Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices

Teaching With the GlobalSurgBox: Trainer Perceptions of a Portable Surgical Simulator

OBJECTIVES

Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation.

DESIGN

An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers.

SETTING

Academic medical training centers or conferences in the United States, Rwanda and Kenya.

PARTICIPANTS

10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident.

RESULTS

The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox.

CONCLUSION

The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

A scoping review on the trends of digital anatomy education

Digital technologies are changing the landscape of anatomy education. To reveal the trend of digital anatomy education across medical science disciplines, searches were performed using PubMed, EMBASE, and MEDLINE bibliographic databases for research articles published from January 2010 to June 2021 (inclusive). The search was restricted to publications written in English language and to articles describing teaching tools in undergraduate and postgraduate anatomy and pre-vocational clinical anatomy training courses. Among 156 included studies across six health disciplines, 35% used three-dimensional (3D) digital printing tools, 24.2% augmented reality (AR), 22.3% virtual reality (VR), 11.5% web-based programs, and 4.5% tablet-based apps. There was a clear discipline-dependent preference in the choice and employment of digital anatomy education. AR and VR were the more commonly adopted digital tools for medical and surgical anatomy education, while 3D printing is more broadly used for nursing, allied health and dental health education compared to other digital resources. Digital modalities were predominantly adopted for applied interactive anatomy education and primarily in advanced anatomy curricula such as regional anatomy and neuroanatomy. Moreover, there was a steep increase in VR anatomy combining digital simulation for surgical anatomy training. There is a consistent increase in the adoption of digital modalities in anatomy education across all included health disciplines. AR and VR anatomy incorporating digital simulation will play a more prominent role in medical education of the future. Combining multimodal digital resources that supports blended and interactive learning will further modernize anatomy education, moving medical education further away from its didactic history.

Simulator Fidelity Does Not Affect Training for Robot-Assisted Minimally Invasive Surgery

This study was undertaken to compare performance using a surgical robot after training with one of three simulators of varying fidelity. Methods: Eight novice operators and eight expert surgeons were randomly assigned to one of three simulators. Each participant performed two exercises using a simulator and then using a surgical robot. The primary outcome of this study is performance assessed by time and GEARS score. Results: Participants were randomly assigned to one of three simulators. Time to perform the suturing exercise (novices vs. experts) was significantly different for all 3 simulators. Using the da Vinci robot, peg transfer showed no significant difference between novices and experts and all participants combined (mean time novice 2.00, expert 2.21, p = 0.920). The suture exercise had significant differences in each group and all participants combined (novice 3.54, expert 1.90, p = 0.001). ANOVA showed p-Values for suturing (novice 0.523, expert 0.123) and peg transfer (novice 0.742, expert 0.131) are not significantly different. GEARS scores were different (p < 0.05) for novices and experts. Conclusion: Training with simulators of varying fidelity result in similar performance using the da Vinci robot. A dry box simulator may be as effective as a virtual reality simulator for training. Further studies are needed to validate these results.

Serious gaming and virtual reality in the multimodal training of laparoscopic inguinal hernia repair: a randomized crossover study

BACKGROUND

The aim of this study was to assess the transferability of surgical skills for the laparoscopic hernia module between the serious game Touch Surgery™ (TS) and the virtual reality (VR) trainer Lap Mentor™. Furthermore, this study aimed to collect validity evidence and to discuss "sources of validity evidence" for the findings using the laparoscopic inguinal hernia module on TS.

METHODS

In a randomized crossover study, medical students (n = 40) in their clinical years performed laparoscopic inguinal hernia modules on TS and the VR trainer. TS group started with "Laparoscopic Inguinal Hernia Module" on TS (phase 1: Preparation, phase 2: Port Placement and Hernia Repair), performed the module first in training, then in test mode until proficiency was reached. VR group started with "Inguinal Hernia Module" on the VR trainer (task 1: Anatomy Identification, task 2: Incision and Dissection) and also performed the module until proficiency. Once proficiency reached in the first modality, the groups performed the other training modality until reaching proficiency. Primary endpoint was the number of attempts needed to achieve proficiency for each group for each task/phase.

