Face and content validity of Xperience™ Team Trainer: bed-side assistant training simulator for robotic surgery

Measures of performance and proficiency in robotic assisted surgery: a systematic review

Robotic assisted surgery (RAS) has seen a global rise in adoption. Despite this, there is not a standardised training curricula nor a standardised measure of performance. We performed a systematic review across the surgical specialties in RAS and evaluated tools used to assess surgeons' technical performance. Using the PRISMA 2020 guidelines, Pubmed, Embase and the Cochrane Library were searched systematically for full texts published on or after January 2020-January 2022. Observational studies and RCTs were included; review articles and systematic reviews were excluded. The papers' quality and bias score were assessed using the Newcastle Ottawa Score for the observational studies and Cochrane Risk Tool for the RCTs. The initial search yielded 1189 papers of which 72 fit the eligibility criteria. 27 unique performance metrics were identified. Global assessments were the most common tool of assessment (n = 13); the most used was GEARS (Global Evaluative Assessment of Robotic Skills). 11 metrics (42%) were objective tools of performance. Automated performance metrics (APMs) were the most widely used objective metrics whilst the remaining (n = 15, 58%) were subjective. The results demonstrate variation in tools used to assess technical performance in RAS. A large proportion of the metrics are subjective measures which increases the risk of bias amongst users. A standardised objective metric which measures all domains of technical performance from global to cognitive is required. The metric should be applicable to all RAS procedures and easily implementable. Automated performance metrics (APMs) have demonstrated promise in their wide use of accurate measures.

Face, content, and construct validity of the virtual immersive operating room simulator for training laparoscopic procedures

BACKGROUND

The aim of this work is to present the face, content, and construct validation of the virtual immersive operating room simulator (VIORS) for procedural training of surgeons' laparoscopic psychomotor skills and evaluate the immersive training experience.

METHODS

The VIORS simulator consists of an HMD Oculus Rift 2016 with a visor on a 1080 × 1200 pixel OLED screen, two positioning sensors with two adapted controls to simulate laparoscopic instruments, and an acrylic base to simulate the conventional laparoscopic setup. The immersion consists of a 360° virtual operating room environment, based on the EndoSuite at Hospital Infantil de Mexico Federico Gomez, which reproduces a configuration of equipment, instruments, and common distractions in the operating room during a laparoscopic cholecystectomy procedure. Forty-five surgeons, residents, and medicine students participated in this study: 27 novices, 13 intermediates, and 5 experts. They completed a questionnaire on the realism and operating room immersion, as well as their capabilities for laparoscopic procedural training, scored in the 5-point Likert scale. The data of instrument movement were recorded and analyzed using 13 movement analysis parameters (MAPs). The experience during training with VIORS was evaluated through NASA-TLX.

RESULTS

The participants were enthusiastic about the immersion and sensation levels of the VIORS simulator, with positive scores on the realism and its capabilities for procedural training using VIORS. The results proved that the VIORS simulator was able to differentiate between surgeons with different skill levels. Statistically significant differences were found in nine MAPs, demonstrating their construct validity for the objective assessment of the procedural laparoscopic performance. At cognitive level, the inversion experience proves a moderate mental workload when the laparoscopic procedure is carried out.

CONCLUSION

The VIORS simulator has been successfully presented and validated. The VIORS simulator is a useful and effective device for the training of procedural laparoscopic psychomotor skills.

The role of the bedside assistant in robot-assisted surgery: A critical synthesis

INTRODUCTION

Robot-assisted surgery has grown exponentially since its inception and first approval in the United States in the year 2000. The surgeon operating with the assistance of the robot sits remotely to the patient and another practitioner assists at the bedside. The role of the bedside assistant and the training that is required to undertake this role are understudied topics.

AIM

To explore the functions, training and professional development of the bedside assistant in robot-assisted surgery and propose the necessary foundations for the safe enactment of the role in the United Kingdom.

METHODS

Through critical interpretative synthesis, relevant literature was systematically searched and analysed to inform integration of evidence.

RESULTS

Seventy-three studies were retrieved from the literature, across several health care disciplines and surgical specialities. These were critically analysed to inform a theoretically sound account grounded on evidence.

