Sequential learning of psychomotor and visuospatial skills for laparoscopic suturing and knot tying—a randomized controlled trial “The Shoebox Study” DRKS00008668

Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study

BACKGROUND

The learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees.

METHODS

This randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores.

RESULTS

The participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001).

CONCLUSIONS

Structured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.

[Evidence, Availability and Future Visions in Simulation in General and Visceral Surgery]

Practice makes perfect - a saying that everyone has certainly heard. Surgeons of all levels of training can demonstrably practice to some extent on simulators. This training outside the operating theatre and independent of patients makes sense, both ethically and financially. Although the effectiveness of simulation in surgery has been proven several times, simulation training is not a mandatory part of surgical specialist training in Germany. Simulation covers a very wide range in terms of application, effort and costs. This review is intended to give an overview of the systems and their areas of application and the target group. The focus lies on the commonly available systems and possible advantages and disadvantages. Practical skills are in the foreground and all three pillars of general and visceral surgery - conventional techniques, laparoscopy and robotics - are taken into account. However, simulators alone do not achieve cost-benefit effectiveness. The full potential of such an investment can only be exploited with a site-specific, structured training concept in which simulation training according to the post-graduate year and appropriate allocation to surgeries in the operating room are closely interlinked. It should always be possible to train basic skills on site. The significant additional costs for complex simulation systems are possible, depending on the financial resources, or should be purchased in a network or for national courses. The techniques of immersive virtual reality in combination with artificial intelligence and deformation algorithms will certainly play a decisive role for the future of simulation, whereby the use of the available systems must be a primary goal. The integration of simulation into specialist training should be striven for, not least in order to justify the costs.

Video-based training of situation awareness enhances minimally invasive surgical performance: a randomized controlled trial

BACKGROUND

Many training curricula were introduced to deal with the challenges that minimally invasive surgery (MIS) presents to the surgeon. Situational awareness (SA) is the ability to process information effectively. It depends on general cognitive abilities and can be divided into three steps: perceiving cues, linking cues to knowledge and understanding their relevance, and predicting possible outcomes. Good SA is crucial to predict and avoid complications and respond efficiently. This study aimed to introduce the concept of SA into laparoscopic training.

METHODS

This is a prospective, randomized, controlled study conducted at the MIS Training Center of Heidelberg University Hospital. Video sessions showing the steps of the laparoscopic cholecystectomy (LC) were used for cognitive training. The intervention group trained SA with interposed questions inserted into the video clips. The identical video clips, without questions, were presented to the control group. Performance was assessed with validated scores such as the Objective Structured Assessment of Technical Skills (OSATS) during LC.

RESULTS

72 participants were enrolled of which 61 were included in the statistical analysis. The SA-group performed LC significantly better (OSATS-Score SA: 67.0 ± 11.5 versus control: 59.1 ± 14.0, p value = 0.034) and with less errors (error score SA: 3.5 ± 1.9 versus control: 4.7 ± 2.0, p value = 0.027). No difference in the time taken to complete the procedure was found. The benefit assessment analysis showed no difference between the groups in terms of perceived learning effect, concentration, or expediency. However, most of the control group indicated retrospectively that they believed they would have benefitted from the intervention.

CONCLUSION

This study suggests that video-based SA training for laparoscopic novices has a positive impact on performance and error rate. SA training should thus be included as one aspect besides simulation and real cases in a multimodal curriculum to improve the efficiency of laparoscopic surgical skills training.

Factors Influencing Performance in Laparoscopic Suturing and Knot Tying: A Cohort Study

BACKGROUND

 Laparoscopic suturing and knot tying are regarded as some of the most difficult laparoscopic skills to learn. Training is essential to reach proficiency, but available training opportunities are limited. Various techniques to improve training have been evaluated. It appears that individual-related factors affect initial performance and response to training. Thus, the current study aimed to assess factors influencing laparoscopic-suturing and knot-tying performances.

METHODS

 All patients were trained one-on-one (teacher-student) for 3 hours. Patients were tested before training (bowel anastomosis model) and directly after training (congenital diaphragmatic hernia or esophageal atresia model) to evaluate transferability. Primary endpoints were time, knot quality, precision, knot strength, and overall laparoscopic knotting performance. Moreover, factors such as (1) age, (2) gender, (3) handedness, (4) previous training or operative experience, (5) playing an instrument, (6) sportive activities, and (7) computer gaming which may influence the primary endpoints were assessed.

