Off-site training of laparoscopic skills, a scoping review using a thematic analysis

Comparison of distance versus in-person laparoscopy training using a low-cost laparoscopy simulator-a randomized controlled multi-center trial

INTRODUCTION

Simulation training programs are essential for novice surgeons to acquire basic experience to master laparoscopic skills. However, current state-of-the-art laparoscopy simulators are still expensive, limiting the accessibility to practical training lessons. Furthermore, training is time intensive and requires extensive spatial capacity, limiting its availability to surgeons. New laparoscopic simulators offer a cost-effective alternative, which can be used to train in a digital environment, allowing flexible, digital and personalized laparoscopic training. This study investigates if training on low-cost simulators in a digital environment is comparable to in-person training formats.

MATERIALS AND METHODS

From June 2023 to December 2023, 40 laparoscopic novices participated in this multi-center, prospective randomized controlled trial. All participants were randomized to either the ‟distance" (intervention) or the "in-person" (control) group. They were trained in a standardized laparoscopic training curriculum to reach a predefined level of proficiency. After completing the curriculum, participants performed four different laparoscopic tasks on the ForceSense system. Primary endpoints were overall task errors, the overall time for completion of the tasks, and force parameters.

RESULTS

In total, 40 laparoscopic novices completed digital or in-person training. Digital training showed no significant differences in developing basic laparoscopic skills compared to in-person training. There were no significant differences in median overall errors between both training groups for all exercises combined (intervention 3 vs. control 4; p value = 0.74). In contrast, the overall task completion time was significantly lower for the group trained digitally (intervention 827.92 s vs. control 993.42; p value = 0.015). The applied forces during the final assessment showed no significant differences between both groups for all exercises. Overall, over 90% of the participants rated the training as good or very good.

CONCLUSION

Our study shows that students that underwent digital laparoscopic training completed tasks with a similar number of errors but in a shorter time than students that underwent in-person training. Nevertheless, the best strategies to implement such digital training options need to be evaluated further to support surgeons' personal preferences and expectations.

Evaluation of the benefit of indocyanine green as an educational and practical tool for ureteral identification in laparoscopic pelvic surgery: a cross-sectional study

BACKGROUND

Indocyanine green (ICG) is a visible near-infrared fluorescent dye. Several studies have reported its benefit in identifying important anatomical structures, tissue vascularization, and sentinel lymph nodes in the case of tumors. Studies have shown that ICG is critical and safe in gynecologic surgeries. However, research on how ICG dye can help surgeons in laparoscopic surgeries correctly identify the course of the ureter has yet to be further investigated.

METHOD

This cross-sectional study enrolled 62 gynecology attending and resident surgeons who were asked to identify the course of the ureter on images of laparoscopic surgeries. The results were then compared with images in which ICG dye highlighted the course of the ureter. The purpose of this study was to detect the ability of surgical assistants and residents to adequately identify the course of the ureter in laparoscopic pelvic surgeries.

RESULTS

No statistically significant differences were found in terms of year of residency, years of experience, number of laparoscopic procedures attended, and correct identification of ureter course. ICG proved useful in identifying the correct ureteral trajectory.

CONCLUSIONS

ICG can be a valuable tool to improve the correct identification of ureters and improve surgical outcomes.

Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition

OBJECTIVE

Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback.

DESIGN

We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis.

SETTING

We performed this study at a single tertiary academic institution: the University of California, San Francisco.

PARTICIPANTS

We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment.

RESULTS

Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment.

CONCLUSIONS

We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.

Measuring Small Bowel Length in Bariatric Surgery: An Ex Vivo Laparoscopic Training Experiment

INTRODUCTION

Determining limb length in gastric bypass procedures is a crucial step to ensure significant weight loss without risking malnutrition. This study investigated the effect of ex vivo training on the skills needed to determine limb lengths.

MATERIALS AND METHODS

This was a single-center ex vivo training experiment in a teaching hospital in the Netherlands. We designed a training exercise with marked ropes in a laparoscopic trainer box. All ten surgical residents participated and practiced the skill of estimating limb length. Before and after the two-week period their results on a 150-centimeter limb length task were evaluated.

