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Awad L, Reed B, Bollen E, Langridge BJ, Jasionowska S, Butler PEM, Ponniah A. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robot Surg 2024; 18:254. [PMID: 38878229 PMCID: PMC11180031 DOI: 10.1007/s11701-024-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/19/2024] [Indexed: 06/19/2024]
Abstract
The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.
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Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK.
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK.
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
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Leijte E, De Blaauw I, Rosman C, Botden SMBI. Transferability of the robot assisted and laparoscopic suturing learning curves. J Robot Surg 2024; 18:56. [PMID: 38280121 PMCID: PMC10821960 DOI: 10.1007/s11701-023-01753-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/11/2023] [Indexed: 01/29/2024]
Abstract
Robot assisted surgery (RAS) is increasingly used, and besides conventional minimally invasive surgery (cMIS) surgeons are challenged to learn an increased array of skills. This study aimed to assess the influence of both learning curves on each other. A prospective randomized crossover study was performed. Participants without cMIS or RAS experience (Groups 1 and 2), and cMIS experienced, (Group 3) were recruited. Three suturing tasks (intracorporal suturing, tilted plane and anastomosis needle transfer) were performed on the EoSim cMIS simulator or RobotiX RAS simulator up to twenty repetitions. Subsequently, Groups 1 and 2 performed the tasks on the other modality. Outcomes were simulator parameters, validated composite and pass/fail scores. In total forty-three participants were recruited. Overall RAS suturing was better in Group 1 (cMIS followed by RAS tasks) and 3 (RAS tasks) versus Group 2 (RAS followed by cMIS tasks) for time (163 s and 157 s versus 193 s p = 0.004, p = 0.001) and composite scores (92/100 and 91/100 versus 89/100 p = 0.008, p = 0.020). The cMIS suturing was better for Group 2 versus 1 (time 287 s versus 349 s p = 0.005, composite score 96/100 versus 94/100 p = 0.002). Significant differences from the RAS suturing pass/fail were reached earlier by Group 3, followed by Groups 1 and 2 (repetition six, nine and twelve). In cMIS suturing Group 2 reached significant differences from the pass/fail earlier than Group 1 (repetition four versus six). Transferability of skills was shown for cMIS and RAS, indicating that suturing experience on cMIS or RAS is beneficial in learning either approach.
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Affiliation(s)
- E Leijte
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein 10 Route 618, 6500HB, Nijmegen, The Netherlands.
- Department of Paediatric Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - I De Blaauw
- Department of Paediatric Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Rosman
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein 10 Route 618, 6500HB, Nijmegen, The Netherlands
| | - S M B I Botden
- Department of Paediatric Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Behera K, McKenna M, Smith L, McKnight G, Horwood J, Davies MM, Torkington J, Ansell J. Transferring laparoscopic skills to robotic-assisted surgery: a systematic review. J Robot Surg 2024; 18:11. [PMID: 38214801 DOI: 10.1007/s11701-023-01757-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/15/2023] [Indexed: 01/13/2024]
Abstract
Robotic-Assisted Surgery (RAS) is experiencing rapid expansion, prompting the integration of robotic technical skills training into surgical education programs. As access to robotic training platforms remains limited, it is important to investigate the transferability of laparoscopic skills to RAS. This could potentially support the inclusion of early years laparoscopic training to mitigate the learning curve associated with robotic surgery. This study aims to assess the transferability of laparoscopic skills to robotic surgery. A systematic search was conducted using the PRISMA checklist to identify relevant articles. PubMed, MEDLINE, Embase, and Cochrane databases were searched, and inclusion and exclusion criteria were applied to collate eligible articles. Included were original articles comparing the performance of comparable tasks on both laparoscopic and robotic platforms written in English. Non-peer reviewed papers, conference abstracts, reviews, and case series were excluded. Seventeen articles met the inclusion criteria. Among these, 10 studies (59%) demonstrated skill transferability from laparoscopic surgery (LS) to robotic surgery (RS); while one study (5.8%) showed no significant transferability. Four studies highlighted the positive impact of prior laparoscopic training on robotic skill, whereas six papers suggested no significant difference between laparoscopic novices and experienced laparoscopists when utilizing a robotic simulator. Five studies evaluated advanced surgical skills such as intracorporeal knot tying and suturing, revealing superior robotic performance among experienced laparoscopists compared to novice learners. Laparoscopic skills appear to be transferrable to robotic surgery, particularly in complex surgical techniques. Robotic simulators demonstrate a significant reduction in the learning curve for surgical novices, albeit to a lesser extent for experienced laparoscopists.