RESULTS

 In total, 172 medical students or novice surgical residents were included. Training significantly improved all outcome parameters assessed in the current study. More than 50% of the patients reached proficiency after 3 hours of training. Personal factors like operative experience, playing music instruments, sportive activities, and computer gaming affected some outcome parameters. Handedness and gender affected initial performance but differences partially subsided after training. Younger participants showed a much better response to training.

CONCLUSION

 In conclusion, several factors influence initial performance and response to the training of laparoscopic suturing and knot tying. Surgeons who want to improve their laparoscopic performance, should concentrate on playing a musical instrument and performing sports rather than playing videos gaming. It appears that training is a key and more practice opportunities should be incorporated into medical school and surgical curricula. Moreover, handedness may affect the outcome but only if the training concepts are not tailored to the dominant hand of the surgeon. Future training and surgical curricula should adapt to this and tailor their concepts accordingly.

Video-based learning of coping strategies for common errors improves laparoscopy training-a randomized study

AIMS

The aim of this study was to investigate whether shifting the focus to solution orientation and developing coping strategies for common errors could increase the efficiency of laparoscopic training and influence learning motivation. The concept of coping has been particularly defined by the psychologist Richard Lazarus [Lazarus and Folkman in Stress, appraisal, and coping, Springer publishing company, New York, 1984]. Based on this model, we examined the use of observational learning with a coping model for its effectiveness as a basic teaching model in laparoscopic training.

METHODS

55 laparoscopically naive medical students learned a standardized laparoscopic knot tying technique with video-based instructions. The control group was only offered a mastery video that showed the ideal technique and was free from mistakes. The intervention group was instructed on active error analysis and watched freely selectable videos of common errors including solution strategies (coping model) in addition to the mastery videos.

RESULTS

There was no statistically significant difference between the intervention and control groups for number of knot tying attempts until proficiency was reached (18.8 ± 5.5 vs. 21.3 ± 6.5, p = 0.142). However, there was a significantly higher fraction of knots achieving technical proficiency in the intervention group after first use of the coping model (0.7 ± 0.1 vs. 0.6 ± 0.2, p = 0.026). Additionally, the proportion of blinded attempts that met the criteria for technical proficiency was significantly higher for the intervention group at 60.9% vs. 38.0% in control group (p = 0.021). The motivational subscore "interest" of the validated score on current motivation (QCM) was significantly higher for the intervention group (p = 0.032), as well as subjective learning benefit (p = 0.002) and error awareness (p < 0.001).

CONCLUSION

Using video-based learning of coping strategies for common errors improves learning motivation and understanding of the technique with a significant difference in its qualitative implementation in laparoscopy training. The ability to think in a solution-oriented, independent way is necessary in surgery in order to recognize and adequately deal with technical difficulties and complications.

Learning of Intracorporal Knot Tying in Minimally Invasive Surgery by Video or Expert Instruction

INTRODUCTION

 Minimally invasive surgery skill laboratories are indispensable in training, especially for complex procedural skills such as intracorporal suturing and knot tying (ICKT). However, maintaining a laboratory is expensive, and specially trained teachers are in short supply. During the COVID-19 pandemic, in-person instruction has reduced to almost zero, while model learning via video instruction (VID) has become an integral part of medical education. The aim of this study was to compare the learning effectiveness and efficiency of ICKT by laparoscopically inexperienced medical students through video versus direct expert instruction.

MATERIALS AND METHODS

 A secondary analysis of two randomized controlled trials was performed. We drew data from students who were trained in ICKT with expert instruction (EXP, n = 30) and from students who were trained via VID, n = 30). A laparoscopic box trainer including laparoscope was used for ICKT. Objective Structured Assessment of Technical Skills (OSATS), knot quality, and total ICKT time were the parameters for the assessment in this study. Proficiency criteria were also defined for these parameters.

RESULTS

 Students in the EXP group performed significantly better in OSATS-procedure-specific checklist (PSC) and knot quality compared with students in the VID group, with no difference in task time. Of the students who reached the proficiency criteria for OSATS-PSC and knot quality, those in the EXP group required fewer attempts to do so than those in the VID group. Students in both groups improved significantly in all parameters over the first hour of evaluation.

CONCLUSION

 For the laparoscopically inexperienced, training in ICKT through expert instruction presents an advantage compared with video-based self-study in the form of faster understanding of the procedure and the associated consistent implementation of good knot quality. Both teaching methods significantly improved participants' ICKT skills.

