Simulation-based VATS resection of the five lung lobes: a technical skills test

Evolution of Three-Dimensional Computed Tomography Imaging in Thoracic Surgery

Radiologic reconstruction technology allows the wide use of three-dimensional (3D) computed tomography (CT) images in thoracic surgery. A minimally invasive surgery has become one of the standard therapies in thoracic surgery, and therefore, the need for preoperative and intraoperative simulations has increased. Three-dimensional CT images have been extensively used, and various types of software have been developed to reconstruct 3D-CT images for surgical simulation worldwide. Several software types have been commercialized and widely used by not only radiologists and technicians, but also thoracic surgeons. Three-dimensional CT images are helpful surgical guides; however, in almost all cases, they provide only static images, different from the intraoperative views. Lungs are soft and variable organs that can easily change shape by intraoperative inflation/deflation and surgical procedures. To address this issue, we have developed a novel software called the Resection Process Map (RPM), which creates variable virtual 3D images. Herein, we introduce the RPM and its development by tracking the history of 3D CT imaging in thoracic surgery. The RPM could help develop a real-time and accurate surgical navigation system for thoracic surgery.

Training simulator efficacy in developing thoracic and general surgical skills in a residency programme: a pilot study

OBJECTIVES

Virtual training simulators have been introduced in several surgical disciplines to improve residents' abilities. Through the use of the LapSim® virtual training simulator (Surgical Science, Göteborg, Sweden), this study aims to plan an effective learning path in minimally invasive thoracic and general surgery.

METHODS

All thoracic and general surgery trainees in their 1st and 2nd year of residency at the University of Insubria were enrolled and randomized into 2 groups: residents undergoing an intensive twice-a-week virtual training programme (group A: n = 8) and those undergoing a once-weekly non-intensive virtual training programme (group B: n = 9). The virtual training programme was divided into 4 modules, each of 12 weeks. In the 1st module, trainees repeated grasping, cutting, clip application, lifting and grasping, and fine dissection exercises during each training session. Seal-and-cut exercise was performed as the initial and final test. Data on surgical manoeuvres (time and on mistakes) were collected; intra- and inter-group comparisons were planned.

RESULTS

No significant differences were observed between groups A and B at the 1st session, confirming that the 2 groups had similar skills at the beginning. After 12 weeks, both groups showed improvements, but comparing data between initial and final test, only Group A registered a significant reduction in total time (P-value = 0.0015), left (P-value = 0.0017) and right (P-value = 0.0186) instrument path lengths, and in left (P-value = 0.0010) and right (P-value = 0.0073) instrument angular path lengths, demonstrating that group A acquired greater precision in surgical manoeuvres.

CONCLUSIONS

Virtual simulator training programme performed at least twice a week was effective for implementing basic surgical skills required for the trainee's professional growth. Additional virtual training modules focused on more complex exercises are planned to confirm these preliminary results.

Video-assisted thoracoscopic surgery simulation and training: a comprehensive literature review

BACKGROUND

Video-assisted thoracic surgery (VATS) has become the standard for lung cancer diagnosis and treatment. However, this surgical technique requires specific and dedicated training. In the past 20 years, several simulator systems have been developed to promote VATS training. Advances in virtual reality may facilitate its integration into the VATS training curriculum. The present review aims to first provide a comprehensive overview of the simulators for thoracoscopic surgery, focused especially on simulators for lung lobectomy; second, it explores the role and highlights the possible efficacy of these simulators in the surgical trainee curriculum.

METHODS

A literature search was conducted in the PubMed, EMBASE, Science Direct, Scopus and Web of Science databases using the following keywords combined with Boolean operators "AND" and "OR": virtual reality, VR, augmented reality, virtual simulation, mixed reality, extended reality, thoracic surgery, thoracoscopy, VATS, video-assisted thoracoscopic surgery, simulation, simulator, simulators, training, and education. Reference lists of the identified articles were hand-searched for additional relevant articles to be included in this review.

RESULTS

Different types of simulators have been used for VATS training: synthetic lung models (dry simulators); live animals or animal tissues (wet simulators); and simulators based on virtual or augmented reality. Their role in surgical training has been generally defined as useful. However, not enough data are available to ascertain which type is the most appropriate.

CONCLUSIONS

Simulator application in the field of medical education could revolutionize the regular surgical training curriculum. Further studies are required to better define their impact on surgeons' training programs and, finally, on patients' quality of care.

Training and assessment using the LapSim laparoscopic simulator: a scoping review of validity evidence

INTRODUCTION

The LapSim (Surgical Science, Sweden) laparoscopic simulator is a high-fidelity virtual reality simulator for use in endoscopic surgical training. This review critiques the current validity evidence for the LapSim laparoscopic simulator, specifically with respect to its potential use as a tool and method of training and assessment in surgery.

METHODS

A scoping review of the MEDLINE (PubMed), EMBASE, Cochrane and Web of Science databases was conducted in accordance with PRISMA guidelines (2020)-scoping review extension. Articles were included if they presented validity evidence for the use of the LapSim in operative skill training or assessment, in accordance with Messick's validity framework. European Association of Endoscopic Surgeons (EAES) guidelines (2005) were used to provide recommendations for the use of the LapSim in operative performance training and assessments.