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Affiliation(s)
- Karishma Behera
- NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh, EH1 3EG, UK
| | - Matthew McKenna
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, Wales, UK
| | - Laurie Smith
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, Wales, UK
| | - Gerard McKnight
- Health Education and Improvement Wales (HEIW), Cardiff, Wales, UK
| | - James Horwood
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, Wales, UK
| | - Michael M Davies
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, Wales, UK
| | - Jared Torkington
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, Wales, UK
| | - James Ansell
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, Wales, UK.
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Pietersen PI, Hertz P, Olsen RG, Møller LB, Konge L, Bjerrum F. Transfer of skills between laparoscopic and robot-assisted surgery: a systematic review. Surg Endosc 2023; 37:9030-9042. [PMID: 37875694 DOI: 10.1007/s00464-023-10472-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/17/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Robot-assisted surgery is today well-implemented in many surgical specialties, but requires another skill set than laparoscopy. Most often, robot-assisted surgery is considered add-on to laparoscopic skills but very little is known about the transfer of skills. The aim of the study was to examine to what extent surgical skills are transferable between laparoscopic and robot-assisted surgery. METHODS A systematic search was conducted in three databases (Ovid Medline, Embase, and Web of Science). Studies investigating transfer of skills between laparoscopy and robot-assisted surgery in either a phantom-based, simulation-based, animal model, or clinical setting were eligible for inclusion. Quality assessment was done using the Medical education research study quality instrument and educational New Ottawa Scale. RESULTS Of 15,610 studies identified, 89 studies continued to full-text reading, and 37 studies were included. Four studies were found non-comparable and were left out of the results for the primary outcome. All 33 studies explored transfer from laparoscopy to robot-assisted surgery and 17 found a positive transfer whereas 15 did not. Only 11 studies explored transfer from robot-assisted surgery to laparoscopy, of which only three found a positive transfer. CONCLUSION An almost equal number of publications found a positive transfer and no transfer from laparoscopic to robot-assisted surgery. Fewer studies explored the transfer from robot-assisted surgery to laparoscopy. Very little evidence supports that surgeons trained solely in robot-assisted surgery can perform laparoscopy. This must be considered in future training programs as robot-assisted surgery is expected to become the first-in-line modality for many future surgeons.
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Affiliation(s)
- Pia Iben Pietersen
- Department of Radiology, Odense University Hospital, Kløvervænget 10, Entrance 112, 2nd floor, 5000, Odense C, Denmark.
- Simulation Center (SimC), Odense University Hospital, Odense, Denmark.
| | - Peter Hertz
- Department of Surgery, Hospital Lillebaelt, University of Southern Denmark, Kolding, Denmark
| | - Rikke Groth Olsen
- Copenhagen Prostate Cancer Center, Rigshospitalet, Copenhagen, Denmark
- Center for HR & Education, The Capital Region of Denmark, Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
| | - Louise Birch Møller
- Center for HR & Education, The Capital Region of Denmark, Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
| | - Lars Konge
- Center for HR & Education, The Capital Region of Denmark, Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bjerrum
- Center for HR & Education, The Capital Region of Denmark, Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Hardon SF, Willuth E, Rahimi AM, Lang F, Haney CM, Felinska EA, Kowalewski KF, Müller-Stich BP, van der Peet DL, Daams F, Nickel F, Horeman T. Crossover-effects in technical skills between laparoscopy and robot-assisted surgery. Surg Endosc 2023:10.1007/s00464-023-10045-6. [PMID: 37097456 PMCID: PMC10338573 DOI: 10.1007/s00464-023-10045-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/25/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Robot-assisted surgery is often performed by experienced laparoscopic surgeons. However, this technique requires a different set of technical skills and surgeons are expected to alternate between these approaches. The aim of this study is to investigate the crossover effects when switching between laparoscopic and robot-assisted surgery. METHODS An international multicentre crossover study was