Telementoring of Open and Laparoscopic Knot Tying and Suturing Is Possible: A Randomized Controlled Study

AIM

 Several motor learning models have been used to teach highly complex procedural skills in medical education. The aim of this randomized controlled trial was to assess the efficiency of telementoring of open and laparoscopic suturing of medical students compared to conventional in-person teaching and training.

METHODS

 After randomization, 23 medical students were assigned to either the telementoring or the in-person training group. Both groups were taught by surgically trained residence with a student-teacher ratio of 1:1 (teacher-student). Open suturing was assessed in a model of congenital diaphragmatic hernia and laparoscopic suturing in a model of bowel anastomosis. All subjects were trained according to the spaced learning concept for 3 hours. Primary end points were time, knot quality, precision, knot strength, and overall knotting performance/competency. Furthermore, we utilized the Surgery Task Load Index to evaluate the cognitive load of both teaching techniques. Students' subjective progress regarding skill acquisitions and acceptance of telementoring was assessed using a nine-item questionnaire.

RESULTS

 All 23 trainees significantly improved after training in all knot attributes. More than 90% of all subjects reached proficiency in both groups. In-person training and telementoring were similarly practical, and no significant differences regarding speed, knot quality, precision, knot stability, and procedure performance/competency were found. Students perceived no difference in acquisition of factual or applicational knowledge between the two groups. General acceptance of telementoring was moderate in both groups before training, but increased during training in students actually assigned to this group, in comparison to students assigned to conventional teaching.

CONCLUSION

 The current study shows that telementoring of open and laparoscopic suturing is an ideal answer to the current coronavirus disease 2019 pandemic, ensuring continuous training. On-site training and telementoring are similarly effective, leading to substantial improvement in proficiency in intracorporeal suturing and knot tying. Likewise, students' subjective progress regarding skill acquisitions and cognitive load does not differ between teaching methods. Skepticism toward telementoring decreases after exposure to this learning method. Given our results, telementoring should be considered a highly effective and resource-saving educational approach even after the current pandemic.

Telestration with augmented reality for visual presentation of intraoperative target structures in minimally invasive surgery: a randomized controlled study

AIMS

In minimally invasive surgery (MIS), intraoperative guidance has been limited to verbal communication without direct visual guidance. Communication issues and mistaken instructions in training procedures can hinder correct identification of anatomical structures on the MIS screen. The iSurgeon system was developed to provide visual guidance in the operating room by telestration with augmented reality (AR).

METHODS

Laparoscopic novices (n = 60) were randomized in two groups in a cross-over design: group 1 trained only with verbal guidance first and then with additional telestration with AR on the operative screen and vice versa for group 2. Training consisted of laparoscopic basic training and subsequently a specifically designed training course, including a porcine laparoscopic cholecystectomy (LC). Outcome included time needed for training, performance with Global Operative Assessment of Laparoscopic Skills (GOALS), and Objective Structured Assessment of Technical Skills (OSATS) score for LC, complications, and subjective workload (NASA-TLX questionnaire).

RESULTS

Telestration with AR led to significantly faster total training time (1163 ± 275 vs. 1658 ± 375 s, p < 0.001) and reduced error rates. LC on a porcine liver was performed significantly better (GOALS 21 ± 5 vs. 18 ± 4, p < 0.007 and OSATS 67 ± 11 vs. 61 ± 8, p < 0.015) and with less complications (13.3% vs. 40%, p < 0.020) with AR. Subjective workload and stress were significantly reduced during training with AR (33.6 ± 12.0 vs. 30.6 ± 12.9, p < 0.022).

CONCLUSION

Telestration with AR improves training success and safety in MIS. The next step will be the clinical application of telestration with AR and the development of a mobile version for remote guidance.

Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

The Spaced Learning Concept in Combination With Halsted and Peyton - A Randomized Controlled Study

BACKGROUND

Several motor learning models have been used to teach highly complex procedural skills in medical education. Two approaches are often employed amongst health care professionals: Halsted's "See one - do one - teach one" concept and Peyton's Four-step approach. Peyton's deconstruction of the learning process into 4 sub-steps was reported to be preferable for learning/acquiring/teaching complex clinical skills. However, a new increasingly popular technique is known as the spaced learning method. In a previous study, we were able to confirm that the spaced learning concept is superior for laparoscopic suturing and knot tying compared to conventional training curricula, this current study aimed to assess the influence of spaced learning in combination with Halsted's and Peyton's tutoring approaches on laparoscopic knot tying of medical students.