RESULTS

Before training, 10 surgical residents estimated 150 centimeters of small bowel with an absolute deviation of 21% [range 9-30]. After the training experiment, the residents measured with 8% [2-20] deviation (P = .17). The 8 residents who trained sufficiently improved statistically significantly to an absolute deviation of 5% [2-17] (P = .012). Over 70% of the participants felt their skills had improved.

CONCLUSIONS

With sufficient training, surgical residents' skills in measuring small bowel length improved when tested in an ex vivo model. Residents became more confident in their laparoscopic measurement skills. This ex vivo training model is a alternative and addition to on-site training.

An At-Home Laparoscopic Curriculum for Junior Residents in Surgery, Obstetrics/Gynecology, and Urology

Introduction

Laparoscopic surgery requires significant training, and prior studies have shown that surgical residents lack key laparoscopic skills. Many educators have implemented simulation curricula to improve laparoscopic training. Given limited time for dedicated, in-person simulation center practice, at-home training has emerged as a possible mechanism by which to expand training and promote practice. There remains a gap in published at-home laparoscopic curricula employing embedded feedback mechanisms.

Methods

We developed a nine-task at-home laparoscopic curriculum and an end-of-curriculum assessment following Kern's six-step approach. We implemented the curriculum over 4 months with first- to third-year residents.

Results

Of 47 invited residents from general surgery, obstetrics/gynecology, and urology, 37 (79%) participated in the at-home curriculum, and 25 (53%) participated in the end-of-curriculum assessment. Residents who participated in the at-home curriculum completed a median of six of nine tasks (interquartile range: 3-8). Twenty-two residents (47%) responded to a postcurriculum survey. Of these, 19 (86%) reported that their laparoscopic skills improved through completion of the curriculum, and the same 19 (86%) felt that the curriculum should be continued for future residents. Residents who completed more at-home curriculum tasks scored higher on the end-of-curriculum assessment (p = .009 with adjusted R 2 of .28) and performed assessment tasks in less time (p = .004 with adjusted R 2 of .28).

Discussion

This learner-centered laparoscopic curriculum provides guiding examples, spaced practice, feedback, and graduated skill development to enable junior residents to improve their laparoscopic skills in a low-stakes, at-home environment.

There is a need for a paradigm shift in laparoscopic surgical training: results of a nationwide survey among teaching hospitals in Switzerland

BACKGROUND

Surgical training curricula have changed little over the past decades. Current advances in surgical techniques, especially in minimally invasive surgery, as well as the rapidly changing socioeconomic environment pose a major challenge for the training of young surgeons. The aim of this survey was to provide a representative overview of the surgical training landscape in Switzerland focusing on laparoscopic surgical training: How do department chairs of teaching hospitals deal with the above challenges, and what should a future training curriculum look like?

METHODS

This is a prospective, questionnaire-based, cross-sectional study among the heads of departments of all certified surgical teaching hospitals in Switzerland.

RESULTS

The overall response rate was 56% (48/86) and 86% (19/22) for tertiary centers. Two-thirds of the centers (32) organize themselves in training networks. Laparoscopic training courses are offered in 25 (52%) hospitals, mainly in tertiary centers. Self-training opportunities exist in 40 (83%) hospitals. In addition to commercial (27) and self-built (7) box trainers, high-fidelity trainers are available in 16 (33%) hospitals. A mandatory training curriculum exists in 7 (15%) facilities, and a training assessment is performed in 15 (31%) institutions. Thirty-two (65%) heads of departments indicated that residents have sufficient practical exposure in the operating room, but the ability to work independently with obtaining the specialist title is seen critically (71%). They state that the surgical catalog does not adequately reflect the manual skills of the resident (64%). The desire is for training to be restructured from a numbers-based to a performance-based curriculum (53%) and for tools to assess residents' manual skills (56%) to be introduced.

CONCLUSIONS

Department chairs stated that the existing curriculum in Switzerland does not meet the requirements of a modern training curriculum. This study highlights the need to create an improved, competency-based curriculum that ensures the training of a new generation of surgeons, taking into account the growing evidence of the effectiveness of state-of-the-art training modalities such as simulation or proficiency-based training.