conducted. Trainees with distinctly different levels of experience were divided into three groups (novice, intermediate, expert). Each trainee performed six trials of a standardized suturing task using a laparoscopic box trainer and six trials using the da Vinci surgical robot. Both systems were equipped with the ForceSense system, measuring five force-based parameters for objective assessment of tissue handling skills. Statistical comparison was done between the sixth and seventh trial to identify transition effects. Unexpected changes in parameter outcomes after the seventh trial were further investigated. RESULTS A total of 720 trials, performed by 60 participants, were analysed. The expert group increased their tissue handling forces with 46% (maximum impulse 11.5 N/s to 16.8 N/s, p = 0.05), when switching from robot-assisted surgery to laparoscopy. When switching from laparoscopy to robot-assisted surgery, intermediates and experts significantly decreased in motion efficiency (time (sec), resp. 68 vs. 100, p = 0.05, and 44 vs. 84, p = 0.05). Further investigation between the seventh and ninth trial showed that the intermediate group increased their force exertion with 78% (5.1 N vs. 9.1 N, p = 0.04), when switching to robot-assisted surgery. CONCLUSION The crossover effects in technical skills between laparoscopic and robot-assisted surgery are highly depended on the prior experience with laparoscopic surgery. Where experts can alternate between approaches without impairment of technical skills, novices and intermediates should be aware of decay in efficiency of movement and tissue handling skills that could impact patient safety. Therefore, additional simulation training is advised to prevent from undesired events.
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Affiliation(s)
- Sem F Hardon
- Department of Surgery, Amsterdam UMC - VU University Medical Center, ZH 7F 005 De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
| | - E Willuth
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - A Masie Rahimi
- Department of Surgery, Amsterdam UMC - VU University Medical Center, ZH 7F 005 De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Skills Centre for Health Sciences, Amsterdam, The Netherlands
| | - F Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Caelan M Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Eleni A Felinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Karl-Friedrich Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC - VU University Medical Center, ZH 7F 005 De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC - VU University Medical Center, ZH 7F 005 De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - F Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Tim Horeman
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Transfer of open and laparoscopic skills to robotic surgery: a systematic review. J Robot Surg 2022:10.1007/s11701-022-01492-9. [PMID: 36418717 PMCID: PMC10374669 DOI: 10.1007/s11701-022-01492-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022]
Abstract
AbstractDue to its advantages over open surgery and conventional laparoscopy, uptake of robot-assisted surgery has rapidly increased. It is important to know whether the existing open or laparoscopic skills of robotic novices shorten the robotic surgery learning curve, potentially reducing the amount of training required. This systematic review aims to assess psychomotor skill transfer to the robot in clinical and simulated settings. PubMed, EMBASE, Cochrane Library and Scopus databases were systematically searched in accordance with PRISMA guidelines from inception to August 2021 alongside website searching and citation chaining. Article screening, data extraction and quality assessment were undertaken by two independent reviewers. Outcomes included simulator performance metrics or in the case of clinical studies, peri- and post-operative metrics. Twenty-nine studies met the eligibility criteria. All studies were judged to be at high or moderate overall risk of bias. Results were narratively synthesised due to heterogeneity in study designs and outcome measures. Two of the three studies assessing open surgical skill transfer found evidence of successful skill transfer while nine of twenty-seven studies evaluating laparoscopic skill transfer found no evidence. Skill transfer from both modalities is most apparent when advanced robotic tasks are performed in the initial phase of the learning curve but quality and methodological limitations of the existing literature prevent definitive conclusions. The impact of incorporating laparoscopic simulation into robotic training curricula and on the cost effectiveness of training should be investigated.
