A randomised comparative study evaluating learning curves of novices in a basic single-incision laparoscopic surgery task

Effects of Real Time Feedback on Novice's Laparoscopic Learning Curve

OBJECTIVE

Analyze the learning curve of medical students when they are trained with a laparoscopic box trainer and are presented with different modes of real-time feedback on their performance in the laparoscopic suturing procedure.

DESIGN

A prospective randomized controlled trial (RTC) was performed. Three groups were proposed: control, visual, and haptic. The block randomization technique was used to assign the participants to one of the three groups. Each group trained the intracorporeal square flat knot task in a standardized FLS box simulator. A total of 11 sessions were programmed for this study: a pre-training session, eight training sessions, a post-training session, and a follow-up session. Measurement of the generated reaction force during the task were taken weekly for the first 10 sessions (pre-training, training, and post-training); then, the follow-up measurement was taken a month after.

SETTING

This study was carried out in a single center at the Unidad de Simulación de Posgrado (USIP) of the postgraduate medicine program of the Universidad Nacional Autónoma de México (UNAM) between May and August 2023.

PARTICIPANTS

The eligible participants were medical students without experience in minimally invasive surgery. All social service intern medics doing their social service in the USIP were invited to participate. A total of 20 participants entered the study from which 18 of them finished all the programmed sessions.

RESULTS

A total of ten metrics were extracted from the reaction force signal measured at each session. All metrics are directly proportional to the reaction force and low magnitudes imply high tissue-handling proficiency. All groups improved their tissue handling skills, being the visual group the one who achieved better performance, followed by the haptic group and lastly the control group.

CONCLUSION

The use of real time feedback, especially visual feedback can help novices to shorten the learning process of tissue handling and achieve a better proficiency in advanced tasks in shorter training periods.

Novices' learning curve in single-port surgery using three surgical training programs

BACKGROUND

The objective of this study was to evaluate the novices' learning curves and proficiency level reached in laparoendoscopic single-site (LESS) surgery using three surgical training programs.

MATERIAL AND METHODS

Participants were randomly divided into three groups, who trained in a specific practice regimen for 12 days using a laparoscopic box simulator and three tasks. Group A trained in three stages using conventional laparoscopic surgery (CLS) with straight instruments, and LESS with straight and articulating instruments for four days each. Group B trained in two stages in LESS with straight and articulating instruments for six days each. Group C trained only in LESS with articulating instruments exclusively for all 12 days. Performance was registered daily during the 12 days to evaluate the participants' progress.

RESULTS

Pre- and post-training analysis of the three groups showed significant differences in performance, denoting the significant improvement in their LESS skills, with no difference between the groups. Group C reached a high level of technical competence with their specific training program in LESS, obtaining a lower asymptote and slow learning rate.

CONCLUSION

Specific training programs in LESS settings using articulated instruments showed a slower learning rate than the other programs but better proficiency in the technique with the best surgical performance.

Clinical outcomes of single incision laparoscopic surgery for colorectal cancer: A propensity score-matched analysis between well-experienced and novice surgeons

Background

Single incision laparoscopic surgery (SILS) is a recent advancement in minimally invasive techniques for colorectal cancer (CRC). However, SILS is a technically challenging procedure for novice surgeons. The aim of this study was to evaluate clinical outcomes of SILS for CRC performed by novice surgeons compared with those performed by well-experienced surgeons.

Methods

We retrospectively analyzed 1004 consecutive patients with stage I-IV CRC who underwent SILS between May 2009 and December 2018, using propensity score-matched analysis.

Results

After propensity score-matching, we enrolled 344 patients (n = 172 in each group). Before matching, significant group-dependent differences were observed in terms of age (P = 0.034) and tumor location (P < 0.001). After matching, preoperative clinical factors were similar between groups, but operative time was longer in the Novice group (213 vs 171 min, P < 0.001). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the Novice group (23 vs 25, P = 0.040), and the number of patients with lymph node metastases was smaller in the Novice group (57 vs 86, P = 0.002). The 3-year disease-free survival rate was 85.8% in the Novice group and 89.9% in the Experienced group (P = 0.512). Three-year overall survival rate was 92.2% in the Novice group and 90.0% in the Experienced group (P = 0.899).

