Take-home training in a simulation-based laparoscopy course

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.

RoboticSurgery4all: are discovery courses important for robotic surgery skills acquisition?

Cost, logistics, and availability of robotic simulation opportunities suppose a real challenge for robotic surgery training. We aimed to test a new methodology for introduction to robotic surgery pre-congress courses. Two different "introduction to robotic surgery" pre-congress courses were developed. A new methodology using a sleeve/bypass, a ventral TAPP and an inguinal TAPP silicone models was implemented. After the session, the trainees answered a questionnaire to evaluate the course and the methodology using 1-5 Likert scales. A total of 21 participants participated in the courses and (72.2%) had no experience in robotic surgery. All trainees rated the course as good or excellent. There was a strong agreement between participants regarding the adequacy of the silicone models for this type of simulation/course. Trainees agree that the course gave them more confidence to perform a real robotic procedure, increased their interest in robotic surgery and made them feel ready to start their robotic surgery pathway. Congresses are a frequent way of contact between surgeons and robotic systems, mostly in the form of technical demonstrations or pre-congress courses. Our methodology showed that it is possible to allow for this contact in a low-cost way. This kind of courses is well received by congress delegates and have a positive educational impact. Despite of being "Discovery" courses, they have a positive impact on the congress, on the acquisition of robotic surgery skills and increase the interest in robotic surgery.

A Study of Surgical Residents' Self-Assessment of Open Surgery Skills Using Gap Analysis

BACKGROUND

Surgical residents need structured and objective feedback to develop their skills and become capable of performing surgical procedures autonomously. A shortage of experienced surgical staff has prompted residents to seek feedback from self-assessment and peer assessments.

OBJECTIVES

We investigated whether surgical residents can reliably rate their own and their peers' basic surgical skills using the Global Rating Scale (GRS) from the Objective Structured Assessment of Technical Skills.

METHODS

The study was a prospective and descriptive study conducted using gap analysis at the Copenhagen Academy for Medical Education and Simulation (Copenhagen, Denmark) from 2016 to 2017. Surgical residents were recruited during a course in basic open surgical skills. Among 102 course participants, 53 met the inclusion criteria and 22 participated in the study.

RESULTS

We recruited surgical residents based in the Capital Region and Zealand Region of Demark, and 42% of eligible residents participated in the study. Surgical residents underestimated their own surgical performance (median, 17 [range, 15-18] vs. 20 [range, 19.75-22]; P < 0.001). They also rated their peers lower than an experienced rater did (median 10 [range, 8.75-14] vs. 15 and median 20.5 [range, 19-22] vs. 23; both P < 0.001). Gap analysis revealed residents had unrecognized strengths (ie, self-underappraisal) in most GRS domains.

CONCLUSIONS

Ratings are unreliable when surgical residents assess their own and their peers' performances using GRS. A gap analysis revealed unrecognized strengths in time and motion, instrument handling, knowledge of instruments and sutures, and knowledge of specific procedure as well as unrecognized weaknesses in flow of operation and forward planning.

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.

Using Self-Rated Examinations to Ensure Competence in Laparoscopy

INTRODUCTION

Asking participants to rate their own performance during unsupervised training in laparoscopy is reliable and may be cost-effective. The objective of the study was to explore the reliability of self-rated examinations where participants rate their own performance and decide themselves when they have passed tasks in basic laparoscopic skills.

METHODS

This prospective observational study was conducted at the Copenhagen Academy for Medical Education and Simulation where simulation-based laparoscopic skill training is offered. Here, participants taking part in a basic laparoscopic skills course were asked to rate their own performance and decide when they had passed the Training and Assessment of Basic Laparoscopic Techniques test. To explore reliability, all examinations were video recorded and rated by a blinded rater after the end of the course.

RESULTS

Thirty-two surgical trainees participated in the course, and 28 completed the study. We found a high reliability when comparing self-rated scores and blinded ratings with an intraclass correlation coefficient of 0.89 ( P < 0.001); self-rated scores compared with blinded ratings were not significantly different (mean = 451 vs. 455, P = 0.28), and the participants did not underestimate nor overestimate their performance.

CONCLUSIONS

Ratings from self-rated examinations in a basic laparoscopic skills course are reliable, and participants neither underestimate nor overestimate their performance. Self-rated examinations may also be beneficial because they also can offer a cost-effective approach to assessment of surgical trainees.

Effectiveness of an inexpensive short-term theoretical-practical course on videosurgery for surgeons in training

BACKGROUND

The rapid development of video surgery and minimally invasive surgical techniques prompted many studies on the methods of teaching these techniques to young surgeons in training. However, the characteristics of a short-term course that is both easily accessible and efficient for this group of surgeons remain controversial. To investigate this issue, a short-term training method was proposed for first year surgery residents, using inexpensive handmade wooden simulation boxes with the students smartphones as cameras. Its effectiveness was evaluated, as well as possible factors that could influence student performance, such as gender and previous experience with video games.