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Kanitra JJ, Khogali-Jakary N, Gambhir SB, Davis AT, Hollis M, Moon C, Gupta R, Haan PS, Anderson C, Collier D, Henry D, Kavuturu S. Transference of skills in robotic vs. laparoscopic simulation: a randomized controlled trial. BMC Surg 2021; 21:379. [PMID: 34711220 PMCID: PMC8554974 DOI: 10.1186/s12893-021-01385-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/18/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Elucidating how robotic skills are best obtained will enable surgeons to best develop future robotic training programs. We perform a randomized controlled trial to assess the performance of robotic compared to laparoscopic surgery, transference of pre-existing skills between the two modalities, and to assess the learning curve between the two using novice medical students. METHODS Forty students were randomized into either Group A or B. Students practiced and were tested on a peg transfer task in either a laparoscopic simulator (LS) and robotic simulator (RS) in a pre-defined order. Performance, transference of skills and learning curve were assessed for each modality. Additionally, a fatigue questionnaire was issued. RESULTS There was no significant difference between overall laparoscopic scores (219 ± 19) and robotic scores (227 ± 23) (p = 0.065). Prior laparoscopic skills performed significantly better on robotic testing (236 ± 12) than without laparoscopic skills (216 ± 28) (p = 0.008). There was no significant difference in scores between students with prior robotic skills (223 ± 16) than without robotic skills (215 ± 22) (p = 0.162). Students reported no difference in fatigue between RS and LS. The learning curve plateaus at similar times between both modalities. CONCLUSION Novice medical students with laparoscopic skills performed better on a RS test than students without laparoscopic training, suggesting a transference of skills from laparoscopic to robotic surgery. These results suggest laparoscopic training may be sufficient in general surgery residencies as the skills transfer to robotic if used post-residency.
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Affiliation(s)
- John J Kanitra
- Department of Surgery, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Nashwa Khogali-Jakary
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Sahil B Gambhir
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - Alan T Davis
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Michael Hollis
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Caroline Moon
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Rama Gupta
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Pamela S Haan
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Cheryl Anderson
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Deborah Collier
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - David Henry
- Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Srinivas Kavuturu
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA.
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DeStephano CC, Nitsche JF, Heckman MG, Banks E, Hur HC. ACOG Simulation Working Group: A Needs Assessment of Simulation Training in OB/GYN Residencies and Recommendations for Future Research. JOURNAL OF SURGICAL EDUCATION 2020; 77:661-670. [PMID: 31859227 DOI: 10.1016/j.jsurg.2019.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/29/2019] [Accepted: 12/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs. DESIGN Cross-sectional survey. SETTING Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States. PARTICIPANTS Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents. RESULTS Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently. CONCLUSIONS Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.
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Affiliation(s)
| | - Joshua F Nitsche
- Wake Forest School of Medicine Department of OB/GYN, Winston-Salem, North Carolina
| | - Michael G Heckman
- Mayo Clinic Department of Surgical Gynecology, Jacksonville, Florida; Mayo Clinic Division of Biomedical Statistics and Informatics, Jacksonville, Florida
| | - Erika Banks
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, New York, New York
| | - Hye-Chun Hur
- Division of Gynecologic Specialty Surgery, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
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Rodrigues Armijo P, Huang CK, Carlson T, Oleynikov D, Siu KC. Ergonomics Analysis for Subjective and Objective Fatigue Between Laparoscopic and Robotic Surgical Skills Practice Among Surgeons. Surg Innov 2019; 27:81-87. [PMID: 31771411 DOI: 10.1177/1553350619887861] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction. Our aim was to determine how self-reported and objectively measured fatigue of upper limb differ between laparoscopic and robotic surgical training environments. Methods. Surgeons at the 2016 SAGES Conference Learning Center and at our institution were enrolled. Two standardized surgical tasks (peg transfer [PT] and needle passing [NP]) were performed twice in each surgical skills practical environments: (1) laparoscopic training-box environment (Fundamentals of Laparoscopic Surgery [FLS]) and (2) Mimic dV-trainer (MIMIC). Muscle activation of upper trapezius (UT), anterior deltoid (AD), flexor carpi radialis, and extensor digitorum were recorded using surface electromyography (EMG; Trigno, Delsys, Inc, Natick, MA). Subjective fatigue was self-reported using Piper Fatigue Scale-12. Analysis was done using SPSS v25.0, α = .05. Results. Demographics were similar between FLS (N = 14) and MIMIC (N = 12). For PT, MIMIC had a significant increase in EMGRMS of UT (P < .001) and AD (P < .001). Conversely, FLS led to significant decreased muscle fatigue in UT (P = .015). For NP, MIMIC had a significant increase in EMGRMS for UT (P = .034) and AD (P = .031), but FLS induced more muscle fatigue for AD (P = .004). There was significant decrease in self-reported fatigue after performing FLS tasks (P = .030) but not after MIMIC (P = .663). Conclusion. Our results showed that practice with MIMIC resulted in greater activation of shoulder muscles, while FLS caused more significant muscle fatigue in the same muscles. This could be due to ergonomic disadvantages and nonoptimal ergonomic settings. Further studies are needed to understand the optimal ergonomics and its impact on fatigue and muscle activation during use of both the FLS and MIMIC training systems.
