July 2003, by four community surgeons with no formal advanced laparoscopic training. Each surgeon was telementored by an expert surgeon from a tertiary care hospital. Telementoring was achieved with real-time two-way audio-video communications over Internet Protocol or Integrated Services Digital Network lines with bandwidths from 385 kbps to 1.2 mbps. The procedures included 10 bowel resections, 5 Nissen fundoplications, 2 splenectomies, 1 reversal of a Hartmann procedure, and 1 ventral hernia repair. Two of the 19 procedures (11%) were converted to open. There were no intraoperative complications and two postoperative complications (11%). The primary surgeon considered telementoring useful in all cases (median score, 4 of 5). The mentor was also comfortable with the quality of the laparoscopic surgery performed (median score, 4 of 5). Telecommunication bandwidth for audio and video transmission was found to be a critical factor in the quality of telementoring process. Telementoring is safe and feasible. It allows community surgeons with no formal advanced laparoscopic training to benefit from expert intraoperative advice during the performance of advanced laparoscopic procedures. It may also reduce health-care costs by avoiding the need to refer and transfer patients to tertiary care centers.

Assessment of the learning curve for lumbar microendoscopic discectomy

OBJECTIVE

An understanding of the learning curve of a new surgical procedure is essential for its safe clinical integration, teaching, and assessment. This knowledge is currently deficient for lumbar microendoscopic discectomy (MED). The present article aims to profile the learning curve for MED of an individual surgeon in a hospital not previously exposed to this procedure.

METHODS

The first 35 cases of MED for posterolateral lumbar disc prolapse causing radiculopathy performed at the Princess Alexandra Hospital, Brisbane, Australia, were studied prospectively. The learning curve was assessed using surgery time, conversion rate, complication rate, surgeon "comfort," and key learning steps.

RESULTS

The duration of surgical operating time decreased over the course of the study, initially rapidly and then more gradually. There were three conversions to open discectomy in the first 7 cases and none in the next 28 cases. The complexity of cases increased over the series, and the complication rate decreased. The asymptote of the learning curve seems to be approximately 30 cases. The specific learning tasks of MED include lateral lamina radiology, scope vision, visuospatial orientation, smaller field of view, angle of approach and tube position, and care and handling of endoscope equipment.

CONCLUSION

A learning curve for MED has been demonstrated. Further assessment of this curve for a population of surgeons is necessary before a clinical assessment of open discectomy versus MED can be embarked upon.

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

BACKGROUND

There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses.

METHODS

Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA.

RESULTS

The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001).

CONCLUSIONS

OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

Comparison of different training models for laparoscopic surgery in neonates and small infants

BACKGROUND

Minimally invasive surgery in small children and infants requires special skills and training. This experimental study compares the efficiency of an in vitro pelvic trainer (PT) and an a in vivo animal model (AM).

METHODS

For this study, 12 residents were prospectively randomized into two groups. Initially, all had to pass a basic skill assessment (3 tasks). Then endoscopic small bowel biopsy was performed (8 times) either with the in vitro PT (group A) or the in vivo AM (group B). Finally, all had to demonstrate this procedure in the in vivo AM and repeat the basic skill assessment. A quality index (complications, suture, biopsy) was evaluated.

RESULTS

Initially, there was no difference between the two groups. Interestingly, the mean regression gradient of the index for the in vitro PT (group A) was significantly better than for the in vivo AM (group B). In the final in vivo operation, however, the mean index for the in vitro PT (group A) worsened significantly, whereas it increased for the in vivo AM (group B) (p = 0.037).

CONCLUSION

Adequate training for an isolated mechanical task such as gut biopsy can be supplied using a pelvic trainer or animal model with similar effects. However in vivo performance of the same task requires secondary surgical skills, which are conveyed during live training with greater success. Consequently, stepwise teaching with both modules seems reasonable before these procedures are approached in neonates or small children.

Transition from open to laparoscopic adrenalectomy: the need for advanced training

BACKGROUND

We sought to determine the learning curve for laparoscopic adrenalectomy (LA), current use of the procedure, and if indications for adrenalectomy had changed in the past decade.

METHODS

A retrospective chart review was performed for all adrenalectomies after 1990. Practicing community surgeons in Oregon were mailed a questionnaire.

RESULTS

Seventy-five LAs were performed at the Oregon Health and Sciences University and Portland VA Medical Center. Average operating room (OR) time was 161 min and average estimated blood loss (EBL) was 84 ml. There were four complications and two conversions. Comparing the first 20 to the last 20 patients, OR times were 154 vs 159 min (not significant), and EBL was 102 vs 47 ml ( p < 0.05). There were two vs one complications ( p > 0.05) and one conversion each. Most residents completed less than two procedures during training, and community surgeons performed none during training. Of 17 currently performing LA, 14 had postresidency training. Open technique was used more often for hormonal ablation and malignancy.