Conclusion

SILS for CRC was safely performed by novice surgeons under the guidance of well-experienced surgeons, and could provide satisfactory oncological outcomes.

Can a Fully Articulating Electromechanical Laparoscopic Needle Driver Compare with a Robotic Platform in Transabdominal Preperitoneal Inguinal Hernia Repair?

Background: Enhanced laparoscopic instruments are filling the gap between straight-stick laparoscopic equipment and robotic platforms. We sought to evaluate the performance and cost of the HandX™ device during mesh fixation and peritoneal flap closure of transabdominal preperitoneal (TAPP) inguinal hernia repairs. Methods: The video recordings of a consecutive series of TAPP surgeries using the articulated needle driver device were compared with a series of surgeries on the DaVinci robotic platform by a single surgeon. Two critical steps of the procedure were analyzed: mesh fixation and peritoneal closure. A cost analysis between the two platforms was completed. Results: We analyzed 27 cases using the new needle driver and 27 cases using the DaVinci Surgical Robotic system. To evaluate the learning curve (LC) with the HandX device, we created three groups (G1, G2, and G3). The two latter groups were combined and called after LC. Mean fixation time using the DaVinci system was 258.1 seconds (±100.4) compared with 391.5 (±95.9) using the articulating handheld laparoscopic needle driver after LC (P < .001). The average time for peritoneal closure was 418.6 (±192.1) seconds for DaVinci and 634.5 (±159.5) seconds for HandX (P < .001). When comparing the after-LC HandX cases and the DaVinci system stratified by side, there was no significant difference in peritoneal closure in the right side (520.1 seconds (84.3) with the HandX versus 444.2 seconds (229.7) using the DaVinci system (P = .353). When evaluating direct cost of the instruments, HandX cases had a lower cost (310 USD) when compared with the cost of using DaVinci (973 USD). Conclusions: The new smart articulating needle driver may be a cost-effective means of bringing some of the benefits of the robotic platform to laparoscopy.

Initial experience using a handheld fully articulating software-driven laparoscopic needle driver in TAPP inguinal hernia repair

Background

The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a widely performed minimally invasive operation, but can present considerable ergonomic challenges for the surgeon. Our objective was to determine if a novel handheld software-driven laparoscopic articulating needle driver can mitigate these difficulties.

Methods

The video recordings of a consecutive series of TAPP cases by a single surgeon using the articulating device were compared with a series of cases using straight-stick laparoscopy. Two critical steps of the procedure were analyzed for time: mesh fixation and peritoneal suture closure. These steps were then compared before and after 10 initial consecutive cases to analyze whether the surgeon demonstrated improvement. A cost analysis was also performed between the two techniques.

Results

For mesh fixation, the surgeon averaged 227 s using tacker devices, compared with 462.4 s using the novel laparoscopic device (p = 0.06). For the peritoneal closure component of the operation, the surgeon improved the time per suture pass during closure from 60.61 s during the first 10 cases to 38.84 s after the first 10 cases (p = 0.0004), which was comparable to the time per stitch for standard laparoscopy (34.8 s vs 34.84 s, p = 0.997). Left-sided inguinal hernia repairs using the articulating device demonstrated a significantly longer time per stitch during peritoneal closure compared to the right side after first 10 cases (left: 40.62 s; right: 27.91, p = 0.005). Our direct cost analysis demonstrated that suture closure of the peritoneum using the articulating device was more cost-effective than tack fixation.

Conclusions

After only a 10 case initial experience, a laparoscopic hand-held articulating needle driver is comparable to standard laparoscopy to complete suture mesh fixation and peritoneal closure for TAPP inguinal hernia repair. Further, the feasibility of suture mesh fixation minimizes the need for costly tacker devices. This instrument appears to be a promising tool in this largely minimally invasive era of hernia repair.

