Computer-controlled endoscopic performance assessment system

Laparoscopic Suturing as a Barrier to Broader Adoption of Laparoscopic Surgery

BACKGROUND

Laparoscopic surgery is increasingly replacing the open procedure because of its many patient-related benefits that are well aligned with policies and programs that seek to optimize health system performance. However, widespread adoption of laparoscopic surgery has been slow, in part, because of the complexity of laparoscopic suturing. The objective of this study was to review the clinical and economic impacts of laparoscopic suturing in key procedures and to assess its role as a barrier to the broader adoption of laparoscopic surgery.

DATABASE

A medical literature search of MEDLINE, EMBASE, and BIOSIS from January 2010 through June 2016 identified 47 relevant articles.

CONCLUSION

Laparoscopic suturing and intracorporeal knot tying may result in extended surgical time, complications, and surgeon errors, while improving patient quality of life through improved cosmesis, diet toleration, and better bowel movements. Despite advancement in surgical techniques and the availability of newer surgical tools, the complexity of laparoscopic suturing continues to be a barrier to greater adoption of MIS. The results of the study underscore the need for development of proficiency in laparoscopic suturing, which may help improve patient outcomes and reduce healthcare costs.

Why laparoscopists may opt for three-dimensional view: a summary of the full HTA report on 3D versus 2D laparoscopy by S.I.C.E. (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie)

Background

Three-dimensional view in laparoscopic general, gynaecologic and urologic surgery is an efficient, safe and sustainable innovation. The present paper is an extract taken from a full health technology assessment report on three-dimensional vision technology compared with standard two-dimensional laparoscopic systems.

Methods

A health technology assessment approach was implemented in order to investigate all the economic, social, ethical and organisational implications related to the adoption of the innovative three-dimensional view. With the support of a multi-disciplinary team, composed of eight experts working in Italian hospitals and Universities, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaire and self-reported interviews, applying a final MCDA quantitative approach, and considering the dimensions resulting from the EUnetHTA Core Model.

Results

From systematic search of literature, we retrieved the following studies: 9 on general surgery, 35 on gynaecology and urology, both concerning clinical setting. Considering simulated setting we included: 8 studies regarding pitfalls and drawbacks, 44 on teaching, 12 on surgeons’ confidence and comfort and 34 on surgeons’ performances. Three-dimensional laparoscopy was shown to have advantages for both the patients and the surgeons, and is confirmed to be a safe, efficacious and sustainable vision technology.

Conclusions

The objective of the present paper, under the patronage of Italian Society of Endoscopic Surgery, was achieved in that there has now been produced a scientific report, based on a HTA approach, that may be placed in the hands of surgeons and used to support the decision-making process of the health providers.

Electronic supplementary material

The online version of this article (10.1007/s00464-017-6006-y) contains supplementary material, which is available to authorized users.

Transanal TME - really needed?

In the last decade, thanks to natural orifice translumenal endoscopic surgery, the application of laparoscopy through the anus has gained interest from both research and clinical point of views. Therefore, an increased number of transanal procedures have been reported, from the resection of a large rectal polyp to total mesorectal excision, and for controlling perioperative complications like leak, bleeding, and stenosis. Currently, the most popular surgical trend remains transanal total mesorectal excision. In this article, the technique, advantages, and disadvantages are discussed.

Have You Wondered About Your Colleague’s Surgical Skills?

Surgical skills are important for surgical competence. Surgical skills may be assessed during residency but are not routinely evaluated in practicing surgeons. The current literature is reviewed to evaluate models for objectively assessing surgical skills. Since most studies evaluate models as teaching tools, some extrapolations are necessary. Based on the current literature, recommendations are made for adapting physical models and computer simulations to a program for surgical skills monitoring and remediation for practicing surgeons.

Methodological Infrastructure in Surgical Ergonomics: A Review of Tasks, Models, and Measurement Systems

Though in its infancy, the discipline of surgical ergonomics is increasingly valued. Still, little has been written regarding this field's tasks, models, and measurement systems. These 3 critical experimental components are crucial in objectively and accurately assessing joint and postural control as exhibited by expert laparoscopic surgeons. Such assessments will establish characteristic patterns important for surgical training. In addition, risk factors associated with both minimally invasive surgical instruments and the operating room environment can be identified and minimized. Our review focuses on evidence-based experimental ergonomic studies undertaken in the field of laparoscopic surgery. Publications were located through PubMed and other database and library searches. This article describes tasks, models, and measurement systems and considers their specific applications and the types of data obtainable with the use of each. Advantages and limitations, especially those of measurement systems, are compared and discussed. Future trends and directions believed necessary for optimal investigation and results are also addressed.