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Affiliation(s)
| | - Chun-Kai Huang
- University of Nebraska Medical Center, Omaha, NE, USA.,University of Kansas Medical Center, Kansas City, KS, USA
| | - Tyson Carlson
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ka-Chun Siu
- University of Nebraska Medical Center, Omaha, NE, USA
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Moncayo S, Compagnon R, Caire F, Grosos C, Bahans C, Ilhero P, Fourcade L, Ballouhey Q. Transition effects from laparocscopic to robotic surgery skills in small cavities. J Robot Surg 2019; 14:525-530. [PMID: 31515680 DOI: 10.1007/s11701-019-01024-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
Conventional laparoscopic surgery (LS) is being challenged by the ever-increasing use of robotic surgery (RS) to perform reconstructive procedures. The purpose of this study was to assess the acquisition of skills in both techniques and the potential transfer of skills from one technique to the other when restricted spaces are involved. A preclinical randomized crossover study design was implemented. Twelve subjects performed two different reproducible drill procedures: "Thread the Ring" (TR) and "Transfer the Plot" (TP). To assess surgical proficiency in confined workspaces, these exercises were performed with LS and RS technology in a pediatric laparoscopic surgery (PLS) simulator. Each performance was recorded and evaluated by two reviewers using objective structured assessment of technical skills (OSATS). The times to complete the TP and the TR procedure were significantly shorter with RS compared to LS (64 s vs. 319 s; p < 0.0001 for both TP and TR). A significant transfer effect of skills between LS and RS was noted for the TP exercise (p = 0.006). The percentage improvement was greater overall with LS, meaning a higher number of trials were required to adequately master the procedure. This study demonstrated that RS performed significantly better compared to LS on pediatric simulation devices. A transfer effect was identified from LS to RS exclusively. The learning curves showed that progression was definitely longer with LS. These results, indicate that novice surgeons should be encouraged to persist with learning LS, and they support the use of a pediatric robotic simulation device.
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Affiliation(s)
- S Moncayo
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France
| | - R Compagnon
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France
| | - F Caire
- Service de Neurochirurgie, Hôpital Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges Cedex, France
| | - C Grosos
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France
| | - C Bahans
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France
| | - P Ilhero
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France
| | - L Fourcade
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France
| | - Q Ballouhey
- Service de Chirurgie Viscérale Pédiatrique, Hôpital des Enfants, 8 Avenue Dominique Larrey, 87042, Limoges Cedex, France.
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11
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Estes SJ, Lindheim SR. Reproductive surgery: glimpses into the past and thoughts for the future (part 2). Fertil Steril 2019; 112:406-407. [PMID: 31446899 DOI: 10.1016/j.fertnstert.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 11/25/2022]
Abstract
This month's Views and Reviews continues with part two of the series regarding reproductive surgery. The roles of reproductive surgery in müllerian anomalies, tubal and pelvic disease, fertility preservation, and male reproductive surgery are included. Augmenting each contribution, authors have added images and videos to their reflections.
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Affiliation(s)
- Stephanie J Estes
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Penn State Health, Hershey, Pennsylvania.
| | - Steven R Lindheim
- Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Center for Reproductive Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China; Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China
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12
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Everett EN, Forstein DA, Bliss S, Buery-Joyner SD, Craig LB, Graziano SC, Hampton BS, Hopkins L, McKenzie ML, Morgan H, Pradhan A, Page-Ramsey SM. To the Point: The expanding role of simulation in obstetrics and gynecology medical student education. Am J Obstet Gynecol 2019; 220:129-141. [PMID: 30696555 DOI: 10.1016/j.ajog.2018.10.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 11/16/2022]
Abstract
This article, from the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC), provides educators with an overview of the use of simulation in undergraduate medical education in the field of obstetrics and gynecology. Simulation plays an important role in the education of medical students. Students are increasingly serving as clinical observers and providing less direct patient care. Simulation can help standardize education and ensure quality and comparability across an enlarging educational environment. This article summarizes the expanding role of simulation in undergraduate medical education in obstetrics and gynecology and its effect on important learner outcomes such as confidence, knowledge, skills, workplace behaviors, and translation to patient care.