Quantifying the cognitive cost of laparo-endoscopic single-site surgeries: Gaze-based indices

BACKGROUND

Despite the growing interest concerning the laparo-endoscopic single-site surgery (LESS) procedure, LESS presents multiple difficulties and challenges that are likely to increase the surgeon's cognitive cost, in terms of both cognitive load and performance. Nevertheless, there is currently no objective index capable of assessing the surgeon cognitive cost while performing LESS. We assessed if gaze-based indices might offer unique and unbiased measures to quantify LESS complexity and its cognitive cost. We expect that the assessment of surgeon's cognitive cost to improve patient safety by measuring fitness-for-duty and reducing surgeons overload.

METHODS

Using a wearable eye tracker device, we measured gaze entropy and velocity of surgical trainees and attending surgeons during two surgical procedures (LESS vs. multiport laparoscopy surgery [MPS]). None of the participants had previous experience with LESS. They performed two exercises with different complexity levels (Low: Pattern Cut vs. High: Peg Transfer). We also collected performance and subjective data.

RESULTS

LESS caused higher cognitive demand than MPS, as indicated by increased gaze entropy in both surgical trainees and attending surgeons (exploration pattern became more random). Furthermore, gaze velocity was higher (exploration pattern became more rapid) for the LESS procedure independently of the surgeon's expertise. Perceived task complexity and laparoscopic accuracy confirmed gaze-based results.

CONCLUSION

Gaze-based indices have great potential as objective and non-intrusive measures to assess surgeons' cognitive cost and fitness-for-duty. Furthermore, gaze-based indices might play a relevant role in defining future guidelines on surgeons' examinations to mark their achievements during the entire training (e.g. analyzing surgical learning curves).

The influence of prior laparoscopic experience on learning laparoendoscopic single site surgery: a prospective comparative preliminary study using cystorraphy in a live porcine model

Background

The purpose of this study is to assess the impact of prior laparoscopic experience on the ability to learn laparoendoscopic single site surgery (LESS) skills.

Methods

A total of 33 urologists who completed a training program in LESS surgery were recruited for this study. After completing the educational course and training, the study participants demonstrated LESS suturing and knot-tying via a 2-cm cystotomy in a live porcine model for 15 min. An objective structured assessment of technical skills (OSATS) was used to evaluate videos of each participant’s procedure. The participants were divided according to laparoscopic experience; advanced experienced group (AS), intermediate experienced group (IS), novice group (NS).

Results

Three participants in the NS group completed the porcine cystorrhaphy in 15 min (30.0%), 3 (25.0%) completed the task in the IS group, and 3 (27.2%) completed it in the AS group. There were no statistically significant differences in the mean total OSATS quality score (NS; 16.7, IS; 18.5, AS; 16.8) among the 3 groups. Concerning all each assessment, there were also no statistically significant difference. Additionaly, the mean total OSATS quantity score (NS; 4.1, IS; 3.5, AS; 4.3) did not differ significantly among groups. The NS group succeeded a mean of 1.4 knots, the IS group succeeded 0.9, and the AS group 1.3 (p = 0.727).

Conclusions

There was no significant difference among the groups in LESS proficiency after training. Surgeons who were novices in conventional laparoscopic surgery reached comparable scores to those of experienced laparoscopic surgeons after training.

Comparison of the Effect of Instrument Type on Transanal Endoscopic Surgery Learning Curves

BACKGROUND

Transanal endoscopic surgery (TES) can be technically difficult due to the constraints of operating through a narrow proctoscope channel. In this study, we compared the performance of surgical novices using instruments with and without articulating shafts to perform a simulated TES task.

METHODS

Medical students each performed 10 repetitions of the Fundamentals of Laparoscopic Surgery circle-cut task. Participants were randomized into 3 groups: 2 performed the task through a TES proctoscope using scissors with either a rigid (TES-R) or articulating (TES-A) shaft. The third group performed the task laparoscopically (LAP).