METHODS

Thirty-six first-year General Surgery residents, entering in 2019 and 2020, participated in the study: 21 were males and 15 were females with ages between 22 and 29 years old, (mean 25.47 years). All participants performed a pre-established exercise (placing two simple stitches using a laparoscopic simulator), which was timed and scored. They then participated in a short theoretical-practical course, consisting of an initial lecture followed by 4 exercises on handcrafted wooden laparoscopic video surgery simulators. Afterwards, they were asked to repeat the same exercise from the first step. Finally, they answered a questionnaire that included questions on previous videogame experience. The data were tabulated and submitted to statistical analysis.

RESULTS

In the pre-training exercise, 15 (41.66%) participants were able to perform the two simple stitches in the simulator box within the maximum time limit of 5 minutes. After the short course, 22 (61.11%) of participants were able to perform the complete exercise. Improvement in the time to complete the practical exercise was statistically significant (p = 0.0296) after participating in the theoretical-practical course. A better pre- and post-training performance was demonstrated by the 17 participants with experience with video games (p = 0.0116), and a better post-training performance was demonstrated by female participants (p = 0.0405).

CONCLUSION

This short-term inexpensive theoretical-practical course in laparoscopic training for surgeons in training was effective in reducing the execution time of a laparoscopic stitch in a simulation box. Previous experience with video games and/or female gender appear to be associated with improved performance.

Test-enhanced learning improves learner attendance during a laparoscopic box trainer simulation program

Background

Laparoscopy is the gold standard approach for many surgical procedures, but it is a complex skill to learn. Laparoscopic simulation training may help, but it is unclear how to best engage trainees in these programs. Test‐enhanced learning (TEL) uses regular, well‐defined assessments of performance throughout the training phase of learning.

Aim

The aim of this study was to assess the effects of TEL on a laparoscopic simulation program involving a cohort of medical student volunteers.

Materials and methods

A prospective cohort study was performed with a convenience sample of 40 medical students. Students were recruited to participate in a ten‐week laparoscopic simulation program. Twenty students participated in a laparoscopic surgical program with TEL (‘TEL group’), and 20 students participated in a standard laparoscopic simulation program (‘control group’).

Results

Attendance in the TEL group was significantly higher than in the standard group (71 vs 51.5%, P = 0.03). There was no difference between groups in mean time scores. Four themes were identified in qualitative data drawn from student surveys – personal traits and motivators, training context, clear goals and feedback enabling understanding of one's own performance.

Conclusion

Testing laparoscopic skills throughout a learning program, in conjunction with individualised feedback and tracking of learning trajectory, increases trainee attendance. Laparoscopic simulation training programs are encouraged to reflect on the pedagogic framework in which their procedural skills training operates.

Proctored preceptorship model for learning eTEP repair for inguinal hernia for general surgery residents

BACKGROUND

Enhanced-view total extra-peritoneal (eTEP) inguinal hernia repair is a technically demanding procedure with a steep learning curve.

AIM

Examine the feasibility and effectiveness of an instructor approach to teaching residents how to perform laparoscopic eTEP independently following a dedicated course of individual teaching.

METHODS

Prospective analysis of eTEP procedures performed by residents between March 2018 and September 2020. Six residents dispersed into three groups-Group A: two junior residents, Group B: two mid-level residents and Group C: two senior residents. All residents performed a unilateral IHR comprised of five core steps. Data reviewed for each procedure included the time of each step, total time and autonomy degree as assessment for every step: 1st degree-dependent (physical assistance), 2nd degree-partially dependent (vocal assistance) and 3rd degree-independent. Early and late procedures were divided at 50% of cases.

RESULTS

Participants performed 44 procedures (220 steps). Late procedures presented with a significant improvement in all degrees of autonomy (1st degree p = 0.002, 2nd degree p = 0.007 and 3rd degree p < 0.0001) and in every step (Step 1 p = 0.015, Step 2 p = 0.006, Step 3 p < 0.0001, Step 4 p < 0.0001, Step 5 p = 0.002). There was no significant difference in surgery duration between early and late procedures (p = 0.32). At early procedures, junior residents needed significantly higher rates of physical intervention (1st degree) compared to the senior residents (p = 0.004). Conversely, there was no significant difference in 2nd degree of autonomy (p = 0.46), 3rd degree (p = 0.06) and surgery duration (p = 0.16). The last three procedures performed by all participants had no significant difference between the seniority groups in autonomy (1st degree p = 0.1, 2nd degree p = 0.18 and 3rd degree p = 0.1).

CONCLUSION

Dedicated course with an individual instructor's approach is effective in achieving competence, autonomy and confidence in performing eTEP in a short time.

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.