Conception and prospective multicentric validation of a Robotic Surgery Training Curriculum (RoSTraC) for surgical residents: from simulation via laboratory training to integration into the operation room

There is a lack of training curricula and educational concepts for robotic-assisted surgery (RAS). It remains unclear how surgical residents can be trained in this new technology and how robotics can be integrated into surgical residency training. The conception of a training curriculum for RAS addressing surgical residents resulted in a three-step training curriculum including multimodal learning contents: basics and simulation training of RAS (step 1), laboratory training on the institutional robotic system (step 2) and structured on-patient training in the operating room (step 3). For all three steps, learning content and video tutorials are provided via cloud-based access to allow self-contained training of the trainees. A prospective multicentric validation study was conducted including seven surgical residents. Transferability of acquired skills to a RAS procedure were analyzed using the GEARS score. All participants successfully completed RoSTraC within 1 year. Transferability of acquired RAS skills could be demonstrated using a RAS gastroenterostomy on a synthetic biological organ model. GEARS scores concerning this procedure improved significantly after completion of RoSTraC (17.1 (±5.8) vs. 23.1 (±4.9), p < 0.001). In step 3 of RoSTraC, all participants performed a median of 12 (range 5-21) RAS procedures on the console in the operation room. RoSTraC provides a highly standardized and comprehensive training curriculum for RAS for surgical residents. We could demonstrate that participating surgical residents acquired fundamental and advanced RAS skills. Finally, we could confirm that all surgical residents were successfully and safely embedded into the local RAS team.

Virtual fundamentals of laparoscopic surgery (FLS) boot-camp using telesimulation: an educational solution during the covid-19 pandemic

BACKGROUND

The Fundamentals of Laparoscopic Surgery (FLS) is an internationally recognized educational and certification program designed to teach the knowledge and skills required for basic laparoscopic surgery. Previously, our institution has organized an FLS boot-camp to teach PGY1 residents the FLS manual skills. During the COVID-19 pandemic, in-person sessions were not possible. The purpose of this study was to utilize telesimulation as an education solution for teaching FLS technical skills to PGY1 residents during the COVID-19 pandemic.

METHODS

A virtual FLS program was established. A complete, easily portable FLS kit was distributed to participants and instructors to set up an FLS box and connect remotely using telesimulation. The program was delivered by three senior residents using the Zoom™ platform. Participants were split into groups of 3-4 individuals, each receiving three 1-h sessions. Sessions were structured with initial demonstration of tasks followed by individual coaching of participants in 'break-out' rooms. The official FLS exam was administered in-person on the 4th week. Pre- and post-course surveys were administered to participants gauging self-reported proficiency with FLS tasks and overall course feedback. Anonymized FLS exam results were collected.

RESULTS

A total of 14 residents participated, and 11 responded to the survey. Participants reported that their overall FLS skills proficiency significantly improved on a 5-point likert scale from 1.5 ± 0.5 pre-course to 4.0 ± 0.5 post-course (mean ± SD). Participants unanimously stated that having the FLS box at home was valuable and enabled them to practice more. On the FLS exam, 13 of 14 participants passed the manual skills component.

CONCLUSIONS

We developed a telesimulation hands-on FLS course as an alternative to in-person training. The course was practical and effective and was preferred to traditional methods by participants. With ever-expanding technological solutions, virtual telesimulation education is an attractive and underutilized tool, not only in the setting of COVID-19, but also more broadly across current educational programs.

Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students

Background

Postpartum hemorrhage (PPH) is an obstetric emergency, and training of health-care providers for early diagnosis and intervention improves morbidity and mortality. Regular simulation-based training modules are conducted in our institute for health-care providers. The objective of this study was to assess the final-year medical students on their subjective improvement in the management of PPH after an off-site simulation-based training which was conducted after a conventional lecture.

Methods

A survey was administered on medical students and their subjective retrospective analysis of both pre and post off-site simulation was collected. The survey was analyzed, and results were formulated.

Results

Forty-six students completed the survey. Although students felt their confidence level in enumerating the steps in management of PPH less than 50% before the drill, it increased to 70% after the drill. The confidence of the students in carrying out the procedures of PPH also increased. The results showed a considerable subjective improvement in skill and cognitive enhancement after an off-site simulation-based training. There was a significant improvement in the pre and postsimulation training scores in the test. The faculty felt that there was an enhancement in learning after the simulation training.