CONCLUSION

Operative time and complications do not decrease with experience, but EBL does. Few, if any, residents acquire enough experience to perform LA in practice. The procedure is performed laparoscopically more often for benign disease.

Bile duct injury during laparoscopic cholecystectomy: results of a national survey

OBJECTIVE

To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency.

SUMMARY BACKGROUND DATA

Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern.

METHODS

An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated).

RESULTS

Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair.

CONCLUSIONS

Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Cusum analysis of trends in operative selection and conversion rates for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) requires a high degree of technical ability, spatial resolution and dexterity. Assessing trainees and competent operators is an important aspect of quality assurance in patient care. Most institutions quote mean conversion rate as a method of comparing operators' performance. The purpose of the present study was to use the technique of cumulative sum (cusum) analysis to determine whether a learning curve phenomenon exists in operators performing LC.

METHODS

Data were obtained retrospectively by reviewing the operative records of all patients undergoing elective and acute cholecystectomy for a 30-month period coinciding with the commencement of LC at North Shore Hospital. Patients' age and gender, date and type of operative procedure, duration of operation, and name of operator were recorded. Mean and cusum-transformed data were derived for all operations as well as for four individual operators' performances.

RESULTS

Over the study period a total of 614 cholecystectomies was performed, with 85% attempted laparoscopically. A total of 9.8% required conversion to the open technique. Time trend analysis with the cusum technique for all surgeons revealed an inverse relationship between selection rate and conversion rate. Analysis of four individual surgeons revealed three different time trend profiles.

CONCLUSION

There was a direct inverse relationship between conversion rate and selection rate, in that careful selection is associated with a low conversion rate. Comparison of individual surgeons' performance showed wide variation, with only one surgeon exhibiting the phenomenon of a learning curve. Contrary to other reports, we found that performance on LC was not always related to operative experience. This highlights the need for a more objective method to analyse operator competence than operator experience alone.

Training Background as a Factor in the Conversion Rate of Laparoscopic Cholecystectomy

The present study reports findings concerning the impact of the learning environment on the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC). At Metro-West Medical Center (Framingham, MA) seven surgeons performed 866 LCs between 1990 and 1995. Group I consisted of three surgeons who learned the procedure as part of their General Surgery Residency training, whereas the remaining four surgeons representing Group II learned the procedure through private courses. We emphasize the importance of the surgeons’ training background on the conversion rates, operative times, and length of hospitalization for patients undergoing LC. The conversion rates, operative times, and complication rates were analyzed with and without a 2-year period of adjustment to compensate for the learning curve of early procedures. Operative times and conversion rates from LC to OC were lower for cases done by surgeons from Group I, even when the learning curve was corrected. The complication rates were higher for surgeons in Group II, but this did not reach statistical significance. As surgeons from Group II gained more experience their operation times and conversion rates decreased. However, there still was a statistically significant difference in favor of surgeons who learned the procedure as part of a structured curriculum. These data suggest a long-lasting influence of the learning environment on the conversion rates and operative times.

Optimal teaching environment for laparoscopic splenectomy

BACKGROUND

Traditional surgical teaching depends on graduated acquisition of skill learned in residency. The introduction of minimal access techniques after residency training has created a new paradigm dependent on animate course experiences and limited preceptor training. The outcome of performance of a new skill "learned" in these settings has not been assessed. The purpose of this study was to test the benefit of an animate course compared with a precepted operating room experience in learning to perform a laparoscopic splenectomy.

METHODS

All attending surgeons who had taken a 1-day course to learn laparoscopic splenectomy (n = 37) and those who had undergone an intraoperative preceptorship (in their hospital) by the lead author (n = 15) were polled to ascertain their previous experience with laparoscopy and with laparoscopic splenectomy since the intervention. The course included lectures, operative videos, and an animal lab. Statistical differences were measured using a t test.