RESULTS

Students starting with TS needed significantly less attempts to reach proficiency for task 1 on the VR trainer than students who started with the VR trainer (TS = 2.7 ± 0.6 vs. VR = 3.2 ± 0.7; p = 0.028). No significant differences for task 2 were observed between groups (TS = 2.3 ± 1.1 vs. VR = 2.1 ± 0.8; p = 0.524). For both phases on TS, no significant skill transfer from the VR trainer to TS was observed. Aspects of validity evidence for the module on TS were collected.

CONCLUSION

The results show that TS brought additional benefit to improve performances on the VR trainer for task 1 but not for task 2. Skill transfer from the VR trainer to TS could not be shown. VR and TS should thus be used in combination with TS first in multimodal training to ensure optimal training conditions.

Ability to Perform Laparoscopic Intra- and Extracorporeal Suture Ligations in a Live Canine Ovariectomy Model after Simulation Training

Veterinary resident training in minimally invasive surgery is currently inconsistent and depends on innate psychomotor skills. Simulation training has been shown to effectively increase basic skills, but demonstration of simulation training effects on advanced skills in the operating room is sparse. We aimed to determine if simulation-trained novice surgeons were able to perform laparoscopic suture ligation in live dogs. Three novice laparoscopic surgeons underwent a 12-session simulation training program with subsequent laparoscopic skills testing to demonstrate competency. The median skills scores of trainees and of one experienced surgeon were 417 and 472, respectively. Eighteen healthy client-owned (shelter) dogs were operated on by four surgeons: one experienced American College of Veterinary Surgeons (ACVS) diplomate, two novice ACVS residents, and one novice ACVS diplomate. Laparoscopic ovariectomy was performed with suture ligation of the ovarian pedicles. Successful surgery was defined as no evidence of ovarian vessel bleeding after transection of the pedicles. Simulation-trained novices performed successful suture-ligated ovariectomies in 11/13 dogs (85%), and the experienced surgeon in 5/5 (100%) dogs. Median total ligation time was 30 minutes (range: 17-57), which was not different among surgeons (p = .118). Median total surgery time was 105 minutes (range: 69-156) for novices and 89 minutes (range: 65-99) for the experienced surgeon (p = .038). Extensive simulation training including suturing may contribute toward surgery residents being able to perform complex laparoscopic procedures. These results need to be confirmed in larger numbers of trainees.

Defining medical simulators for simulation-based education in EUS: Theoretical approach and a narrative review

Choosing the right simulator for tasks in simulation-based education in medicine will affect the trainees’ skills. However, there is a shortage in the vocabularies used for describing medical simulators and the contextual usage of simulators. We propose methods for approaching the task of choosing and defining the simulators needed, regardless of it being an acquisition or development process. It is advocated that efforts are made in defining the simulator's requirements before making any choice in regards to development processes. Multiple advantages are attained by keeping the simulator simple, both educational and development wise. Issues on validating simulators are discussed and highlighted as actions where interprofessional communication is likely to fail. The following conventional terms in medical education are problematic in regard to establishing a clear communication: Virtual reality, fidelity, validation, and simulation. The text is finalized in a short discussion on applying the methods in an EUS/endobronchial ultrasound (EBUS) context. The work is the authors’ interpretation of an invitation having the title “Development of EUS and EBUS training models and simulators.”

Tele-education assisted mentorship in surgery (TEAMS)

Tele-education assisted mentorship in surgery (TEAMS) is a novel methodology for surgical skills training with remote, hands-on, high-fidelity, and low-cost simulation-based education and one-to-one mentorship with longitudinal assessments. We review the background, methodology, and our experience with implementing TEAMS as an adjunct to traditional methods of surgical education and mentorship.

Time trial of dry box laparoscopic surgical training improves laparoscopic surgical skills and surgical outcomes

INTRODUCTION

The present study assessed the utility of a dry box time trial during laparoscopic surgical training to improve laparoscopic surgical skills and surgical outcomes.

METHODS

In a monthly time trial, surgeon trainees twice completed a set task that involved grasping a suture, aligning a needle with a needle holder, passing the suture, making three knots, and cutting the two tails of the suture. The mean suturing time was then analyzed. To assess the utility of this time trial, we analyzed the short-term outcomes of patients with stage I to III colon cancer who had undergone laparoscopic colectomy before and after the introduction of the time trial.