METHODS

After randomization, 20 medical students were either assigned to Halsted's or Peyton's teaching approach and trained one-on-one (teacher-student). Additionally, all subjects were trained according to the spaced learning concept, containing 40 minutes of content-blocks, followed by a 20-minute break involving coordinated, standardized physical activity. This was repeated three times. Primary endpoints were time, knot quality, precision, knot strength, as well as overall laparoscopic knotting performance and competency. To evaluate the motivation of the subjects, an 18-item questionnaire was utilized to measure four motivational factors (anxiety, probability of success, interest, and challenge).

RESULTS

All trainees significantly improved after training in all knot attributes. Trainees assigned to Halsted's method were able to significantly outperform the Peyton group in knot quantity within 30 minutes (p = 0.013), time/knot (p = 0.033), performance score (p = 0.009), and precision (p = 0.032). No significant difference between Halsted and Peyton was found for knot strength and quality. Furthermore, no significant difference was identified comparing motivation pre- and post-training. However, subjects in the Peyton appeared to be significantly more anxious after training.

CONCLUSION

Combining spaced learning technique with Halsted's "see one - do one - teach one" appears to be superior to Peyton's Four-step approach in conjunction with spaced learning in surgical naïve students. We recommend further studies evaluating the combination of spaced learning with Halsted and Peyton's instructional methods.

[Robot-assisted surgery as an elective-fascinating lesson(s)?]

Hintergrund

Auch wenn sich roboterassistiertes Operieren zu einem verbreiteten Standardverfahren in einigen chirurgischen Fächern entwickelt hat, ist es im Lehrplan heutiger Medizinstudierender unterrepräsentiert.

Fragestellung

Wir berichten vom deutschlandweit ersten Wahlfach „Robotische Chirurgie“ für Studierende an einer urologischen Universitätsklinik.

Material und Methoden

In einer Kleingruppe mit zehn Studierenden wurden in sechs Treffen à 2 h theoretische Grundlagen und praktische Fertigkeiten in der robotischen Chirurgie vermittelt, inklusive einer Hospitation während einer urologischen roboterassistierten Operation. Der Zuwachs an Wissen (10 MCQ-Fragen) und Fähigkeiten (Übungen Camera 0, Clutch, Sea Spikes 1) an einem robotischen Simulationssystem wurde quantifiziert und die studentische Einschätzung evaluiert.

Ergebnisse

Bei den 10 Teilnehmenden war ein signifikanter Wissenszuwachs messbar, am Ende wurden in derselben theoretischen Prüfung im Median 3,5 mehr korrekte Antworten gegeben (p = 0,011). In zwei von drei praktischen Übungen stieg die Gesamtpunktzahl signifikant an (Camera 0 und Sea Spikes 1, für beide p < 0,05), in der Übung „Clutch“ verbesserte sich nur die Bewegungsökonomie (p = 0,028). Das Modul wurde (sehr) gut bewertet und die Teilnehmenden konnten sich am Ende deutlich stärker vorstellen, später Urologe/in zu werden (p = 0,007).

Schlussfolgerungen

Bei einem Bedarf von studentischer Seite, mehr über roboterassistierte Operationen zu lernen, erscheint ein Wahlfach als geeignetes Format, um theoretische Grundlagen und praktische Fertigkeiten in der robotischen (urologischen) Chirurgie zu vermitteln. Zusätzlich hat es das Potenzial, auf das Fachgebiet Urologie aufmerksam zu machen und könnte potenziell neue Kolleginnen und Kollegen gewinnen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00120-021-01756-6) enthält als zusätzliches Material das in diesem Beitrag durchgeführte Eingangstestat zur Prüfung des Vorwissens der Studierenden in einer theoretischen Prüfung (10 Multiple-choice-Fragen).

An overview on 3D printing for abdominal surgery

BACKGROUND

Three-dimensional (3D) printing is a disruptive technology that is quickly spreading to many fields, including healthcare. In this context, it allows the creation of graspable, patient-specific, anatomical models generated from medical images. The ability to hold and show a physical object speeds up and facilitates the understanding of anatomical details, eases patient counseling and contributes to the education and training of students and residents. Several medical specialties are currently exploring the potential of this technology, including general surgery.

METHODS

In this review, we provide an overview on the available 3D printing technologies, together with a systematic analysis of the medical literature dedicated to its application for abdominal surgery. Our experience with the first clinical laboratory for 3D printing in Italy is also reported.

RESULTS

There was a tenfold increase in the number of publications per year over the last decade. About 70% of these papers focused on kidney and liver models, produced primarily for pre-interventional planning, as well as for educational and training purposes. The most used printing technologies are material jetting and material extrusion. Seventy-three percent of publications reported on fewer than ten clinical cases.