RESULTS

Thirty-two of the 37 (86.5%) taking the course and all 15 of the precepted surgeons responded. There was no difference between the groups regarding prior laparoscopic experience (P = 0.73), laparoscopic training during residency (P = 0.74), academic or private practice (P = 0.48), or follow-up since the intervention (P = 0.36). The participants graded the courses (1 to 5, 5 = excellent) at an average of 4.72. Fourteen of 15 precepted surgeons have performed laparoscopic splenectomy as compared with 2 of 32 taking courses (nonprecepted surgeons; P <0.0001). The number of laparoscopic splenectomies performed totaled 112 for precepted surgeons and 4 for nonprecepted surgeons (P = 0.0003). The nonprecepted surgeons performed significantly more open splenectomies than laparoscopic (95 versus 13 respectively, P = 0.02). Reasons quoted not to proceed with laparoscopic splenectomy included waiting for the perfect patient, concern of hilar management, and splenic size.

CONCLUSION

Surgeons precepted in their own operating room performed a laparoscopic splenectomy more readily than those gaining experience from a course only (93% versus 6%, respectively) despite no difference in their preintervention experience and having the opportunity to do so. The expectation of the eventual performance of advanced laparoscopic techniques depends on a precepted experience.

Improving continuing medical education for surgical techniques: applying the lessons learned in the first decade of minimal access surgery

OBJECTIVE

To examine the first decade of experience with minimal access surgery, with particular attention to issues of training surgeons already in practice, and to provide a set of recommendations to improve technical training for surgeons in practice.

SUMMARY BACKGROUND DATA

Concerns about the adequacy of training in new techniques for practicing surgeons began almost immediately after the introduction of laparoscopic cholecystectomy. The concern was restated throughout the following decade with seemingly little progress in addressing it.

METHODS

A preliminary search of the medical literature revealed no systematic review of continuing medical education for technical skills. The search was broadened to include educational, medical, and psychological databases in four general areas: surgical training curricula, continuing medical education, learning curve, and general motor skills theory.

RESULTS

The introduction and the evolution of minimal access surgery have helped to focus attention on technical skills training. The experience in the first decade has provided evidence that surgical skills training shares many characteristics with general motor skills training, thus suggesting several ways of improving continuing medical education in technical skills.

CONCLUSIONS

The educational effectiveness of the short-course type of continuing medical education currently offered for training in new surgical techniques should be established, or this type of training should be abandoned. At present, short courses offer a means of introducing technical innovation, and so recommendations for improving the educational effectiveness of the short-course format are offered. These recommendations are followed by suggestions for research.

Laparoscopic training on bench models: better and more cost effective than operating room experience?

BACKGROUND

Developing technical skill is essential to surgical training, but using the operating room for basic skill acquisition may be inefficient and expensive, especially for laparoscopic operations. This study determines if laparoscopic skills training using simulated tasks on a video-trainer improves the operative performance of surgery residents.

STUDY DESIGN

Second- and third-year residents (n= 27) were prospectively randomized to receive formal laparoscopic skills training or to a control group. At baseline, residents had a validated global assessment of their ability to perform a laparoscopic cholecystectomy based on direct observation by three evaluators who were blinded to the residents' randomization status. Residents were also tested on five standardized video-trainer tasks. The training group practiced the video-trainer tasks as a group for 30 minutes daily for 10 days. The control group received no formal training. All residents repeated the video-trainer test and underwent a second global assessment by the same three blinded evaluators at the end of the 1-month rotation. Within-person improvement was determined; improvement was adjusted for differences in baseline performance.

RESULTS

Five residents were unable to participate because of scheduling problems; 9 residents in the training group and 13 residents in the control group completed the study. Baseline laparoscopic experience, video-trainer scores, and global assessments were not significantly different between the two groups. The training group on average practiced the video-trainer tasks 138 times (range 94 to 171 times); the control group did not practice any task. The trained group achieved significantly greater adjusted improvement in video-trainer scores (five of five tasks) and global assessments (four of eight criteria) over the course of the four-week curriculum, compared with controls.

CONCLUSIONS

Intense training improves video-eye-hand skills and translates into improved operative performance for junior surgery residents. Surgical curricula should contain laparoscopic skills training.

Acquiring surgical skills

BACKGROUND

Technical competence is the bedrock of surgery, yet it has only recently been viewed as a valid area for either critical evaluation or formal teaching.

METHODS

This review examines the teaching of surgical skills. The core is derived from a literature search of the Medline computer database.

RESULTS AND CONCLUSION

The impetus for surgical change has generally related to the introduction of new technology. Advances initially allowed for open operation within the main body cavities; more recently minimal access surgery has appeared. The latter was introduced in an inappropriate manner, which has led to the evolution of teaching of technical skills away from an apprenticeship-based activity towards more formal skill-based training programmes. There is now a need for a solid theoretical base for the teaching of manual skills that accommodates concepts of surgical competence.