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Affiliation(s)
- Elise N Everett
- Department of Obstetrics and Gynecology, The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT.
| | - David A Forstein
- Department of Obstetrics and Gynecology, Touro College of Osteopathic Medicine, Harlem, New York, NY
| | - Susan Bliss
- Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, NC
| | - Samantha D Buery-Joyner
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Inova Campus, Falls Church, VA
| | - LaTasha B Craig
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Scott C Graziano
- Department of Obstetrics and Gynecology, Loyola University Chicago, Department of Obstetrics and Gynecology, Stritch School of Medicine, Maywood, IL
| | - Brittany S Hampton
- Department of Obstetrics and Gynecology, Women & Infants Hospital of RI, Providence, RI
| | - Laura Hopkins
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Margaret L McKenzie
- Department of Obstetrics and Gynecology, Cleveland Clinic South Pointe Hospital, Cleveland, OH
| | - Helen Morgan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Archana Pradhan
- Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School-New Brunswick, New Brunswick, NJ
| | - Sarah M Page-Ramsey
- Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX
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13
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Virtual reality simulator versus box-trainer to teach minimally invasive procedures: A meta-analysis. Int J Surg 2018; 61:60-68. [PMID: 30529216 DOI: 10.1016/j.ijsu.2018.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/23/2018] [Accepted: 12/04/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND To evaluate the effectiveness of virtual reality simulator (VRS) training compared to box-trainer training (BT) for learning outcomes in minimally invasive surgery (MIS) techniques. MATERIALS AND METHODS A systematic review of the literature was performed using CENTRAL, MEDLINE, EMBASE, Scopus, CINAHL, LILACS. The primary outcomes were time to perform MIS and performance score in MIS. After being selected, the articles were evaluated for methodological quality and risk of bias. The results were evaluated for quality of evidence and meta-analysis was performed. RESULTS 20 randomized clinical trials were included in the qualitative analysis and 14 were used in the meta-analysis. VRS training was more efficient than BT training (P < 0.00001, 95% CI: 35.08 to -25.01) when evaluating participant time needed to complete the peg task. In descriptive analysis, VRS training was better than BT training in participant performance score to perform MIS. There was no statistical difference in the meta-analysis in the time needed to perform surgery, time to complete basic or advanced tasks and performance score for basic or advanced tasks. CONCLUSIONS VRS training was better than BT training in participant performance scores when performing MIS and in the time needed to complete the basic task of peg transfer. In all other outcomes, regardless of the student's level of experience or type of activity, the two forms of training were equivalent.
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14
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Mitchell JD, Amir R, Montealegre-Gallegos M, Mahmood F, Shnider M, Mashari A, Yeh L, Bose R, Wong V, Hess P, Amador Y, Jeganathan J, Jones SB, Matyal R. Summative Objective Structured Clinical Examination Assessment at the End of Anesthesia Residency for Perioperative Ultrasound. Anesth Analg 2018; 126:2065-2068. [DOI: 10.1213/ane.0000000000002826] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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15
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Visuospatial abilities and fine motor experiences influence acquisition and maintenance of fundamentals of laparoscopic surgery (FLS) task performance. Surg Endosc 2018; 32:4639-4648. [PMID: 29777356 DOI: 10.1007/s00464-018-6220-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 05/09/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Minimally invasive surgery poses a unique learning curve due to the requirement for non-intuitive psychomotor skills. The fundamentals of laparoscopic surgery (FLS) program trains and certifies residents in such skills. However, innate predictors of FLS performance and maintenance remain to be described. This single-centre observational study aimed to assess for candidate factors influencing the acquisition and maintenance of FLS performance amongst a surgically naïve cohort. METHODS Laparoscopically naïve medical students were recruited from pre-clinical university grades. Participants completed five visuospatial/psychomotor tests and a questionnaire surveying non-surgical experiences and personality traits. Individuals completed baseline assessments of FLS standard tasks followed by an intensive training course over week one and two on inanimate box trainers. A post-training assessment was performed in week three to evaluate acquisition. Participants were withdrawn from exposure and retested at four 1-month intervals to assess maintenance requirements. RESULTS Forty-nine participants enrolled with 35 (71.4%) and 33 (67.3%) completing acquisition and maintenance phases, respectively. Mean age of participants was 19.3 (± 1.2) years with 