Building a framework for ergonomic research on laparoscopic instrument handles

Laparoscopic surgery carries the advantage of minimal invasiveness, but ergonomic design of the instruments used has progressed slowly. Previous studies have demonstrated that the handle of laparoscopic instruments is vital for both surgical performance and surgeon's health. This review provides an overview of the sub-discipline of handle ergonomics, including an evaluation framework, objective and subjective assessment systems, data collection and statistical analyses. Furthermore, a framework for ergonomic research on laparoscopic instrument handles is proposed to standardize work on instrument design.

Single-incision laparoscopy: a review of the indications, techniques and results after more than 700 procedures

Single-incision laparoscopy (SIL) gained in popularity in the last 5-7 years, as a new philosophy has emerged to reduce the invasiveness of minimally invasive surgery. Various abdominal procedures using fewer and smaller trocars in order to obtain pure SIL have been described. To overcome some known problems of SIL, such as establishing the conventional multiport laparoscopic working triangulation, the non-ergonomic positioning of the surgeon, and the increased cost of each procedure, a particular SIL technique has been developed. The technique involves reusable trocars along with specially designed DAPRI curved reusable instruments introduced through the same incision but laterally to the optical system. Hence, the main principle of conventional multiport laparoscopy--working in an appropriate triangulation while maintaining the scope in the center--is respected. The final scar is 15 mm and the cost of the procedure remains unchanged because reusable materials are used. All the abdominal procedures, including upper and lower gastrointestinal, colorectal, hepatobiliopancreatic, solid organs, gynecologic and abdominal wall hernia repair, are here reported, as are the indications for and the results after 740 procedures. In conclusion, SIL has to be considered as one of the most attractive techniques of the new minimally invasive era.

Single-access transumbilical laparoscopic unroofing of a giant hepatic cyst using reusable instruments

INTRODUCTION

Single-access laparoscopy has garnered growing interest in recent years in an attempt to improve cosmesis, reduce postoperative pain, and minimize abdominal wall trauma.

CASE DESCRIPTION

A female patient suffering from a symptomatic giant biliary cyst of the liver segments 4-7-8 was admitted for transumbilical single-access laparoscopic cyst unroofing. The procedure was performed using a standard 11-mm reusable trocar for a 10-mm, 30 degree-angled, rigid scope and curved reusable instruments inserted transumbilically without trocars. Operative time was 90 minutes, and the final incision length was 14 mm. The use of minimal pain medication permitted discharge on the third postoperative day, and after 25 months, the patient remains asymptomatic with a no visible umbilical scar.

CONCLUSIONS

Giant biliary cysts can be removed by single-access laparoscopy. Because of this technique, surgeons work in ergonomic positions, and the cost of the procedure remains similar to that of the multitrocar technique. The incision length and the use of pain medication are kept minimal as well.

Suprapubic single-incision laparoscopic right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Single-incision laparoscopy (SIL) has gained significance recently. The umbilicus has been the preferred access site for SIL. Suprapubic access site (SAS) can be an alternative, especially for a right hemicolectomy (RH).

METHODS

Between November 2011 and July 2012, 7 consecutive patients underwent suprapubic SIL RH (SSILRH). The median age was 53 years, and the median body mass index was 23.9 kg/m2. Indications for surgery included appendicular tumor (1) and adenocarcinoma of the right colon (6). Three reusable trocars were used, and the resection was performed through the SAS. An intracorporeal linear stapled anastomosis was performed, the mesenteric defect was closed, and the access site was used for specimen extraction.

RESULTS

No patient required additional trocars or conversion to an open surgery. The median laparoscopic time was 222 minutes, and the median final incision length was 50 mm. The median Visual Analogue Scale score (0-10) at 6, 18, 30, 42, 54, 66, and 78 postoperative hours was 6, 6, 2, 2, 2, 2, and 2, respectively. The median hospital stay was 4 days.

CONCLUSIONS

SSILRH is useful because the SAS can be enlarged for extraction of the specimen without compromising the cosmetic outcome. The mesocolic and mesenteric dissections are on the same axis as the access site. The intracorporeal anastomosis can be performed without traction. Finally, positioning of the operative table improves exposure of the operative field and allows the surgeon to maneuver the colon and small bowel intracorporeally.