CONCLUSION

The increasing application of 3D printing in abdominal surgery reflects the dawn of a new technology, although it is still in its infancy. The potential benefit of this technology is clear, however, and it may soon lead to the development of new hospital facilities to improve surgical training, research, and patient care.

Can the Learning Curve of Laparoscopic Sacrocolpopexy Be Reduced by a Structured Training Program?

OBJECTIVE

The aim of this study was to establish whether the learning curve for laparoscopic sacral colpopexy (LSC) could be significantly reduced in a structured learning program.

METHODS

We conducted a prospective study aimed at mapping the learning curve of LSC in the setting of a structured learning program for a urogynecology fellow at the Royal Brisbane and Women's Hospital.The fellow was laparoscopic suturing and dissection naive at the commencement of her fellow position and was required to assist in 20 LSCs, video-edit 2 procedures, and undertake laparoscopic suturing and knot tying training on a laparoscopic trainer for 2 h/wk during the trial period.After the completion of this structured learning program, the fellow began performing LSC as the primary surgeon.Symptomatic assessment of pelvic organ prolapse and pelvic floor dysfunction was undertaken preoperatively and 12 months postoperatively using the Australian Pelvic Floor Questionnaire.Objective success at 12 months was defined as less than stage 2 prolapse in any compartment. Subjective success was defined as no prolapse on Q 28 to 31 on the Australian Pelvic Floor Questionnaire, and patient-determined success was defined as "much" or "very much better" on the Patient Global Impression of Improvement at 12 months.

RESULTS

Five consecutive LSC in 90 minutes or less without intraoperative or postoperative complications was achieved by case 18. Overall objective success at 12 months was 91%, and subjective and patient-determined success was 95%.

CONCLUSION

Previous studies on LSC that report a similar learning curve have recorded much longer operating times. We believe that the shorter operating time, without compromise to outcomes and complication rates, is a result of the structured learning program.

A prospective study of the effect of video games on robotic surgery skills using the high-fidelity virtual reality RobotiX simulator

BACKGROUND

Robot-assisted surgery is a growing field. Prior video game experience might give advantage to novice robotic surgeons.

AIM

Assessing if prior video gaming experience gives advantage in performing high-fidelity virtual reality (VR)-simulated robotic surgery.

METHODS

In this observational study, 30 medical students and 2 interns (17 females; 15 males) with median age 25 years (range, 24-26 years) were recruited and subsequently divided into groups according to prior gaming experience; gamers (≥6 video game hours/week) vs nongamers (<6 video game hours/week). Participants performed VR-simulated urethrovesical anastomosis on RobotiX Mentor, which measured performance parameters. Participants answered a questionnaire for demographics and gaming experience. Groups were compared using Mann-Whitney U and multiple regression.

RESULTS

Gamers significantly outperformed nongamers in 3 of 24 performance metrics (p<0.05), and there was a trend toward better results for 7 of the 21 remaining metrics. Males outperformed females in 5 of 24 metrics (p<0.05) but were overrepresented among gamers.

CONCLUSION

Prior video game experience >6 hrs/week might give advantage in simulated robotic surgery. We recommend future studies testing this hypothesis to develop simulator programs for certification of robotic surgeons.

Taxonomy of educational objectives and learning theories in the training of laparoscopic surgical techniques in a simulation environment

The acquisition of psychomotor skills in surgery is the central component of medical residency programs in General Surgery and Specialties. Making learning more effective is a cornerstone of educational processes. This article portrays aspects of educational taxonomies and learning theories that may be involved in the training of surgery. Among the many taxonomies and educational theories applicable to learning in surgery, the following stand out: 1) Dave's taxonomy- Hierarchy to actions that facilitate the acquisition of psychomotor skills; 2) Miller's theory- Step-by-step definition that facilitates acquisition; 3) Ericsson's theory- Competence after repetition of the practice followed by systematic reinforcement; 4) Vigotsky's theory- Definition of the role of the specialist in learning; and 5) Theory of Boud, Schon and Ende- Importance of feedback for students and teachers. Knowledge of these tools by teachers and preceptors can facilitate learning in surgery, especially in more complex activities.

One or two trainees per workplace for laparoscopic surgery training courses: results from a randomized controlled trial

BACKGROUND

There are no standards for optimal utilization of workplaces in laparoscopic training. This study aimed to define whether laparoscopy training should be done alone or in pairs (known as dyad training).