68.6% female predominance. Participants demonstrated significant improvements in all five tasks during the acquisition (p < 0.05) period and maintenance of skills with task exposure at 1-month intervals. Significant predictors of skill acquisition included: card rotations for intracorporeal knot (p = 0.027) and combined tasks (p = 0.028) and cube comparisons for extracorporeal knot (p = 0.040). During skill maintenance: Card rotations predicted performance across all tasks (p < 0.05), Cube comparisons for tasks 1/2/4/5 (p < 0.05), PicSOR for peg transfer (p = 0.017) and grooved pegboard for peg transfer (p = 0.023) and ligating-loop (p = 0.038) tasks. Musical instrument experience demonstrated associations with skill acquisition in peg transfer (p = 0.042) and intracorporeal knot (p = 0.034) while video gaming predicted performance in these tasks (p < 0.05) during the maintenance phase. A sporting background or competitive personality did not influence skill performance. CONCLUSIONS Multiple visuospatial abilities and non-surgical experiences positively influenced FLS performance during skill acquisition and/or maintenance. Further consideration to these individual factors may facilitate selection of more technically adaptable surgical residents.
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16
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Robotic skills can be aided by laparoscopic training. Surg Endosc 2017; 32:2683-2688. [PMID: 29214515 DOI: 10.1007/s00464-017-5963-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND General Surgery is currently the fastest growing specialty with regards to robotic surgical system utilization. Contrary to the experience in laparoscopy, simulator training for robotic surgery is not widely employed partly because robotic surgical simulators are expensive. We sought to determine the effect of a robotic simulation curriculum and whether robotic surgical skills could be derived from those psychomotor skills attained in laparoscopic training. METHODS Twenty-seven trainees with no prior robotic experience and limited laparoscopy exposure were randomly assigned to one of three training groups: no simulator training, training on a fundamentals of laparoscopic surgery (FLS™) standard box trainer, and training on a robotic computer based simulator (da Vinci Skills Simulator™). Baseline robotic surgical skills were assessed on the clinical robot docked to a standard FLS trainer box on two tasks-intracorporeal knot tying and peg transfer. Subjects subsequently underwent four 1-h long training sessions in their assigned training environment over a course of several weeks. Robotic surgical skills were reassessed on the robot on the same two tasks used to assess skills prior to training. RESULTS FLS training resulted in a greater score improvement than no training for both knot and peg scores. FLS training was also determined to result in greater score improvement than robotic simulator training for knot tying. There was no significant difference in peg transfer or knot tying scores when comparing robotic simulator training and no training. CONCLUSIONS Robotic surgical skills can be in part derived from psychomotor skills developed in a laparoscopic trainer, especially for complex skills such as intracorporeal knot tying. Acquisition of robotic surgical skills may be enhanced by practice on a laparoscopic simulator using the FLS curriculum. This may be especially helpful when a robotic simulator is not available or is poorly accessible.
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17
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Novellis P, Alloisio M, Vanni E, Bottoni E, Cariboni U, Veronesi G. Robotic lung cancer surgery: review of experience and costs. J Vis Surg 2017; 3:39. [PMID: 29078602 DOI: 10.21037/jovs.2017.03.05] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 02/22/2017] [Indexed: 11/06/2022]
Abstract
Use of robot-assisted techniques is growing fast in several surgical disciplines, now including thoracic surgery. The paper reviews experience of robotic surgery to resect lung cancer and in particular analyzes data on the costs of these procedures in comparison to open surgery and video-assisted thoracoscopic surgery (VATS). Retrospective studies published over 14 years show that robotic surgery for lung cancer has the advantages of minimally invasive surgery for patients, and some advantages over VATS for the surgeon. Limited data indicate that oncological outcomes are comparable with those of VATS and open surgery, while lymph node dissection may be more radical. Other studies indicate that robotic surgery for lung cancer offers no advantages either in terms of costs or outcomes. The high costs of purchase, maintenance and consumables are a concern and continue to limit uptake of robot systems in thoracic surgery. Most studies-but not all-indicate that robotic surgery for lung cancer is more expensive than VATS and open surgery. However limited data also indicate that hospitals can make a profit from robotic thoracic surgery, as costs seem to be lower than reimbursements from paying bodies. Nevertheless robotic thoracic surgery is still too expensive for many public hospitals, particularly in low income countries. Entry of new surgical robot manufacturers onto the market will bring much-needed competition that may also lead to cost reduction.