Single-access laparoscopic adjustable gastric band removal: technique and initial experience

BACKGROUND

Single-access laparoscopy (SAL) has gained significant interest in recent years. Potential benefits, beyond cosmetic outcomes, could be reduction of abdominal trauma, decreased risk of incisional hernia and diminished postoperative pain. Technique and initial experience in patients submitted to laparoscopic adjustable gastric band removal (LAGBR) through SAL is reported here.

METHODS

Between December 2009 and March 2012, 14 patients (9 females, 5 males) underwent LAGBR through SAL. Indications for operation were band intolerance (11), pouch dilatation (2) and insufficient weight loss (1). The mean age was 40.3 ± 9.1 years (range 26-57), and the mean interval time between LAGB placement and removal was 94.7 ± 41.9 months (range 37-157). The mean weight and the mean body mass index at the time of LAGBR were 89.3 ± 17.6 kg (range 65-119) and 30.6 ± 4.5 kg/m(2) (range 25.3-36.7), respectively. Technically, the previous port site scar was used as the single-access site to the abdominal cavity. An 11-mm reusable trocar was adopted for a 10-mm regular scope, besides curved reusable instruments.

RESULTS

No patients required conversion to open surgery and none necessitated additional trocars. The mean laparoscopic time was 24.6 ± 7.9 min (range 13-37), and the mean final scar length was 3.6 ± 0.3 cm (range 3-4). Two patients experienced early postoperative complications. The mean hospital stay was 1.3 ± 1.1 days (range 1-5). The mean follow-up time was of 18 ± 9.8 months (range 3-30), and there were no late complications.

CONCLUSIONS

LAGBR can be safely performed through SAL. Thanks to this technique, the laparoscopic working triangulation is established as well as the ergonomic positions of the surgeon. Due the use of only reusable material, the cost of this SAL remains similar to multiport laparoscopy.

Initial experience in single-incision transumbilical laparoscopic liver resection: indications, potential benefits, and limitations

Background. Single-incision transumbilical laparoscopic liver resection (SITLLR) has been recently described in limited series. We report our experience in SITLLR and discuss the future of this approach in terms of indications, potential benefits, and limitations, with a special reference to laparoscopic liver resection (LLR). Patients and Methods. Six patients underwent SITLLR. Indications were biliary cysts (3 cases), hydatid cysts (2), and colorectal liver metastasis (1). Procedures consisted in cysts unroofing, left lateral lobectomy, pericystectomy, and wedge resection. SITLLR was performed with 11 mm reusable trocar, 10 or 5 mm 30° scopes, 10 mm ultrasound probe, curved reusable instruments, and straight disposable bipolar shears. Results. Neither conversion to open surgery nor insertion of supplementary trocars was necessary. Median laparoscopic time was 105.5 minutes and median blood loss 275 mL. Median final umbilical scar length was 1.5 cm, and median length of stay was 4 days. No early or late complications occurred. Conclusion. SITLLR remains a challenging procedure. It is feasible in highly selected patients, requiring experience in hepatobiliary and laparoscopic surgery and skills in single-incision laparoscopy. Apart from cosmetic benefit, our experience and literature review did not show significant advantages if compared with multiport LLR, underlying that specific indications remain to be established.

Technical competence in surgeons

In this paper, we review the literature to date on technical competence in surgeons; how it can be defined, taught to trainees and assessed. We also examine how we can predict which candidates for surgical training will most likely develop technical competence. While technical competency is just one aspect of what makes a good surgeon, we have recognized a need to review the literature in this area and to combine this with broader definitions of competency. Our review found that several methods are available to objectively measure, assess and predict technical competence and should be used in surgical training.

Single-access laparoscopic surgery using new curved reusable instruments: initial hundred patients

In recent years, laparoscopic surgery underwent a huge investment from both the clinical and research points of view to perform classic procedures through a single (S) incision or single port, resulting in the development of different instruments and ports. The main advantage of the S-access laparoscopy (SAL) is cosmesis. Future investigations will provide other potential advantages, such as improvement in postoperative pain and patient satisfaction. We report our initial experience on 115 patients utilizing a SAL (appendectomy, cholecystectomy, incisional hernia repair, Nissen fundoplication, upper gastrointestinal surgery, diagnostic laparoscopy, hepatic resection, splenectomy), along with the new curved reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany). The curves of the instruments enable the surgeon to work in an ergonomic position similar to classic laparoscopy, establishing a working triangulation inside the abdomen as well as outside. The cost of SAL is similar to classic laparoscopy as only reusable products are used.