Virtual reality simulation to enhance laparoscopic salpingectomy skills

BACKGROUND

To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning.

METHODS

A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series.

RESULTS

26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased.

CONCLUSIONS

The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.

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.

Surgical simulation: Current practices and future perspectives for technical skills training

Simulation-based training (SBT) has become a standard component of modern surgical education, yet successful implementation of evidence-based training programs remains challenging. In this narrative review, we use Kern's framework for curriculum development to describe where we are now and what lies ahead for SBT within surgery with a focus on technical skills in operative procedures. Despite principles for optimal SBT (proficiency-based, distributed, and deliberate practice) having been identified, massed training with fixed time intervals or a fixed number of repetitions is still being extensively used, and simulators are generally underutilized. SBT should be part of surgical training curricula, including theoretical, technical, and non-technical skills, and be based on relevant needs assessments. Furthermore, training should follow evidence-based theoretical principles for optimal training, and the effect of training needs to be evaluated using relevant outcomes. There is a larger, still unrealized potential of surgical SBT, which may be realized in the near future as simulator technologies evolve, more evidence-based training programs are implemented, and cost-effectiveness and impact on patient safety is clearly demonstrated.

The laparoscopic inguinal and diaphragmatic defect (LIDD) model: a validation study of a novel box trainer model

BACKGROUND

Paediatric laparoscopic procedures are now becoming routine practice. Therefore, there is a need for simulated laparoscopic models to acquire part-procedural competency prior to direct patient contact in a safe learning environment. For this reason, we chose two paediatric conditions; inguinal hernia (IH) and congenital diaphragmatic hernia (CDH), which were combined to create the laparoscopic inguinal and diaphragmatic defect (LIDD) model. Our aim was to assess this novel surgical simulation model by determining its construct and content validity.

METHODS

A total of 107 participants completed the validation study: volunteer medical students (novices), surgical trainees (intermediate) and consultant surgeons (experts). Basic demographic data were collected. Subjects were shown a pre-recorded video of both exercises. The assessment exercise involved closing both the simulated inguinal or diaphragmatic hernial orifice. The task was assessed using a novel scoring system with a maximum score of 21 for IH model and 15 for the CDH. The content validity was assessed by a 6-point Likert scale of the expert group.

RESULTS

105/107 participants successfully completed the two exercises. Both aspects of the LIDD model revealed a statistical significance between the scores obtained by the three groups of subjects. Experts scored 20.3/21 for the IH and 14.8/15 for the CDH models which significantly higher than medical students (6.3/21 and 5.3/15; p < 0.05 for both) and trainees (11.2/21 and 9.3/15; p < 0.05 for both). Similarly, trainees performed significantly better than medical students in both models (p < 0.05). Therefore, the LIDD model was found to have a good construct validity. It was, however, unable to differentiate between the various levels of trainees in the intermediate group. Content validity from the experts revealed that there was a high score for the potential of both aspects of LIDD (4.8 and 4.8). There was also a high level of functional fidelity for task completion (4.0 and 4.0).

CONCLUSIONS

We have demonstrated both the construct and content validity of the LIDD model for both laparoscopic IH and CDH repair. It was able to successfully differentiate between the expert, trainees and inexperienced laparoscopic surgeons.

Personalized Video Feedback and Repeated Task Practice Improve Laparoscopic Knot-Tying Skills: Two Controlled Trials

PURPOSE

Compare the effect of personalized feedback (PF) vs. task demonstration (TD), both delivered via video, on laparoscopic knot-tying skills and perceived workload; and evaluate the effect of repeated practice.

METHOD

General surgery interns and research fellows completed four repetitions of a simulated laparoscopic knot-tying task at one-month intervals. Midway between repetitions, participants received via e-mail either a TD video (demonstration by an expert) or a PF video (video of their own performance with voiceover from a blinded senior surgeon). Each participant received at least one video per format, with sequence randomly assigned. Outcomes included performance scores and NASA Task Load Index (NASA-TLX) scores. To evaluate the effectiveness of repeated practice, scores from these trainees on a separate delayed retention test were compared against historical controls who did not have scheduled repetitions.

RESULTS

Twenty-one trainees completed the randomized study. Mean change in performance scores was significantly greater for those receiving PF (difference = 23.1 of 150 [95% confidence interval (CI): 0, 46.2], P = .05). Perceived workload was also significantly reduced (difference = -3.0 of 20 [95% CI: -5.8, -0.3], P = .04). Compared with historical controls (N = 93), the 21 with scheduled repeated practice had higher scores on the laparoscopic knot-tying assessment two weeks after the final repetition (difference = 1.5 of 10 [95% CI: 0.2, 2.8], P = .02).

CONCLUSIONS

Personalized video feedback improves trainees' procedural performance and perceived workload compared with a task demonstration video. Brief monthly practice sessions support skill acquisition and retention.