RESULTS

A total of 31 medical students participated. The LAP group had a faster mean task time than both the TES-R and TES-A groups (LAP 201±120 s vs. TES-R 362±212 s and TES-A 405±212 s, both P <0.001). The TES-R group made more errors (ie, deviation from a perfect circle) than both the other groups. The TES-R group adjusted the proctoscope position during more repetitions than the TES-A group.

CONCLUSIONS

Students had faster task times when operating laparoscopically than through a TES protoscope. Task times were similar between the TES groups using scissors with articulating and rigid shafts; however, use of the articulating instruments resulted in fewer errors and less need to adjust proctoscope position.

Gaze entropy reflects surgical task load

BACKGROUND

Task (over-)load imposed on surgeons is a main contributing factor to surgical errors. Recent research has shown that gaze metrics represent a valid and objective index to asses operator task load in non-surgical scenarios. Thus, gaze metrics have the potential to improve workplace safety by providing accurate measurements of task load variations. However, the direct relationship between gaze metrics and surgical task load has not been investigated yet. We studied the effects of surgical task complexity on the gaze metrics of surgical trainees.

METHODS

We recorded the eye movements of 18 surgical residents, using a mobile eye tracker system, during the performance of three high-fidelity virtual simulations of laparoscopic exercises of increasing complexity level: Clip Applying exercise, Cutting Big exercise, and Translocation of Objects exercise. We also measured performance accuracy and subjective rating of complexity.

RESULTS

Gaze entropy and velocity linearly increased with increased task complexity: Visual exploration pattern became less stereotyped (i.e., more random) and faster during the more complex exercises. Residents performed better the Clip Applying exercise and the Cutting Big exercise than the Translocation of Objects exercise and their perceived task complexity differed accordingly.

CONCLUSIONS

Our data show that gaze metrics are a valid and reliable surgical task load index. These findings have potential impacts to improve patient safety by providing accurate measurements of surgeon task (over-)load and might provide future indices to assess residents' learning curves, independently of expensive virtual simulators or time-consuming expert evaluation.

A Randomized Controlled Study to Evaluate the Impact of Instrument and Laparoscope Length on Performance and Learning Curve in Single-Incision Laparoscopic Surgery

INTRODUCTION

The proximity of instrumentation in single-incision laparoscopic surgery (SILS) creates ergonomic challenges. An innovative method to reduce external collisions between instruments and handles is to use instruments of different lengths. This study evaluated the impact of instrument and laparoscope length on simulated SILS performance.

METHODS

Performance was assessed using peg transfer (PEG) and pattern cutting (CUT) tasks from the Fundamentals of Laparoscopic Surgery (FLS) curriculum. Following baseline testing, surgeons were randomized into 3 trial arms: Control--standard length instruments and standard length laparoscope; group 1--one long instrument, one standard length instrument and standard length laparoscope; and group 2--standard length instruments and long laparoscope. Two phases were undertaken using a validated SILS-modified FLS box trainer: phase 1--25 repetitions of PEG and phase 2--5 repetitions of CUT. FLS scoring parameters measured performance and the Imperial College Surgical Assessment Device (ICSAD) captured motion analysis of hands.

RESULTS

Twenty-three surgeons were recruited--control (n = 7), group 1 (n = 9), and group 2 (n = 7). No significant differences were observed in operative experience or baseline skills performance. Phase 1: Peak FLS score was significantly higher in group 1 compared with control (P = .009). Comparison of learning curves revealed learning plateau was significantly higher in group 1 compared with control (P = .010). Phase 2: Group 1 revealed a trend toward higher peak FLS scores over the control (P = .067). No significant differences in motion analysis of hands were demonstrated using ICSAD.

CONCLUSIONS

This study demonstrates that using instruments of different lengths can improve simulated SILS performance.