High-fidelity, low-cost, automated method to assess laparoscopic skills objectively

BACKGROUND

We sought to define the extent to which a motion analysis-based assessment system constructed with simple equipment could measure technical skill objectively and quantitatively.

METHODS

An "off-the-shelf" digital video system was used to capture the hand and instrument movement of surgical trainees (beginner level = PGY-1, intermediate level = PGY-3, and advanced level = PGY-5/fellows) while they performed a peg transfer exercise. The video data were passed through a custom computer vision algorithm that analyzed incoming pixels to measure movement smoothness objectively.

RESULTS

The beginner-level group had the poorest performance, whereas those in the advanced group generated the highest scores. Intermediate-level trainees scored significantly (p < 0.04) better than beginner trainees. Advanced-level trainees scored significantly better than intermediate-level trainees and beginner-level trainees (p < 0.04 and p < 0.03, respectively).

CONCLUSIONS

A computer vision-based analysis of surgical movements provides an objective basis for technical expertise-level analysis with construct validity. The technology to capture the data is simple, low cost, and readily available, and it obviates the need for expert human assessment in this setting.

Observational clinical human reliability analysis (OCHRA) for competency assessment in laparoscopic colorectal surgery at the specialist level

BACKGROUND

There are no valid and reliable tools to assess competency in advanced laparoscopic surgery at a specialist level. The observational clinical human reliability analysis (OCHRA) may have the required characteristics of such a tool. The aim of this study was to evaluate construct and concurrent validity of OCHRA for competency assessment at a specialist level.

METHODS

Thirty-two video-recorded laparoscopic colorectal resections, performed by experts and delegates of the National Training Program in England, were evaluated. Each video was analysed using OCHRA by identifying errors enacted during surgery. The number of tissue-handling, instrument-misuse, and consequential errors was recorded using video-rating software. Times spent on dissecting (D) and on exposing (E) tissues were also measured (D/E ratio). In addition, two independent expert surgeons globally assessed each video regarding competency (pass vs. fail). Logistic regression was used to predict outcomes.

RESULTS

A total of 399 errors were identified. There was a significant difference when comparing the expert, pass, and fail groups for total errors (median counts for experts = 4, pass = 10, fail = 17; P < 0.001). When comparing the pass and fail groups excluding experts, differences could be found for tissue-handling errors (7 vs. 12; P = 0.005), but not for consequential errors (4 vs. 7; P = 0.059) and instrument-handling errors (4 vs. 5; P = 0.320). The D/E ratio was significantly lower for delegates than for experts (0.6 vs. 1.0; P = 0.001). When all four independent variables were used to predict delegates who passed or failed, the area under the receiver operating characteristic curve was 0.867, sensitivity was 71.4%, and specificity was 90.9%.

CONCLUSION

OCHRA is a valid tool for assessing competency at a specialist level in advanced laparoscopic surgery. It has the potential to be used for recertification and revalidation of specialists.

The Concept of Surgical Assessment: Part 2 – Available Tools

In the past surgical training has been based on many years and long hours of work experience together with examinations, which have been mainly knowledge-based. The reduction in the clinical experience of trainees caused by shifts and the European Working Time Regulations means that new ways are needed to facilitate training and to ensure that competence is achieved. In this paper the current methods of assessment of surgical ability in the UK will be outlined. Other tools available that have evidence to support their use will also be described.

Single-access transumbilical laparoscopic appendectomy and cholecystectomy using new curved reusable instruments: a pilot feasibility study

BACKGROUND

The umbilicus can be considered as the embryological opening for single-access laparoscopic procedures. We report on single-access transumbilical laparoscopic appendectomy (SATLA) and cholecystectomy (SATLC), performed using new curved reusable instruments.

PATIENTS AND METHODS

A retrospective review of a prospectively maintained database of 30 patients who underwent SATLA and 20 patients who underwent SATLC between May and November 2009 was undertaken. All procedures were performed with an 11-mm nondisposable trocar for the scope, and curved reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) placed transumbilically without trocars. Outcome measures were conversion to standard laparoscopy, operative time, scar length, complications, hospital stay, and use of pain medication.