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Affiliation(s)
- Pierluigi Novellis
- Division of Thoracic Surgery, Humanitas Clinical and Research Center, Rozzano (Milan), Italy
| | - Marco Alloisio
- Division of Thoracic Surgery, Humanitas Clinical and Research Center, Rozzano (Milan), Italy.,Department of Biomedical Science, Humanitas University, Rozzano (Milan), Italy
| | - Elena Vanni
- Department of Biomedical Science, Humanitas University, Rozzano (Milan), Italy.,Humanitas Clinical and Research Center, Business Operating Officer, Rozzano (Milan), Italy
| | - Edoardo Bottoni
- Division of Thoracic Surgery, Humanitas Clinical and Research Center, Rozzano (Milan), Italy
| | - Umberto Cariboni
- Division of Thoracic Surgery, Humanitas Clinical and Research Center, Rozzano (Milan), Italy
| | - Giulia Veronesi
- Division of Thoracic Surgery, Humanitas Clinical and Research Center, Rozzano (Milan), Italy
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18
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Orlando MS, Thomaier L, Abernethy MG, Chen CCG. Retention of laparoscopic and robotic skills among medical students: a randomized controlled trial. Surg Endosc 2017; 31:3306-3312. [PMID: 28078455 DOI: 10.1007/s00464-016-5363-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/13/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Although simulation training beneficially contributes to traditional surgical training, there are less objective data on simulation skills retention. OBJECTIVE To investigate the retention of laparoscopic and robotic skills after simulation training. METHODS We present the second stage of a randomized single-blinded controlled trial in which 40 simulation-naïve medical students were randomly assigned to practice peg transfer tasks on either laparoscopic (N = 20, Fundamentals of Laparoscopic Surgery, Venture Technologies Inc., Waltham, MA) or robotic (N = 20, dV-Trainer, Mimic, Seattle, WA) platforms. In the first stage, two expert surgeons evaluated participants on both tasks before (Stage 1: Baseline) and immediately after training (Stage 1: Post-training) using a modified validated global rating scale of laparoscopic and robotic operative performance. In Stage 2, participants were evaluated on both tasks 11-20 weeks after training. RESULTS Of the 40 students who participated in Stage 1, 23 (11 laparoscopic and 12 robotic) underwent repeat evaluation. During Stage 2, there were no significant differences between groups in objective or subjective measures for the laparoscopic task. Laparoscopic-trained participants' performances on the laparoscopic task were improved during Stage 2 compared to baseline measured by time to task completion, but not by the modified global rating scale. During the robotic task, the robotic-trained group demonstrated superior economy of motion (p = .017), Tissue Handling (p = .020), and fewer errors (p = .018) compared to the laparoscopic-trained group. Robotic skills acquisition from baseline with no significant deterioration as measured by modified global rating scale scores was observed among robotic-trained participants during Stage 2. CONCLUSION Robotic skills acquired through simulation appear to be better maintained than laparoscopic simulation skills. CLINICAL TRIAL This study is registered on ClinicalTrials.gov (NCT02370407).
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Affiliation(s)
- Megan S Orlando
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 301 Mason Lord Drive Suite 3200, Baltimore, MD, 21224, USA
| | - Lauren Thomaier
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 301 Mason Lord Drive Suite 3200, Baltimore, MD, 21224, USA
| | - Melinda G Abernethy
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 301 Mason Lord Drive Suite 3200, Baltimore, MD, 21224, USA
| | - Chi Chiung Grace Chen
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 301 Mason Lord Drive Suite 3200, Baltimore, MD, 21224, USA.
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