METHODS

This was a three-arm randomized controlled trial with laparoscopically naïve medical students (n = 100). Intervention groups participated alone (n = 40) or as dyad (n = 40) in a multimodality training curriculum with e-learning, basic, and procedural skills training using box and VR trainers. The control group (n = 20) had no training. Post-performance of a cadaveric porcine laparoscopic cholecystectomy (LC) was measured as the primary outcome by blinded raters using the objective structured assessment of technical skills (OSATS). Global operative assessment of laparoscopic skills (GOALS), time for LC, and VR performances were secondary outcomes.

RESULTS

There were no differences between groups for performance scores [OSATS: alone (40.2 ± 9.8) vs. dyad (39.8 ± 8.6), p = 0.995; alone vs. control (37.1 ± 7.4), p = 0.548; or dyad vs. control, p = 0.590; and GOALS score: alone (10.6 ± 3.0) vs. dyad (10.0 ± 2.7), p = 0.599; alone vs. control (10.1 ± 3.0), p = 0.748; or dyad vs. control, p = 0.998]. Dyad finished LC faster than control [median = 62.5 min (CI 58.0-73.0) vs. 76.5 min (CI 72.0-80+); p = 0.042], while there were no inter-group differences between alone vs. control [median = 69.0 min (CI 62.0-76.0) vs. control; p = 0.099] or alone vs. dyad (p = 0.840). Dyad and alone showed superior performance on the VR trainer vs. control for time, number of movements, and path length, but not for complications and application of cautery.

CONCLUSIONS

The curriculum provided trainees with the laparoscopic skills needed to perform LC safely, irrespective of the number of trainees per workplace. Dyad training reduced the operation time needed for LC. Therefore, dyad training seems to be a promising alternative, especially if training time is limited and resources must be used as efficiently as possible. Trial registration German Clinical Trials Register: DRKS00004675.

Evaluation of App-Based Serious Gaming as a Training Method in Teaching Chest Tube Insertion to Medical Students: Randomized Controlled Trial

BACKGROUND

The insertion of a chest tube should be as quick and accurate as possible to maximize the benefit and minimize possible complications for the patient. Therefore, comprehensive training and assessment before an emergency situation are essential for proficiency in chest tube insertion. Serious games have become more prevalent in surgical training because they enable students to study and train a procedure independently, and errors made have no effect on patients. However, up-to-date evidence regarding the effect of serious games on performance in procedures in emergency medicine remains scarce.

OBJECTIVE

The aim of this study was to investigate the serious gaming approach in teaching medical students an emergency procedure (chest tube insertion) using the app Touch Surgery and a modified objective structural assessment of technical skills (OSATS).

METHODS

In a prospective, rater-blinded, randomized controlled trial, medical students were randomized into two groups: intervention group or control group. Touch Surgery has been established as an innovative and cost-free app for mobile devices. The fully automatic software enables users to train medical procedures and afterwards self-assess their training effort. The module chest tube insertion teaches each key step in the insertion of a chest tube and enables users the meticulous application of a chest tube. In contrast, the module "Thoracocentesis" discusses a basic thoracocentesis. All students attended a lecture regarding chest tube insertion (regular curriculum) and afterwards received a Touch Surgery training lesson: intervention group used the module chest tube insertion and the control group used Thoracocentesis as control training. Participants' performance in chest tube insertion on a porcine model was rated on-site via blinded face-to-face rating and via video recordings using a modified OSATS tool. Afterwards, every participant received an individual questionnaire for self-evaluation. Here, trainees gave information about their individual training level, as well as previous experiences, gender, and hobbies. Primary end point was operative performance during chest tube insertion by direct observance.

RESULTS

A total of 183 students enrolled, 116 students participated (63.4%), and 21 were excluded because of previous experiences in chest tube insertion. Students were randomized to the intervention group (49/95, 52%) and control group (46/95, 48%). The intervention group performed significantly better than the control group (Intervention group: 38.0 [I₅₀=7.0] points; control group: 30.5 [I₅₀=8.0] points; P<.001). The intervention group showed significantly improved economy of time and motion (P=.004), needed significantly less help (P<.001), and was more confident in handling of instruments (P<.001) than the control group.

CONCLUSIONS

The results from this study show that serious games are a valid and effective tool in education of operative performance in chest tube insertion. We believe that serious games should be implemented in the surgical curriculum, as well as residency programs, in addition to traditional learning methods.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00009994; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00009994 (Archived by Webcite at http://www.webcitation.org/6ytWF1CWg).