RESULTS

All SATLA patients had acute appendicitis, and SATLC patients had symptomatic gallstones (15), chronic cholecystitis (3), and acute cholecystitis (2). No extraumbilical trocars were necessary. Mean total operative times were 57.3 ± 15.9 min (SATLA) and 73.9 ± 20.1 min (SATLC). Mean laparoscopic times were 39 ± 13.1 min (SATLA) and 57.5 ± 18.9 min (SATLC). Mean scar lengths were 14.8 ± 2.2 mm (SATLA) and 15.8 ± 2.3 mm (SATLC). Five SATLA patients and one SATLC patient developed postoperative complications. Mean hospital stay was 2.9 ± 1.3 days for SATLA patients and 1.8 ± 0.8 days for SATLC patients. Pain medication used was minimal. At the minimum follow-up of 3 months no late complications were registered.

CONCLUSIONS

SATLA and SATLC can be performed safely using curved reusable instruments, which helps avoid the conflict between the surgeon's hands or between the instruments' tips and allows the surgeon to operate in an ergonomic position. The reusable instruments kept the cost similar to that of classic laparoscopy.

Quantitative measures of performance in microvascular anastomoses

OBJECTIVE

Methods of evaluating surgical performance are mainly subjective. This study introduces a method of evaluating surgical performance using a quantitative analysis of tool tip kinematics.

METHODS

One experienced surgeon performed eight rat microvascular anastomoses over a 2-day interval. An optoelectronic motion analysis system acquired tool tip trajectories at frequencies of 30 Hz. On the basis of a hierarchical decomposition, the procedure was segmented into specific surgical subtasks (free space movement, needle placement and knot throws) from which characteristic measures of performance (tool tip trajectory, excursion and velocity) were evaluated. Comparisons of performance measures across each procedure were indexed (D scale) using the Kolmogorov-Smirnov statistic.

RESULTS

Despite the marker occlusions, tool tip data were obtained 92 +/- 7% (mean +/- SD) of the time during manipulation tasks. Missing data segments were interpolated across gaps of less than 10 sample points with errors less than 0.4 mm. The anastomoses were completed in 27 +/- 4 min (range 20.5-31.4 min) with 100% patency. Tool tip trajectories and excursions were comparable for each hand, while right and left hand differences were found for velocity. Performance measures comparisons across each procedure established the benchmark for an experienced surgeon. The D-scale range was between 0 and 0.5.

CONCLUSION

The study establishes a reproducible method of quantitating surgical performance. This may enhance assessment of surgical trainees at various levels of training.

Training and simulation

Surgical training is a complex process that continues throughout the professional careers of surgeons. Significant changes in training have taken place during the past two decades, stimulated by the introduction of endoscopic surgery. Simulation is used increasingly for both training and assessment of surgeons in addition to the well-established apprenticeship systems. Currently, surgical and medical simulation is undertaken within the confines of skills laboratories. As virtual-reality simulators improve, skills laboratories will transform into virtual-reality simulation centres. Surgical simulation ensures that the learning curve is completed without jeopardising the outcome of patients, or using live animals.

Simulators, first experiences

It is increasingly being recognized that laparoscopic surgery poses specific strains on the surgical novice. Specific psychomotor skills are required, which cannot easily be acquired by extrapolation from open surgery. Also, limited teaching time in the strict surgical training curricula makes it difficult to acquire such skills. Two surgical simulation platforms, the Advanced Dundee Psychomotor Tester (ADEPT(R)), and the Xitact LS500(R), are objects of study in our hospital for the training and objective assessment of laparoscopic task performance. Multiple validation studies, both at our center and at other institutions, are ongoing. Face-construct and content validity of the two systems under investigation have been established at our skills laboratory. This article highlights the most important findings of our studies using simulative surgical lapraoscopic technologies.

Simulation in plastic surgery training and education: the path forward

SUMMARY

Computer-based training simulators have been used extensively, most notably in flight simulation. Over the past 20 years, surgical simulators have been developed, initially for training of minimally invasive surgery and more recently for open surgical simulation. The key effort in today's surgical simulation field is to develop metrics to evaluate how well the skills learned in a simulator translate to improvement in real surgical skills, execution of procedures, and team cooperation in the operating room. The American College of Surgeons has begun implementing a phased approach to introduce simulation in training and education for general surgery. The authors believe that a similar training plan should be mandated for plastic surgery, to take advantage of the use of computers, virtual reality, and simulation in the training of plastic surgery residents and to explore the value of this technology for continuing medical education and maintenance of certification. This article gives a brief background and history of surgical simulation and its technology, followed by a detailed description of the three phases of the American College of Surgeons' plan and how the authors propose that each phase be implemented, with modifications as applicable for trainees in plastic surgery.