RESULTS

The monthly time trial was introduced in October 2018, and 52 surgeon trainees participated in the trials examined in this study. Within 6 months of the program's introduction, the mean suturing time had significantly declined to less than 70% of the time trial, while the standard deviations had declined to less than 30%. In comparisons of the short-term outcomes of laparoscopic colon cancer surgery before (n = 49) and after (n = 46) the introduction of the time trial, the operative time tended to decline (P = .074) after the introduction of the time trial, and blood loss was significantly reduced (P = .018). The rate of postoperative complications was similar before and after the introduction.

CONCLUSION

Regular time trials of laparoscopic surgical suture training using a dry box can be useful for improving laparoscopic surgical skills and surgical outcomes. Moreover, time trials can keep trainees motivated.

The development of laparoscopic skills using virtual reality simulations: A systematic review

Background

Teaching based on virtual reality simulators in medicine has expanded in recent years due to the limitations of more traditional methods, especially for surgical procedures such as laparoscopy.

Purpose of review

To analyze the effects of using virtual reality simulations on the development of laparoscopic skills in medical students and physicians.

Data sources

The literature screening was done in April 2020 through Medline (PubMed), EMBASE and Database of the National Institute of Health.

Eligibility criteria

Randomized clinical trials that subjected medical students and physicians to training in laparoscopic skills in virtual reality simulators.

Study appraisal

Paired reviewers independently identified 1529 articles and included 7 trials that met the eligibility criteria.

Findings

In all studies, participants that trained in virtual simulators showed improvements in laparoscopic skills, although the articles that also had a physical model training group did not show better performance of one model compared to the other.

Limitations

No article beyond 2015 met the eligibility criteria, and the analyzed simulators have different versions and models, which might impact the results.

Conclusion

Virtual reality simulators are useful educational tools, but do not show proven significant advantages over traditional models. The lack of standardization and a scarcity of articles makes comparative analysis between simulators difficult, requiring more research in the area, according to the model suggested in this review.

Systematic review registration number

Registered by the Prospective Register of Systematic Reviews (PROSPERO), identification code CRD42020176479.

An analysis of the cost of postgraduate training in surgery in Ireland compared to other specialties

Introduction

Postgraduate specialty training in Ireland is associated with considerable cost. Some of these are mandatory costs such as medical council fees, while others are necessary to ensure career progression, such as attendance at courses and conferences. In particular, surgical specialities are believed to be associated with high training costs. It is unknown how these costs compare to those borne by counterparts in other specialities.

Aims

The aims of this study were to

Quantify the amount that trainees in Ireland spend on postgraduate training

Determine whether a difference exists between surgery and other non-skill-based specialties in terms of expenditure on training

Methods

A standardised non-mandatory questionnaire was circulated to trainees across two training centres in Ireland. Trainees at all levels were invited to participate.

Results

Sixty responses were obtained. Fifty-seven questionnaires were fully completed and included for analysis. The median expenditure on training was higher for surgical than non-surgical specialities. Subgroup analysis revealed surgical training was associated with higher expenditure on higher degrees and courses compared to medical training (p = 0.035). > 95% of trainees surveyed felt that greater financial support should be available for trainees during the course of their training.

Conclusions

This study demonstrated that a career in surgery is associated with higher ongoing costs for higher degrees and courses than counterparts in non-surgical training. All surgical trainees surveyed felt that better financial support should be available. Increasing financial support for may be a tangible way to mitigate against attrition during training.

Reshaping surgical specialist training in small animal surgery during and after the COVID-19 pandemic

Objective

To assess the perceived effects of the COVID‐19 pandemic on small animal surgical specialist training, among trainees and supervisors and to propose changes, based upon the results, that could be incorporated into training programs.

Study Design

Anonymous online questionnaire survey.

Sample Population

Eighty‐one eligible responses were collected in September 2020, including 52 European College of Veterinary Surgeons (ECVS) residents and 29 ECVS Diplomates acting as supervisors.