CONCLUSION

The role, functions and skills of the bedside assistant in robot-assisted surgery vary across contexts. These were analysed and critically synthetised to produce several keys to the success of bedside assistants in robot-assisted surgery in the context of the United Kingdom and of its national regulations.

Development, manufacture and initial assessment of validity of a 3-dimensional-printed bowel anastomosis simulation training model

Background

It is critical that junior residents be given opportunities to practise bowel anastomosis before performing the procedure in patients. Three-dimensional (3D) printing is an affordable way to provide realistic, reusable intestinal simulators. The aim of this study was to test the face and content validity of a 3D-printed simulator for bowel anastomosis.

Methods

The bowel anastomosis simulator was designed and assembled with the use of desktop 3D printers and silicone solutions. The production cost ranges from $2.67 to $131, depending on which aspects of the model one prefers to include. We incorporated input from a general surgeon regarding design modifications to improve the realism of the model. Nine experts in general surgery (6 staff surgeons and 3 senior residents) were asked to perform an anastomosis with the model and then complete 2 surveys regarding face and content validity. Items were rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”).

Results

The overall average score for product quality was 3.58, indicating good face validity. The average score for realism (e.g., flexibility and texture of the model) was 3.77. The simulator was rated as being useful for training, with an overall average score of 3.98. In general, the participants agreed that the simulator would be a valuable addition to current simulation-based medical education (average score 4.11). They commented that the model would be improved by adding extra layers to simulate mucosa.

Conclusion

Experts found the 3D-printed bowel anastomosis simulator to be an appropriate tool for the education of surgical residents, based on the model’s texture, appearance and ability to undergo an anastomosis. This model provides an affordable way for surgical residents to learn bowel anastomosis. Future research will focus on proving educational efficacy, effectiveness and transfer that can be adapted for laparoscopic anastomosis training, hand-sewing and stapling procedures.

Implementation of a standardized robotic assistant surgical training curriculum

Since 2000, robotic-assisted surgery has rapidly expanded into almost every surgical sub-specialty. Despite the popularity of robotic surgery across the United States, a national consensus for standardized training and education of robotic surgeons or surgical teams remains absent. In this quality improvement initiative, a novel, stepwise iterative Robotic Assistant Surgical Training (RAST) curriculum was developed to broaden and standardize robotic bedside assistant training. Thirteen voluntary participants, capable of fulfilling the bedside assistant role, were evaluated to determine if RAST enhanced the learner's self-perceived level of confidence and comfort in their role as bedside assistant. A pre- and post-RAST training survey and a between-stages repeated-measures survey were conducted. All learner participants reported statistically significant increases in confidence and comfort after RAST training, (p =  < 0.001), and between each stage, F (2, 24 = 60.47, p < .001; [Formula: see text] = 0.834). Participant feedback regarding curriculum improvement was obtained, suggesting the desire for more training and practice, in smaller groups of 2-3 participants. One hundred percent of participants felt RAST was beneficial and that it should be implemented as standardized training during onboarding for all robotic bedside assistants. Thus, a standardized, stepwise iterative robotic bedside assistant curriculum increases learner preparedness, comfort, and confidence, safely away from the patient bedside.

Three Different Learning Curves Have an Independent Impact on Perioperative Outcomes After Robotic Partial Nephrectomy: A Comparative Analysis

Background

Robot-assisted partial nephrectomy (RAPN) has become widely accepted, but its different underlying types of learning curves have not been comparatively analyzed to date. This study aimed to determine and compare the impact that the learning curve of the department, the console surgeon, and the bedside assistant as well as patient-related factors has on the perioperative outcomes of RAPN.

Methods

The study retrospectively analyzed 500 consecutive transperitoneal RAPNs (2007–2018) performed in a tertiary referral center by 7 surgeons and 37 bedside assistants. Patient characteristics and surgical data were obtained. Experience (EXP) was defined as the current number of RAPNs performed by the department, the surgeon, and the assistant. As the primary outcome, the impact of EXP and patient-related factors on perioperative outcomes were analyzed and compared. As the secondary outcome, a cutoff between “experienced” and “inexperienced” was defined. Correlation and regression analysis, receiver operating characteristic curve analysis, Fisher’s exact test, and the Mann–Whitney U test were performed, with p values lower than 0.05 denoting significance.