2D vs. 3D imaging in laparoscopic surgery-results of a prospective randomized trial

PURPOSE

3D imaging is an upcoming technology in laparoscopic surgery, and recent studies have shown that the modern 3D technique is superior in an experimental setting. However, the first randomized controlled clinical trial in this context dates back to 1998 and showed no significant difference between 2D and 3D visualization using the first 3D generation technique, which is now more than 15 years old.

METHODS

Positive results measured in an experimental setting considering 3D imaging on surgical performance led us to initiate a randomized controlled pragmatic clinical trial to validate our findings in daily clinical routine. Standard laparoscopic operations (cholecystectomy, appendectomy) were preoperatively randomized to a 2D or 3D imaging system. We used a surgical comfort scale (Likert scale) and the Raw NASA Workload TLX for the subjective assessment of 2D and 3D imaging; the duration of surgery was also measured.

RESULTS

The results of 3D imaging were statistically significant better than 2D imaging concerning the parameters "own felt safety" and "task efficiency"; the difficulty level of the procedures in the 2D and 3D groups did not differ. Overall, the Raw NASA Workload TLX showed no significance between the groups.

CONCLUSION

3D imaging could be a possible advantage in laparoscopic surgery. The results of our clinical trial show increased personal felt safety and efficiency of the surgeon using a 3D imaging system. Overall of the procedures, the findings assessed using Likert scales in terms of own felt safety and task efficiency were statistically significant for 3D imaging. The individually perceived workload assessed with the Raw NASA TLX shows no difference. Although these findings are subjective impressions of the performing surgeons without a clear benefit for 3D technology in clinical outcome, we think that these results show the capability that 3D laparoscopy can have a positive impact while performing laparoscopic procedures.

Impact of visual-spatial ability on laparoscopic camera navigation training

BACKGROUND

Technical limitations of minimally invasive surgery challenge both surgeons and camera assistants. Current research indicates that visual-spatial ability (VSA) has impact on learning of laparoscopic camera navigation (LCN). However, it remains unclear if complexity of LCN tasks influences the impact of VSA. The aim of this study was to examine the influence of VSA on LCN training within tasks of different complexity levels.

METHODS

The present study was conducted as a monocentric prospective trial. VSA was assessed with a cube comparison test before participants underwent LCN training. LCN training consisted of three tasks with increasing complexity. Each task was performed four times and performance was assessed each time. Correlations and multivariate regression analysis were used to assess the influence of VSA on LCN skills.

RESULTS

Seventy-one participants were included (35 males). Significant performance improvement and faster completion times were observed from the first to fourth trial of all three LCN training tasks. Significant positive correlations between VSA and performance on LCN task 3 were found (performance: r _s = 0.47; p < 0.001, time: r _s = -0.43; p < 0.001). Multivariate regression revealed that higher VSA resulted in greater reduction of time between the first trials of LCN training task 3 (B = -1.67, p = 0.031).

CONCLUSION

In the present study, all trainees improved LCN performance during the training. VSA seems to have impact on LCN performance and training progress particularly for complex LCN tasks. The relation of VSA and LCN performance was stronger for less experienced participants and in the beginning of the learning phase.

Study protocol for a randomized controlled trial on a multimodal training curriculum for laparoscopic cholecystectomy - LapTrain

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The first structured multi-modality laparoscopy training curriculum.

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Assessing the value of a multimodal training platform in medical education.

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Optimizing efficiency of facilities and courses in laparoscopic surgical training.

Background

Although minimally invasive surgery (MIS) has replaced many open procedures in visceral surgery, technical and psychomotor obstacles remain a constant challenge for surgeons and trainees. However, there are various training curricula enabling surgeons to acquire the visuospatial and psychomotor abilities additionally required when performing MIS. Currently accepted training modalities include box-trainers, organ and animal models as well as completely simulated training environments, realized in virtual reality (VR) trainers. All of these methods facilitate an adequate training prior to patient contact, so patient safety can benefit as well. This study aims to evaluate the benefit of a structured multi-modality laparoscopy training curriculum.

Methods

Junior and senior surgical residents are included (n = 60). Groups are stratified with concern to previous experience and training of participants. The training curriculum consists of a standardized sequence of available modalities and exercises on box- and VR-trainers. Specific consideration applies to the training effect during the repeated performance of a laparoscopic cholecystectomy (LC) between intervention (training in between LCs) and control group (no training in between LCs). Analysis of training effects is performed using a cadaveric model for LC and objectified using the validated scoring system Global Operative Assessment of Laparoscopic Skills (GOALS).