Conclusion

Off-site simulation of an emergency condition improves both knowledge and skill in students.

Scotland's "Incentivised Laparoscopy Practice" programme: Engaging trainees with take-home laparoscopy simulation

BACKGROUND

The transfer validity of portable laparoscopy simulation is well established. However, attempts to integrate take-home simulation into surgical training have met with inconsistent engagement worldwide, as for example in our 2014-15 study of an Incentivised Laparoscopy Practice programme (ILPv1). Drawing on learning from our subsequent multi-centre study examining barriers and facilitators, we revised the programme for 2018 onwards. We now report on engagement with the 2018-2022 versions of this home-based simulation programme (ILP v2.1-2.3).

METHODS

In ILP v2.1-2.3, three consecutive year-groups of new-start Core Surgical Trainees (n = 48, 46 and 53) were loaned portable simulators. The 6-month education programme included induction, technical support, and intermittent feedback. Six tasks were prescribed, with video instruction and charting of metric scores. Video uploads were required and scored by faculty. A pass resulted in an eCertificate, expected at Annual Review (but not mandatory for progression). ILP was set within a wider reform, "Improving Surgical Training".

RESULTS

ILP v2.1-2.3 saw pass rates of 94%, 76% and 70% respectively (45/48, 35/46 and 37/53 trainees), compared with only 26% (7/27) in ILP v1, despite now including some trainees not intending careers in laparoscopic specialties. The ILP v2.2 group all reported their engagement with the whole simulation strategy was hampered by the COVID19 pandemic.

CONCLUSIONS

Simply providing take-home simulators, no matter how good, is not enough. To achieve trainee engagement, a whole programme is required, with motivated learners, individual and group practice, intermittent feedback, and clear goals and assessments. ILP is a complex intervention, best understood as a "reform within a reform, within a context."

The Challenges of Dyad Practice in Simulation Training of Basic Open Surgical Skills-A Mixed-Method Study

INTRODUCTION

Simulation training at home improves access to training, but motivation can be difficult to maintain. Dyad training could keep trainees motivated. This study aimed to examine the effect of self-regulated training of basic surgical skills in pairs versus individually.

METHODS

One hundred one medical doctors were included in this prospective, mixed-method, simulation-based study. Participants were randomized to train individually or in pairs during a 6-week course in open surgical skills, consisting of didactic instructions and self-directed training at home. Trainees kept a training log and filled in a questionnaire. Skills were tested before and after the course. Tests were rated by an expert using the Objective Structured Assessment of Technical Skills Global Rating Scale.

RESULTS

Ninety-seven doctors completed the study. We found no differences in test score between dyad and individual trainees. Dyad trainees compared with individual trainees improved by 7.23 points (intercept estimate) versus 6.94 points, respectively (P = 0.881). Dyad trainees trained less frequently [7.3 times (intercept estimate) vs. 12.1 times, P < 0.001, but for longer intervals compared with individual trainees (68 minutes vs. 38 minutes)]. Dyad trainees reported benefits such as having a sparring partner, receiving feedback, corrections, increased motivation, having fun, and more structured training sessions. However, the coordination of training sessions was difficult.

CONCLUSIONS

No differences were found between dyad trainees and individual trainees in improvement of surgical skills. Off-site dyad training led to fewer, but longer training sessions, which may have negatively impacted the effectiveness of training. Dyad trainees perceived dyad training beneficial.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study

Background

Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR).

Methods

In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2–3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points.

Results

Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training.

Conclusion

The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

Remote training in laparoscopy: a randomized trial comparing home-based self-regulated training to centralized instructor-regulated training

Background

Simulation-based surgical training (SBST) is key to securing future surgical expertise. Proficiency-based training (PBT) in laparoscopy has shown promising results on skills transfer. However, time constraints and limited possibilities for distributed training constitute barriers to effective PBT. Home-based training may provide a solution to these barriers and may be a feasible alternative to centralized training in times of assembly constraints.