Systems for tracking minimally invasive surgical instruments

Minimally invasive surgery (e.g. laparoscopy) requires special surgical skills, which should be objectively assessed. Several studies have shown that motion analysis is a valuable assessment tool of basic surgical skills in laparoscopy. However, to use motion analysis as the assessment tool, it is necessary to track and record the motions of laparoscopic instruments. This article describes the state of the art in research on tracking systems for laparoscopy. It gives an overview on existing systems, on how these systems work, their advantages, and their shortcomings. Although various approaches have been used, none of the tracking systems to date comes out as clearly superior. A great number of systems can be used in training environment only, most systems do not allow the use of real laparoscopic instruments, and only a small number of systems provide force feedback.

Karl Storz Lecture. Skills training in pediatric minimal access surgery

Learning the craft of surgery is central to every surgical program. Although effective, acquisition of skills, particularly that of minimal access surgery in the operating theater, is becoming increasingly difficult. Published data indicate that the early phase of the learning curve could be achieved outside the operating room. However, there is no consensus regarding the optimal training schemes and assessment tools. With an increase in the number of operations performed endoscopically and the number of surgeons performing them, the importance of well-defined and validated training programs cannot be overemphasized.

Psychomotor ability testing and human reliability analysis (HRA) in surgical practice

This review deals with the methodology that exists for assessing the intrinsic or innate abilities required for acquisition of the necessary skills with training so that operative competence and proficiency are reached by surgical trainees at the end of the training programme. In addition, it covers human reliability analysis (HRA) as a technique (long-used in high-risk industries) for ensuring safe execution of operations and a good clinical outcome. Both subjects are relatively new in surgery and most of the account is based on work carried out at Dundee University of Dundee Department of Surgery and Molecular Oncology and Surgical Skills Unit over a 10-year period. The methodology for both is still relatively crude but, nonetheless, progress has been made. In surgery the important role of psychomotor ability testing is in the selection of and the assessment of progress of trainees during the surgical residency. HRA applies both to surgical trainees when good habits and practice become ingrained and during the entire working career of consultant surgeons.

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

BACKGROUND

There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses.

METHODS

Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA.

RESULTS

The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001).

CONCLUSIONS

OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

The MISTELS program to measure technical skill in laparoscopic surgery : evidence for reliability

BACKGROUND

The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) is a series of five tasks with an objective scoring system. The purpose of this study was to estimate the interrater and test-retest reliability of the MISTELS metrics and to assess their internal consistency.

METHODS

To determine interrater reliability, two trained observers scored 10 subjects, either live or on tape. Test-retest reliability was assessed by having 12 subjects perform two tests, the second immediately following the first. Interrater and test-retest reliability were assessed using intraclass correlation coefficients. Internal consistency between tasks was estimated using Cronbach's alpha.

RESULTS

The interrater and test-retest reliabilities for the total scores were both excellent at 0.998 [95% confidence interval (CI), 0.985-1.00] and 0.892 (95% CI, 0.665-0.968), respectively. Cronbach's alpha for the first assessment of the test-retest was 0.86.

CONCLUSIONS

The MISTELS metrics have excellent reliability, which exceeds the threshold level of 0.8 required for high-stakes evaluations. These findings support the use of MISTELS for evaluation in many different settings, including residency training programs.

Laparoscopic vascular anastomoses: does robotic (Zeus–Aesop) assistance help to overcome the learning curve?

BACKGROUND

Considerable training is necessary to master laparoscopic suturing and knot-tying. Robotic systems are assumed to facilitate these skills and shorten the learning curve. The effect of laparoscopic experience and robotic assistance on the learning curve of vascular anastomoses was studied.

METHODS

A laparoscopically experienced surgeon and a laparoscopically inexperienced surgeon made alternating laparoscopic vascular anastomoses and robot-assisted laparoscopic vascular anastomoses using a Zeus-Aesop surgical robotic system with various prosthetic conduits and suture materials in a laparoscopic training box.

RESULTS

Neither laparoscopic method influenced the quality score or leakage rate, but with laparoscopic experience, significantly fewer failures were made. Suturing and knot-tying were faster with laparoscopic experience both with and without the robotic system, and fewer stitch actions and knot actions were performed. The learning curves of both surgeons were not improved by the robotic system.