RESULTS

Forty-nine articles were included. An EAES level 2 recommendation was provided with regard to the internal consistency reliability of automated performance metrics in assessing performance. An EAES recommendation of 2 was awarded with respect to the ability of the LapSim to discriminate based on case volume and overall laparoscopic experience (relationships with other variables). Performance assessment metrics on the LapSim correlate with improved performance in the operating room (EAES level of recommendation 1-consequential validity).

CONCLUSION

The LapSim has accumulated substantial evidence supporting the validity of its use in surgical training and assessment. Future studies should explore the relationship between the achievement of performance benchmarks on the LapSim and subsequent patient outcomes, and interrogate the benefits of implementing virtual reality simulation training and assessment curricula in post-graduate surgical training programmes.

Digital Education in General Thoracic Surgery: A Narrative Review

BACKGROUND

Since advanced technologies were introduced into surgical education, a variety of new programs have been developed. However, a comprehensive review of digital education in general thoracic surgery has not been performed. This narrative review was conducted was to identify the current applications of digital education in general thoracic surgery.

METHODS

A literature search was performed using keywords related to general thoracic surgery and digital education, including e-learning and virtual simulation, up to September 2021. Studies published in English investigating the effect of digital education in general thoracic surgery were included.

RESULTS

Thirteen studies met the criteria. The settings were in undergraduate (n = 6) and postgraduate education (residency) (n = 5) and mixed audience with other disciplines (n = 2). Theoretical knowledge (n = 5), technical skills (n = 4), and both knowledge and technical skills (n = 4) were the stated educational objectives for the studies. The didactic materials were transferred to hardware, software, or online platforms and delivered with multimedia materials. Technical skills training for bronchoscopy and chest tube insertion (n = 5) were offered using virtual reality and computer-based simulations. Subjective evaluation was done in 10 studies. Although after the digital education training there was observed improvement in knowledge or skills in 8 studies, studies were not designed to test for superiority compared with controls through randomized controlled studies.

CONCLUSIONS

This review summarizes the current applications of digital education in general thoracic surgery and helps establish the needs for future studies in this field.

Consensus for Thoracoscopic Lower Lobectomy: Essential Components and Targets for Simulation

BACKGROUND

Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training.

METHODS

After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation.

RESULTS

After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein.

CONCLUSIONS

Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development.

Assessing VATS competence based on simulated lobectomies of all five lung lobes

OBJECTIVES

To determine the number of procedures and expert raters necessary to provide a reliable assessment of competence in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy.

METHODS

Three randomly selected VATS lobectomies were performed on a virtual reality simulator by participants with varying experience in VATS. Video recordings of the procedures were independently rated by three blinded VATS experts using a modified VATS lobectomy assessment tool (VATSAT). The unitary framework of validity was used to describe validity evidence, and generalizability theory was used to explore the reliability of different assessment options.

RESULTS

Forty-one participants (22 novices, 10 intermediates, and 9 experienced) performed a total of 123 lobectomies. Internal consistency reliability, inter-rater reliability, and test-retest reliability were 0.94, 0.85, and 0.90, respectively. Generalizability theory found that a minimum of two procedures and four raters or three procedures and three raters were needed to ensure the overall reliability of 0.8. ANOVA showed significant differences in test scores between the three groups (P < 0.001). A pass/fail level of 19 out of 25 points was established using the contrasting groups' standard setting method, leaving one false positive (one novice passed) and zero false negatives (all experienced passed).

CONCLUSION

We demonstrated validity evidence for a VR simulator test with different lung lobes, and a credible pass/fail level was identified. Our results can be used to implement a standardized mastery learning training program for trainees in VATS lobectomies that ensures that everyone reaches basic competency before performing supervised operations on patients.

Standard Setting in Simulation-Based Training of Surgical Procedures: A Systematic Review

OBJECTIVE

This systematic review aims to examine the use of standard-setting methods in the context of simulation-based training of surgical procedures.

SUMMARY OF BACKGROUND

Simulation-based training is increasingly used in surgical education. However, it is important to determine which level of competency trainees must reach during simulation-based training before operating on patients. Therefore, pass/fail standards must be established using systematic, transparent, and valid methods.

METHODS

Systematic literature search was done in four databases (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library). Original studies investigating simulation-based assessment of surgical procedures with application of a standard setting were included. Quality of evidence was appraised using GRADE.

RESULTS

Of 24,299 studies identified by searches, 232 studies met the inclusion criteria. Publications using already established standard settings were excluded (N = 70), resulting in 162 original studies included in the final analyses. Most studies described how the standard setting was determined (N = 147, 91%) and most used the mean or median performance score of experienced surgeons (n = 65, 40%) for standard setting. We found considerable differences across most of the studies regarding study design, set-up, and expert level classification. The studies were appraised as having low and moderate evidence.

CONCLUSION

Surgical education is shifting towards competency-based education, and simulation-based training is increasingly used for acquiring skills and assessment. Most studies consider and describe how standard settings are established using more or less structured methods but for current and future educational programs, a critical approach is needed so that the learners receive a fair, valid and reliable assessment.