Methods

We randomly assigned first-year trainees in abdominal surgery, gynecology, and urology to either centralized instructor-regulated training (CIRT) or home-based self-regulated training (HSRT) in laparoscopy. All participants trained on portable box trainers providing feedback on metrics and possibility for video reviewing. Training in both groups was structured as PBT with graded proficiency exercises adopted from the Fundamentals of Laparoscopic Surgery (FLS). The HSRT group trained at home guided by online learning materials, while the CIRT group attended two training sessions in the simulation center with feedback from experienced instructors. Performance tests consisted of hand–eye and bimanual coordination, suture and knot-tying, and FLS exercises. We analyzed passing rates, training time and distribution, and test performances.

Results

Passing rates were 87% and 96% in the CIRT and HSRT group, respectively. HSRT facilitated distributed training and resulted in greater variation in training times. Task times for hand–eye and bimanual coordination were significantly reduced between pretest and posttest in both groups. Trainees maintained their posttest performances at the 6-month retention test. Our analyses revealed no significant inter-group differences in performances at pretest, posttest, or retention test. Performance improvements in the two groups followed similar patterns.

Conclusion

CIRT and HSRT in laparoscopy result in comparable performance improvements. HSRT in laparoscopy is a feasible and effective alternative to CIRT when offered inside a supportive instructional design. Further research is needed to clarify trainees’ preferences and explore facilitators and barriers to HSRT.

Simulation design and students' satisfaction with home-based simulation learning in oral health therapy

OBJECTIVES

The COVID-19 pandemic presents a challenging situation for dental education, with school closures worldwide. While practical sessions are important for the acquisition of clinical skills, few studies have examined the role of home-based simulation learning (HBSL). This study aims to identify key aspects of simulation design and factors associated with students' satisfaction with HBSL.

METHODS

During a "circuit-breaker" period in Singapore, the Nanyang Polytechnic School of Health & Social Sciences (Oral Health Therapy) distributed portable manikins and instruments to students and staff for use at home. Synchronous teaching sessions with real-time feedback were carried out over the Zoom teleconferencing platform. A cross-sectional survey of students was conducted after 3 weeks of the HBSL program. Multiple linear regression analyses were carried out to assess the association between satisfaction with domains of simulation design and overall satisfaction with HBSL.

RESULTS

The top three factors of importance to students in HBSL were feedback and guided reflection, support, and objectives and information. Final-year students expressed higher levels of overall satisfaction and self-confidence following HBSL than first-year students. Satisfaction with the objectives (β = 0.42, 95% CI 0.26-0.57), support (β = 0.27, 95% CI 0.11-0.42), and problem-solving (β = 0.28, 95% CI 0.10-0.46) domains in the Simulation Design Scale were positively associated with overall student satisfaction and self-confidence in learning.

CONCLUSION

The findings can aid educators in the design of future HBSL programs, with a focus on areas of simulation design that are of importance to students.

Identifying technical skills and clinical procedures in surgery for a simulation-based curriculum: a national general needs assessment

BACKGROUND

The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery.

METHODS

A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study.

RESULTS

Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list.

CONCLUSION

Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

The Implementation Gap in Laparoscopic Simulation Training

BACKGROUND AND AIMS

Simulation-based training in laparoscopy can improve patient safety and efficiency of care, but it depends on how it is used. Research in medical education has moved from demonstrating transferability of simulation training to the operating room to how to best implement it. This study aims to investigate how simulation-based training in laparoscopy has been implemented Scandinavia.

MATERIAL AND METHODS

An online survey was sent out to medical doctors at surgical, gynecological, and urological departments at 138 hospitals in Denmark, Norway, and Sweden. The questionnaire included questions on respondents' baseline characteristics, opinions, access, and actual use of simulation-based training in laparoscopy.

RESULTS

In total, 738 respondents completed the survey. Of these, 636 (86.2%) of respondents agreed or strongly agreed that simulation-based training in laparoscopy should be mandatory. A total of 602 (81.6%) had access to simulation-based training in laparoscopy. Of the total 738 respondents, 141 (19.1%) were offered structured training courses, 129 (17.5%) were required to reach a predefined level of competency, and 66 (8.9%) had mandatory courses in laparoscopy. In all, 72 (9.8%) had never used simulation-based training in laparoscopy.

CONCLUSION

An implementation gap in laparoscopic simulation-based training still exists in Scandinavia. Simulation equipment is generally available, but there is a lack of structured simulation-based training.