CONCLUSIONS

Experience is the most important factor in the performance of laparoscopic vascular anastomoses. The robotic system was not helpful in shortening the learning curve.

Laparoscopic skills training and assessment

BACKGROUND

The introduction of laparoscopic techniques to general surgery was associated with many unnecessary complications, which led to the development of skills laboratories to train novice laparoscopic surgeons. This article reviews the tools currently available for training and assessment in laparoscopic surgery.

METHODS

Medline searches were performed to identify articles with combinations of the following key words: laparoscopy, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers.

RESULTS

Current training involves the use of box trainers with either innate models or animal tissues; it lacks objective assessment of skill acquisition. Virtual reality simulators have the ability to teach laparoscopic psychomotor skills, and objective assessment is now possible using dexterity-based and video analysis systems.

CONCLUSION

The tools are now available for the development of a structured, competency-based, laparoscopic surgical training programme.

Effect of the angle between the optical axis of the endoscope and the instruments' plane on monitor image and surgical performance

BACKGROUND

The aim of the study was to examine the effect of the angle between optical axis of the endoscope and the instruments' plane (OAIP) on the monitor display angle (approach angle between the two instruments on a two-dimensional monitor) and endoscopic task performance.

METHODS

Two experiments were carried out in the Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) using a standard two-dimensional video endoscopic system. In the first experiment, the monitor display angle was measured during use, with OAIP angles ranging between 0 and 80 degrees (at 10 degrees increments) and manipulation angles varying between 45 and 120 degrees (at 15 degrees increments). In the second experiment, 10 surgeons tied 500 intracorporeal knots with OAIP angles of 0 degrees (optical axis in the same plane as the instruments), +15 degrees and +30 degrees (viewing above the instruments' plane), and -15 and -30 degrees (optical axis looking from below instruments' plane). The end points were the execution time and knot quality score (KQS).

RESULTS

In the first experiment, instruments entered the visual field from lateral sides of the monitor with an apparent 180 degrees monitor display angle with a 0 degrees OAIP angle, whereas the monitor display angle approached the actual manipulation angle between the two needle drivers when an 80 degrees OAIP angle was used. In the second experiment, the instruments appeared to enter the image field from the side of the surgeon when the endoscope viewed the instruments from above, whereas instruments entered the field from the opposite side to the surgeon when the endoscope viewed instruments' plane from below. As a result, use of 0 and +15 degrees OATP angles yielded significantly shorter execution times: 70 s compared to 83, 93, and 77 s for +30, -30, and -15 degrees OAIP angles ( p < 0.001), with KQS of 39 degrees and 40 vs 38, 36, and 34%, respectively ( p = 0.257).

CONCLUSIONS

The angle between the optical axis of the endoscope and instruments' plane determines how the instruments appear to enter the operative field. The monitor display angle between the instruments is different from the real manipulation angle unless the OAIP angle is near 80 degrees. The apparent entry of instruments into the operative field becomes intuitive for the surgeon only if the endoscope is viewing from above or in the same plane as the instruments. Hence, the best performance for endoscopic knot tying is obtained with this configuration, and execution time increases significantly with viewing from below the instruments' plane.

The Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) objectifying subjective psychomotor test performance

BACKGROUND

This study was undertaken to establish the value of the Advanced Dundee Psychomotor Tester (ADEPT) as an objective real-time scoring system, correcting for subjective assessor opinion on endoscopic task performance. The main research questions were as follows: Are surgeons good estimators of their own performance on ADEPT? Do surgeons perceive ADEPT to be a valid instrument for measuring laparoscopic skills? Does performance on ADEPT reflect innate psychomotor ability?

METHODS

Each of 45 surgeons completed two runs on ADEPT. The runs comprised five standardized tasks. A posttest visual analog scaled (VAS) questionnaire measuring attitude toward skills testing in general, validation, and performance on ADEPT was used. Subjective responses were compared with objective scores generated through performance on ADEPT.

RESULTS

Surgeons emphasize the importance of using a variety of training methods for surgical residents during their residency, including laparoscopic virtual reality simulators. Monitoring of residents' endoscopic progress seemed to be a key issue. Surgeons themselves underestimate their individual performance on ADEPT (mean subjective score of 6.1 vs mean objective score of 6.6). Self-reported performance on ADEPT is unreliable because confidence intervals between the VAS score and the ADEPT score overlap. Surgeons disagree on the validity of ADEPT. The mean score for validity was 5.8, ranging from 0 to 10 with almost equal distribution over the scale. Innate ability is established as surgeons' scores express high concordance between test run and true run, with 72.7% of the participants' true run score within one distance from the test run.