Single-incision laparoscopic cholecystectomy: a systematic review of methodology and outcomes

PURPOSE

(1) To survey the dissemination of SILC; (2) to determine which SILC method has become mainstream; (3) to determine whether the characteristic complications vary according to the type of procedure.

METHODS

An electronic search of PubMed, Databases@Ovid, and SciVerse Scopus between 2003/01/01 and 2012/12/31 was performed.

RESULTS

The peak number of annually published articles was 70 in 2011. The most common procedures were single skin incision, the use of a SILS Port(®), suture suspension and a 5-mm oblique scope. The intraoperative complications rate was 1.69 %. Postoperative complications occurred in 213/5283 cases. According to the surgical procedure, five factors (approach; P = 0.0017, gallbladder anchorage; P < 0.001, size; P = 0.049 and type; P < 0.001 of the scope, and size of the clip applier; P = 0.074) significantly affected the incidence of wound infection. The incidence of wound seroma/bleeding was significantly influenced by gallbladder anchorage (P = 0.009), the use of curved/articulated instruments (P = 0.048), and the diameter of the clip applier (P < 0.001).

CONCLUSION

To determine the best operative procedure for SILC, an analysis of uniform operative procedures is needed.

Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator - either a video box or a mirrored box - is an option to supplement standard training. However, the impact of this modality on trainees with no prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training versus no training, another box model, animal model, or cadaveric model training for surgical trainees with no prior laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We included all randomised clinical trials comparing box model trainers versus no training in surgical trainees with no prior laparoscopic experience. We also included trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager for analysis. For each outcome, we calculated the standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

Twenty-five trials contributed data to the quantitative synthesis in this review. All but one trial were at high risk of bias. Overall, 16 trials (464 participants) provided data for meta-analysis of box training (248 participants) versus no supplementary training (216 participants). All the 16 trials in this comparison used video trainers. Overall, 14 trials (382 participants) provided data for quantitative comparison of different methods of box training. There were no trials comparing box model training versus animal model or cadaveric model training. Box model training versus no training: The meta-analysis showed that the time taken for task completion was significantly shorter in the box trainer group than the control group (8 trials; 249 participants; SMD -0.48 seconds; 95% CI -0.74 to -0.22). Compared with the control group, the box trainer group also had lower error score (3 trials; 69 participants; SMD -0.69; 95% CI -1.21 to -0.17), better accuracy score (3 trials; 73 participants; SMD 0.67; 95% CI 0.18 to 1.17), and better composite performance scores (SMD 0.65; 95% CI 0.42 to 0.88). Three trials reported movement distance but could not be meta-analysed as they were not in a format for meta-analysis. There was significantly lower movement distance in the box model training compared with no training in one trial, and there were no significant differences in the movement distance between the two groups in the other two trials. None of the remaining secondary outcomes such as mortality and morbidity were reported in the trials when animal models were used for assessment of training, error in movements, and trainee satisfaction. Different methods of box training: One trial (36 participants) found significantly shorter time taken to complete the task when box training was performed using a simple cardboard box trainer compared with the standard pelvic trainer (SMD -3.79 seconds; 95% CI -4.92 to -2.65). There was no significant difference in the time taken to complete the task in the remaining three comparisons (reverse alignment versus forward alignment box training; box trainer suturing versus box trainer drills; and single incision versus multiport box model training). There were no significant differences in the error score between the two groups in any of the comparisons (box trainer suturing versus box trainer drills; single incision versus multiport box model training; Z-maze box training versus U-maze box training). The only trial that reported accuracy score found significantly higher accuracy score with Z-maze box training than U-maze box training (1 trial; 16 participants; SMD 1.55; 95% CI 0.39 to 2.71). One trial (36 participants) found significantly higher composite score with simple cardboard box trainer compared with conventional pelvic trainer (SMD 0.87; 95% CI 0.19 to 1.56). Another trial (22 participants) found significantly higher composite score with reverse alignment compared with forward alignment box training (SMD 1.82; 95% CI 0.79 to 2.84). There were no significant differences in the composite score between the intervention and control groups in any of the remaining comparisons. None of the secondary outcomes were adequately reported in the trials.