Trauma laparoscopy: A prospect of skills training (cohort study)

BACKGROUND

Diagnostic laparoscopy is well-accepted in management of penetrating abdominal trauma (PAT) with the rate of missed injuries below 1%. However, there is a reluctance to accept therapeutic laparoscopy in trauma society. The possible reason is a lack of laparoscopic skills by trauma surgeons. Moreover, no formal laparoscopy training program for trauma exists. The aim of this study was to interrogated our laparoscopy training particularly in trauma setting, and to investigate a possible relation between the seniority of surgeons performing the procedures and the complication rates.

METHODS

All patients managed laparoscopically for PAT from January 2012 to December 2015 were analyzed. The seniority of operating surgeon was correlated with adverse outcomes, and with conversion. Surgeon-consultant (SC), assistant-consultant (AC), surgeon-senior-resident (SSR) and surgeon-junior-resident (SJC) groups were identified. Laparoscopic maneuvers used in this cohort were investigated and the set of essential laparoscopic skills was identified. The laparoscopic training program at our institution was described and discussed.

RESULTS

Out of 283 patients with PAT approached with laparoscopy 33 (11.7%) were converted to laparotomy. Majority (49.6%) of laparoscopy was performed by senior resident. Consultant was an operating surgeon in 21.2% and an assistant in 8% of cases. Consultant was involved in cases with higher severity of injury and the complication rate was higher in the SC and AC groups. Essential laparoscopic skills were camera navigation, mobilization of intraabdominal organs, bowel run and intracorporeal suturing. During training, a senior resident was involved in 19% of operations for trauma. Trauma constituted 16% of all laparoscopy.

CONCLUSION

Laparoscopy for trauma can be safely performed by residents under appropriate supervision. Laparoscopic skills should preferably be obtained during elective non-trauma procedures and transferred to trauma setting. Multimodal goal-directed, proctored training with regular assessments and feedback is effective and skills are transferable to trauma setting.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers

BACKGROUND

Lack of time and access to equipment are recognised barriers to simulation training.

AIM

To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees.

METHOD

Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy).

RESULTS

Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation.

CONCLUSION

A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

A randomized control trial to evaluate the importance of pre-training basic laparoscopic psychomotor skills upon the learning curve of laparoscopic intra-corporeal knot tying

Background

Training of basic laparoscopic psychomotor skills improves the acquisition of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial was designed to evaluate whether pre-training of basic skills, as laparoscopic camera navigation (LCN), hand-eye coordination (HEC), and bimanual coordination (BMC), and the combination of the three of them, has any beneficial effect upon the learning curve of LICK. The study was carried out in a private center in Asunción, Paraguay, by 80 medical students without any experience in surgery. Four laparoscopic tasks were performed in the ENCILAP model (LCN, HEC, BMC, and LICK). Participants were allocated to 5 groups (G1-G5). The study was structured in 5 phases. In phase 1, they underwent a base-line test (T₁) for all tasks (1 repetition of each task in consecutive order). In phase 2, participants underwent different training programs (30 consecutive repetitions) for basic tasks according to the group they belong to (G1: none; G2: LCN; G3: HEC; G4: BMC; and G5: LCN, HEC, and BMC). In phase 3, they were tested again (T₂) in the same manner than at T₁. In phase 4, they underwent a standardized training program for LICK (30 consecutive repetitions). In phase 5, they were tested again (T₃) in the same manner than at T₁ and T₂. At each repetition, scoring was based on the time taken for task completion system.

Results

The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). The LICK group learning curves fitted better to the two-phase exponential decay model. From these curves, the starting points (Y0), the point after HEC training/before LICK training (Y1), the Plateau, and the rate constants (K) were calculated. All groups, except for G4, started from a similar point (Y0). At Y1, G5 scored already better than the others (G1 p = .004; G2 p = .04; G3 p < .0001; G4 NS). Although all groups reached a similar Plateau, G5 has a quicker learning than the others, demonstrated by a higher K (G1 p < 0.0001; G2 p < 0.0001; G3 p < 0.0001; and G4 p < 0.0001).

Conclusions

Our data confirms that training improves laparoscopic skills and demonstrates that pre-training of all basic skills (i.e., LCN, HEC, and BMC) shortens the LICK learning curve.