CONCLUSIONS

Surgeons cannot correctly predict their standardized individual test result on ADEPT. Performance on ADEPT reflects innate psychomotor ability along with improvement over runs. Surgeons are ambivalent in assessing the validity of ADEPT, irrespective of personal performance.

Motion analysis

BACKGROUND

The ability to make an objective evaluation of a surgeon's operative ability remains an elusive goal. In this study, we used motion analysis as a measure of dexterity in the performance of a simulated operation.

METHODS

Fifteen surgeons performed a total of 45 laboratory-based laparoscopic cholecystectomies on a cadaveric porcine liver model. Subjects were assigned to one of three groups according to their level of experience in human laparoscopic cholecystectomy. Electromagnetic tracking devices were used to analyze the surgeon's hand movements as they performed the procedure. Movement data (time, distance, number of movements, and speed of movement) were then compared.

RESULTS

Analysis of variance (ANOVA) movement scores across the three groups showed significantly better performance among the experienced laparoscopic surgeons than the novices. Learning curves across repetitions of procedures were plotted. Novices made more improvement than experts.

CONCLUSIONS

Motion analysis provides useful data for the assessment of laparoscopic dexterity, and the porcine liver model is a valid simulation of the real procedure.

The internet: from basics to telesurgery

The exponential growth in information technology is resulting in a rapid increase in the ability to develop useful applications on the Internet. The purpose of the present article is to provide a brief review of the Internet with a consideration of its relevance to surgeons. This review is intended to indicate a range of relevant issues, rather than to discuss any specific topic in depth. It is becoming difficult for surgeons to reach their full potential unless they exploit Internet-based activities. This is because the ability to rapidly capture information of quality is an essential ingredient in a reflective approach to surgical problems. More futuristic is the prospect of using computer-based technology to operate upon patients from a distance (telesurgery).

Assessing laparoscopic manipulative skills

BACKGROUND

The rapid emergence of laparoscopic surgery over the past decade has highlighted the need for teaching and assessing laparoscopic manipulative skills. Most analyses consist of a measurement of the time to complete a specified task and a subjective assessment by an observer. Objective assessments of accuracy in the performance of manipulative skills have been lacking. To quantify both speed and accuracy during laparoscopic skill performance, we have developed a skills assessment device (SAD) using a laparoscopic simulator platform and computer-based skills assessment software that precisely measures an instrument's movement during performance of timed laparoscopic manipulations.

STUDY DESIGN

The SAD device measures the time necessary for an operator to complete a task, and the movements of the working end of laparoscopic instruments in three dimensions. Ten nonsurgeons performed 10 repetitions of a standardized laparoscopic manipulation. Data were captured in real time for both hands on a personal computer. Accuracy was determined by calculating the sum of all distances traveled. Duration was measured in seconds. Results are group means.

RESULTS

The time necessary to perform defined laparoscopic manipulative skills improved dramatically during the first 3 repetitions and then stabilized. However, accuracy of manipulations continued to improve over all 10 repetitions.

CONCLUSIONS

When untrained subjects are learning a laparoscopic manipulative task, measurement of time alone fails to account for the more protracted learning curve for accuracy. Therefore, devices and training programs that fail to consider objective assessments of accuracy may overestimate laparoscopic proficiency.

Acquiring surgical skills

BACKGROUND

Technical competence is the bedrock of surgery, yet it has only recently been viewed as a valid area for either critical evaluation or formal teaching.

METHODS

This review examines the teaching of surgical skills. The core is derived from a literature search of the Medline computer database.

RESULTS AND CONCLUSION

The impetus for surgical change has generally related to the introduction of new technology. Advances initially allowed for open operation within the main body cavities; more recently minimal access surgery has appeared. The latter was introduced in an inappropriate manner, which has led to the evolution of teaching of technical skills away from an apprenticeship-based activity towards more formal skill-based training programmes. There is now a need for a solid theoretical base for the teaching of manual skills that accommodates concepts of surgical competence.

Objective assessment of surgical dexterity using simulators

Surgical skill, like training for any craft, has traditionally been learnt as an apprenticeship. However, whereas carpenters learn on wood that is never displayed, operative training is done on real clinical cases. Over recent years surgical skills training laboratories have in part, replaced the apprenticeship. This article discusses some of the tools used within such laboratories to ensure optimal surgical performance.