AUTHORS' CONCLUSIONS

The results of this review are threatened by both risks of systematic errors (bias) and risks of random errors (play of chance). Laparoscopic box model training appears to improve technical skills compared with no training in trainees with no previous laparoscopic experience. The impacts of this decreased time on patients and healthcare funders in terms of improved outcomes or decreased costs are unknown. There appears to be no significant differences in the improvement of technical skills between different methods of box model training. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the impacts of box model training on surgical skills in both the short and long term, as well as clinical outcomes when the trainee becomes competent to operate on patients.

Performance analysis on physical simulator of four different instrument setups in laparo-endoscopic single-site (LESS) surgery

BACKGROUND

Over the past decades, minimally invasive surgery has undergone continuous development due to the demand for scarless results, with laparo-endoscopic single-site (LESS) surgery constituting one of today's most favored alternatives. In this study, we aim to assess the relative technical difficulty and performance benefits of dynamic articulating and pre-bent instruments, either combined with conventional laparoscopic tools or not, during the completion of two basic tasks hands-on simulator.

METHODS

A total of 20 surgeons were included and performed two basic simulator tasks-coordination and cutting-carried out using four different combinations of LESS-designed and straight conventional laparoscopy instruments. Assessment took place before and after the completion of a 14-week training program. Performance data were objectively analyzed over video recordings with an adapted global rating scale (a-GRS) for performance evaluation, combined with a registry of total trial completion time.

RESULTS

In the coordination task, the worst performance scores (p < 0.001) and longest completion times (p < 0.001 on first assessment and p < 0.01 on last assessment) were obtained with the two dynamic articulating tip instruments. On the cut trials, no significant differences between the different setups were found in a-GRS scores. The two dynamic articulating tip instruments also constituted the most time-demanding setup on both assessment trials (p < 0.05). The use of two dynamic articulating tip instruments showed significant improvement with training in all measured parameters except for performance in the cut task, in which the increase in a-GRS score was not significant.

CONCLUSIONS

We conclude that the least adequate instrument set for initiation in LESS surgery is the one that combines two dynamic articulating tip instruments, as this has consistently obtained the worst results in all trials. Further data on more complex tasks and on a complete learning and skills-acquisition program must be obtained to confirm these findings.

Have we learned from lessons of the past? A systematic review of training for single incision laparoscopic surgery

INTRODUCTION

Single incision laparoscopic surgery (SILS) represents the next step in laparoscopic surgery in further reducing the invasiveness of surgical procedures with cosmetic advantages. Recalling the increased rates of major complications at the advent of laparoscopic cholecystectomy 20 years ago, however, it is clear that appropriate training is required before adopting a new technique. This study aims to review the current evidence for training and skills acquisition for SILS.

METHODS

A comprehensive database search of PubMED, MEDLINE, EMBASE and Google Scholar was carried out. Studies considered for inclusion were those addressing SILS learning curves, skills acquisition, or training.

RESULTS

21 studies were included in the final analysis. Ten clinical case series with analysis of SILS learning curve demonstrated a significant learning curve for conventional multiport laparoscopic (LAP)-trained surgeons over the course of initial SILS cases, with several studies reporting increased risk of conversion and complication rates. Five laboratory-based studies demonstrated differences in SILS skills acquisition compared with LAP. Six studies describing SILS-specific training curricula were analysed, but none included a robust validation of the curriculum.

CONCLUSIONS

Clinical case series and laboratory-based skills acquisition studies demonstrate the unique requirements of SILS, with skill sets and ergonomic demands which cannot be directly adapted from existing LAP experience. Some studies have already reported higher complication rates in initial SILS cases. To avoid repeating the mistakes of the past, the implementation of an evidence- and competency-based SILS curriculum is necessary to ensure appropriate training of future SILS surgeons.