An objective scoring system for laparoscopic cholecystectomy

BACKGROUND

Direct observation with structured criteria for performance is the most reliable and valid method of assessing technical skill during operative procedures. We developed such a system to evaluate technical performance during a laparoscopic cholecystectomy. The reliability and validity of the system were tested by analyzing the correlation among three observers in a multicenter study and comparing performance with years of surgical experience.

STUDY DESIGN

Thirty consecutive cases of laparoscopic cholecystectomy were recorded on videotape, 10 from each of 3 institutions. Independent scores were generated by three observers examining each of the videotapes, providing a total of 90 scores. Points were awarded for successful completion of each of 23 different steps required to perform a laparoscopic cholecystectomy. Error points were tabulated based on the frequency and relative severity of each of 21 potential technical mistakes during the operation. The final score was assumed to be a relative measure of technical skill and was derived by subtracting error points from points awarded for completion of each step of the procedure. Pearson correlation coefficients were used to assess agreement among examiners and correlation with year of surgical experience.

RESULTS

Agreement in final scores among the three observers was excellent (r = 0.74-0.96) despite the fact that one observer assigned significantly fewer error points. Correlation between year of experience and two-handed technique scoring was good (r = 0.5, p = 0.057), but the correlation between experience and one-handed technique scores was poor (r = 0.02).

CONCLUSIONS

The technical skills required to perform laparoscopic cholecystectomy can reliably be measured using this tool. This method can be used to track the learning curve of surgeons in training, evaluate the efficacy of alternative training tools, and provide a means of self-assessment for the trainee.

A prospective randomized experimental evaluation of three-dimensional imaging in laparoscopy

BACKGROUND

Restricted depth perception in laparoscopy with two-dimensional imaging has been reported to be a major disadvantage of minimally invasive procedures. Three-dimensional imaging units have been available for almost 2 years and are slowly being integrated into endoscopic surgery. So far, potential advantages or disadvantages have not yet been studied prospectively.

METHODS

We evaluated the effects of three-dimensional imaging on surgical performance and its influence on surgeons at different experience levels in a prospective randomized trial. Twenty participants without laparoscopic experience (novices), 20 with less than 50 laparoscopic procedures (beginners), and 20 with more than 50 laparoscopic procedures (advanced surgeons) took part in two different tests (tube test and loop test) on a pelvitrainer. In random order, each test was conducted using a three-dimensional imaging unit under two-dimensional and three-dimensional conditions. During each test, the time was measured and the mistakes counted. The difference of time and number of mistakes for two-dimensional and three-dimensional conditions were calculated for each participant.

RESULTS

Speed (p < 0.0001) and accuracy (p < 0.0001) were significantly better under three-dimensional conditions irrespective of the randomized sequence of each individual test. Speed was also influenced by individual experience (p > 0.02). Performance time decreased by 24.4% +/- 2.8% (m +/- SD), and the number of mistakes decreased by 52.5% +/- 27.9% (m +/- SD), as compared with the two-dimensional mode, with no significant influence of individual experience.

CONCLUSIONS

Three-dimensional imaging significantly improves performance (speed and accuracy) regardless of previous laparoscopic experience. Thus, three-dimensional imaging may further improve the safety aspect of minimally invasive surgery.

The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair

BACKGROUND

Several laparoscopic techniques have been introduced to re pair inguinal hernia, the newest and most promising being a totally extraperitoneal approach. Nevertheless, the surgeon may encounter several complications and technical difficulties associated with the transition from the conventional anterior operation.

METHODS

In late 1993 and 1994, 120 patients were operated on for inguinal hernia using the totally extraperitoneal approach by four laparoscopic surgeons inexperienced in this new technique in a secondary referral setting. Their learning curve was assessed through operation time, perioperative and postoperative complications, and technical difficulties.

RESULTS

Median operative time decreased significantly (P = 0.0003) when going through the learning curve. During the initial part of the learning curve, conversion to another technique was necessary in 10 (8%) cases, and in 6 of these cases, conversion was needed for a peritoneal tear (relative risk for conversion if peritoneal tear was present: 4.0; 95% confidence interval 1.2 to 13.1, P = 0.025). The median operative time for Nyhus type IIIb and IVb hernias was significantly longer than for other types (70 versus 55 minutes, P = 0.003). Median postoperative stay was 2 days (range 0 to 7). There were 10 recurrences within 6 months due to technical or judgement errors.

CONCLUSIONS

For surgeons, the learning curve for totally extraperitoneal laparoscopic hernia repair can be overcome; however, the presence of an experienced surgeon during the procedure is vital, as this may prevent unnecessary recurrences.