Discussion

This study assesses the value of a multimodal training platform in medical education and postgraduate training and aims at illustrating possible guidelines when establishing such a curriculum. Possible factors of influence, such as varying backgrounds, learning motivation and –success among participants are explored in the data analysis and add beneficially to further evaluating the efficacy of such training to more heterogeneous participant groups like medical students and other professionals.

Does rating the operation videos with a checklist score improve the effect of E-learning for bariatric surgical training? Study protocol for a randomized controlled trial

BACKGROUND

Laparoscopic training has become an important part of surgical education. Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed. Surgeons must be well trained prior to operating on a patient. Multimodality training is vital for bariatric surgery. E-learning with videos is a standard approach for training. The present study investigates whether scoring the operation videos with performance checklists improves learning effects and transfer to a simulated operation.

METHODS/DESIGN

This is a monocentric, two-arm, randomized controlled trial. The trainees are medical students from the University of Heidelberg in their clinical years with no prior laparoscopic experience. After a laparoscopic basic virtual reality (VR) training, 80 students are randomized into one of two arms in a 1:1 ratio to the checklist group (group A) and control group without a checklist (group B). After all students are given an introduction of the training center, VR trainer and laparoscopic instruments, they start with E-learning while watching explanations and videos of RYGB. Only group A will perform ratings with a modified Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale checklist for all videos watched. Group B watches the same videos without rating. Both groups will then perform an RYGB in the VR trainer as a primary endpoint and small bowel suturing as an additional test in the box trainer for evaluation.

DISCUSSION

This study aims to assess if E-learning and rating bariatric surgical videos with a modified BOSATS checklist will improve the learning curve for medical students in an RYGB VR performance. This study may help in future laparoscopic and bariatric training courses.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00010493 . Registered on 20 May 2016.

Learning from the surgeon's real perspective - First-person view versus laparoscopic view in e-learning for training of surgical skills? Study protocol for a randomized controlled trial

Background

Surgical proficiency is highly dependent on continuous and efficient training. However, efficacy of training hinges on questions such as accessibility and how intuitively the training can be translated into reality. Minimally invasive surgery (MIS) in particular relies on adequate training modalities in order to compensate for its additional psychomotor and visuospatial challenges. The increasing demand for MIS procedures longs for further enhancement of training and steep learning curves. We are investigating a nouveau training concept that continuously utilizes the first person view as addendum to laparoscopic view. We hypothesize this approach to be more intuitive thus faster and more naturally to apprehend than a laparoscopic view only and aim to establish a new standard to implement into training curricula.

Methods and analysis

The present study is conducted as a monocentric, two-arm randomized trial. Participants undergo a training curriculum in laparoscopic suturing and knot tying, using e-learning video material with either the first-person perspective of the surgeon or the laparoscopic view only. Primary endpoint is the total training time needed to reach a predefined proficiency level. Participants are evaluated by blinded raters using validated checklists. Number of attempts, procedure and knot quality subscore difference as well as metric parameter analysis from the first and last knots analyzed as secondary endpoints. Furthermore, trainees are assessed with regard to surgical background, basic skills level and spatial awareness. A total sample size of 80 participants for the analysis of the primary endpoint was determined, which will be performed as a two-sided t-test.

Ethics and dissemination

Ethical approval was obtained from the Ethics Committee of the Medical Faculty at Heidelberg University (Code S-334/2011). This trial was registered with the German Clinical Trials Register (DRKS) in Freiburg, Germany, on May 6th (DRKS00009997). The results will be published and presented at appropriate conferences.

Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship

Since the first laparoscopic procedure, there has been an steady increase in advanced minimally invasive surgery. These procedures include oncological colorectal, hepatobiliary and upper gastrointestinal surgery. Implementation of these procedures requires different and new skills for the surgeons who wish to perform these procedures. To accomplish this surgical teaching program, a mentorship seems the most ideal method to teach the apprentice surgeon these specific skills.

At the VU medical center a teaching program for a minimally-invasive esophagectomy for esophageal cancer started in 2009. At first it started in different centers in the Netherlands and later on we also started mentoring other institutes throughout Europe, Latin America and India.

In this article we describe our experience and the outcomes of this mentorship in advanced minimally invasive surgery.

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Not all residency programs include a teaching program with the guidance of dedicated mentors.

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Teaching minimally invasive surgery requires a mentor.

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A dedicated team should be set up for learning new minimally invasive techniques.