Results

The EXP of the department, the surgeon, and the assistant each has a major influence on perioperative outcome in RAPN irrespective of patient-related factors. Perioperative outcomes improve significantly with EXP greater than 100 for the department, EXP greater than 35 for the surgeon, and EXP greater than 15 for the assistant.

Conclusions

The perioperative results of RAPN are influenced by three different types of learning curves including those for the surgical department, the console surgeon, and the assistant. The influence of the bedside assistant clearly has been underestimated to date because it has a significant impact on the perioperative outcomes of RAPN.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08856-1) contains supplementary material, which is available to authorized users.

Surgical apprenticeship in the era of simulation

The new tools for transmission of knowledge and skills (simulation, surgery broadcast, virtual reality, augmented reality…) offer novel opportunities for training through mentoring. The peer network is widened; the dissemination of knowledge is accelerated. The new ways of teaching bring benefit to each aspect of the surgical profession: clinical reasoning, performance of technical procedures, stress management, communication and management of severe or exceptional adverse events. Previously, confined to surgical teams, mentoring has been extended to simulation centers, which are becoming virtual hospitals, and it has been prolonged on the Internet via social networks. In the sphere of digital mentoring, objectives are henceforth more structured, skills assessment is more standardized, phases of apprenticeship are redefined, and individualized training contracts are formalized.

Residency training in robotic surgery: The role of simulation

Simulation has become increasingly important in surgical teaching in recent years and the French National Authority for Health (HAS) recently underlined the goal and ethical priority: "never the first time on the patient". Simulation programs have been tested and validated for laparotomy and for laparoscopy, but there is not yet a validated program specific for robotic surgery. Due to substantial advances in this new technology, we have developed a program in Nancy dedicated to outside-the-operating room (OR) teaching of robotic surgery using the Da Vinci robot. This teaching is based on a combined program of theoretical teaching (e-learning) and learning of practical skills using virtual simulators (DV-Trainer®, Robotic Mentor®, DVSS®), mechanical simulators (Dome, Applied® abdominal simulators), microsurgery and wet lab using ex vivo animal organs, anesthetized animals, and cadavers. This program also emphasizes team training. The course is intended for residents in surgical training and is integrated into the specialized study diploma (DES) program for Visceral and Digestive Surgery; it also can be used by qualified surgeons who can integrate it with the Inter-University Diploma (DIU) in General Robotic Surgery for basic techniques and also for DIUs in other surgical specialties (digestive and gynecologic surgery) for robotic uses within their specialty. These courses are based on the concept of step-by-step skills acquisition and verification allowing a transition to safe clinical activity.

Understanding and Assessing Nontechnical Skills in Robotic Urological Surgery: A Systematic Review and Synthesis of the Validity Evidence

OBJECTIVE

Robotic urological surgery (RUS) has seen widespread adoption across institutions in the last decade. To match this rapid growth, it is imperative to develop a structured RUS curriculum that addresses both technical and nontechnical competencies. Emerging evidence has shown that nontechnical skills form a critical component of RUS training. The purpose of this review is to examine the validity evidence of available nontechnical skills assessment tools in RUS.

METHODS

A literature search of MEDLINE, EMBASE, and PsycINFO was conducted to identify primary articles using nontechnical skills assessment tools in RUS. Messick's validity framework and the Medical Education Research Study Quality Instrument were utilized to evaluate the quality of the validity evidence of the abstracted articles.

RESULTS

Of the 566 articles identified, 12 used nontechnical skills assessment tools in RUS. The metrics used ranged from self-assessment using global rating scales, to objective measures such as electroencephalography. The setting of these evaluations ranged from immersive and virtual reality-based simulators to live surgery.

CONCLUSIONS

Limited effort has been made to develop nontechnical skills assessment tools in RUS. Recently, there has been a shift from subjective to objective measures of nontechnical performance, as well as the development of assessments specific to RUS. However, the validity evidence supporting these nontechnical assessments is limited at this time, including their relationship to technical skills, and their impact on surgical outcomes.