Methods

Descriptive statistics were used to analyze the data. Fisher's exact test was used to test for significance.

Results

A reduction in surgical case load was reported by 82% (n = 66/81) of respondents, with 82% (n = 54/66) of those believing that COVID‐19 had a mild‐to‐moderate impact on training. Compared to supervisors, residents were less likely to feel that appropriate guidance, a safe working environment, and measures to preserve training had been provided (p < .01). Only 45% (n = 22/49) of residents reported confidence with performing teleconsultations. Ninety percent (n = 73/81) of respondents considered online “case presentations” and “edited surgical video footage” as a positive ancillary tool.

Conclusion

COVID‐19 has resulted in a reduction in case load and training for the majority of residents. A discrepancy between the opinions of residents and supervisors was noted on various aspects of COVID‐19 related effects.

Impact

Open communication, as well as the use of additional training tools through digital platforms may help to preserve safe and effective training during times of decreased clinical activity. While this study has focused on surgical specialist training, the results could be applied to other disciplines.

The utilisation of 3D printing in paediatric neurosurgery

3D printing technology has evolved over the years and there is a growing interest in its application in paediatric neurosurgery. Modern 3D printers have enabled the development of patient-specific 3D models that provide a realistic representation of complex anatomies and will aid in planning complex procedures. Paediatric neurosurgical operations are challenging and hands-on training is restricted. Surgical simulation training with biomodel has provided a new paradigm for trainees to master their surgical skills before encountering similar scenarios in real-life environment. This paper reviews the aspects of 3D printing for preoperative planning and simulation-based surgical training in paediatric neurosurgery.

Evaluating the influence of music at different sound pressure levels on medical students' performance of standardized laparoscopic box training exercises

BACKGROUND

The influence of music on the performance of surgical procedures such as laparoscopy is controversial and methodologically difficult to quantify. Here, outcome measurements using laparoscopic box training tools under standardized conditions might offer a feasible approach. To date, the effect of music exposure at different sound pressure levels (SPL) on outcome has not been evaluated systematically for laparoscopic novices.

METHODS

Between May 2017 and October 2018, n = 87 students (49 males, 38 females) from Heidelberg University Medical School performed three different laparoscopy exercises using the "Luebecker Toolbox" that were repeated twice under standardized conditions. Time was recorded for each run. All students were randomly assigned to four groups exposed to the same music compilation but at different SPLs (50-80 dB), an acoustically shielded (earplug) group, or a control group (no intervention).

RESULTS

Best absolute performance was shown under exposure to 70 dB in all three exercises (a, b, c) with mean performance time of 121, 142, and 115 s (p < 0.05 for a and c). For the control group mean performance times were 157, 144, and 150 s, respectively. In the earplug group, no significant difference in performance was found compared to the control group (p > 0.05) except for exercise (a) (p = 0.011).

CONCLUSION

Music exposure seems to have beneficial effects on training performance. In comparison to the control group, significantly better results were reached at 70 dB SPL, while exposure to lower (50 or 60 dB) or higher (80 dB) SPL as well as under acoustic shielding did not influence performance.

Deep infiltrating endometriosis with sacral plexus involvement: Improving knowledge through human cadaver dissection

INTRODUCTION

The aim of this study was to assess a human cadaver model of sacral plexus dissection for learning about deep innervation in the female pelvis, and the latter's relationship with deep infiltrating endometriosis.

METHODS

This was a prospective, observational study. Eight residents in obstetrics and gynecology were tested before and after a lecture on innervation of the female pelvis and a cadaver dissection class. Standardized cadaver dissection was used to identify the sacral nerve roots S2 to S4, superior and inferior hypogastric plexuses, hypogastric nerve, and splanchnic nerves.

RESULTS

The residents' level of knowledge improved significantly after a one-hour lecture (p = 0.9.10^-5) and after a cadaver dissection class (p = 0.6.10^-6). The improvement was significantly greater for the dissection class (p = 0.0003). All the pelvic nerve structures were identified in all but one of the cadavers and had similar measurements. A vascular anatomical variant was observed in one case.

CONCLUSION

A human cadaver model is of value for learning about deep pelvic innervation and the latter's relationship with deep infiltrating endometriosis. The reproducibility and safety of cadaver dissection might improve surgical skills.

Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee

Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.

The application of virtual reality in the training of laparoscopic surgery: A systematic review and meta-analysis

BACKGROUND

Virtual reality becomes popular in laparoscopic surgery especially in the training process. An assessment on the learning curve of virtual reality compared to other methods of training or no training needed to be carried out.

MATERIALS AND METHODS

A systematic literature search between 2000 and 2020 was performed through PubMed, Cochrane library's Central, Embase, Clinicaltrials.gov, and Web of Science. All randomized controlled studies included kept the consistency of participants at the baseline and set the same time or repetitions of training. This systematic review and meta-analysis was under the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the methodological quality of systematic reviews(AMSTAR).

RESULTS

Twenty-three randomized controlled studies and five non-randomized concurrent controlled studies were included among 2692 searched studies. Virtual reality was recommended to be applied among no experience medical students or novice surgeons in the laparoscopic training. It had steeper learning curve compared to no training and traditional trainers. While there was no significant difference between virtual reality and box training or video training in the aspect of learning curve. Moreover, it seemed effective to improve the initial stage of learning curve in actual surgery.

CONCLUSION

Virtual reality was not the first choice to be applied into laparoscopic training and it had its applicable surgeons or medical students. The superiority of virtual reality in the skill transfer from training room into operating room needed to be confirmed and complemented with further analyses. More importantly, the cost-effectiveness of virtual reality in the training process and patient safety were badly in need of discussion.

Use of a Low-Cost Portable 3D Virtual Reality Simulator for Psychomotor Skill Training in Minimally Invasive Surgery: Task Metrics and Score Validity

Background

The high cost and low availability of virtual reality simulators in surgical specialty training programs in low- and middle-income countries make it necessary to develop and obtain sources of validity for new models of low-cost portable simulators that enable ubiquitous learning of psychomotor skills in minimally invasive surgery.

Objective

The aim of this study was to obtain validity evidence for relationships to other variables, internal structure, and consequences of testing for the task scores of a new low-cost portable simulator mediated by gestures for learning basic psychomotor skills in minimally invasive surgery. This new simulator is called SIMISGEST-VR (Simulator of Minimally Invasive Surgery mediated by Gestures - Virtual Reality).

Methods

In this prospective observational validity study, the authors looked for multiple sources of evidence (known group construct validity, prior videogaming experience, internal structure, test-retest reliability, and consequences of testing) for the proposed SIMISGEST-VR tasks. Undergraduate students (n=100, reference group), surgical residents (n=20), and experts in minimally invasive surgery (n=28) took part in the study. After answering a demographic questionnaire and watching a video of the tasks to be performed, they individually repeated each task 10 times with each hand. The simulator provided concurrent, immediate, and terminal feedback and obtained the task metrics (time and score). From the reference group, 29 undergraduate students were randomly selected to perform the tasks 6 months later in order to determine test-retest reliability.

Results

Evidence from multiple sources, including strong intrarater reliability and internal consistency, considerable evidence for the hypothesized consequences of testing, and partial confirmation for relations to other variables, supports the validity of the scores and the metrics used to train and teach basic psychomotor skills for minimally invasive surgery via a new low-cost portable simulator that utilizes interaction technology mediated by gestures.

Conclusions

The results obtained provided multiple sources of evidence to validate SIMISGEST-VR tasks aimed at training novices with no prior experience and enabling them to learn basic psychomotor skills for minimally invasive surgery.

Transferability of Simulation-Based Training in Laparoscopic Surgeries: A Systematic Review

Objective

The implementation of simulation-based training in residency programs has been increased, but the transferability of surgical skills in the real operating room is not well documented. In our survey, the role of simulation in surgical training will be evaluated. Study Design. In this systemic review, randomized control trials, which assessed the transferability of acquired skills through simulation in the real operating setting, were included. A systematic search strategy was undertaken using a predetermined protocol.

Results

Eighteen randomized clinical trials were included in this survey. Two studies investigated inguinal hernia repair, six laparoscopic cholecystectomy, five gynecologic procedures, two laparoscopic suturing, and two camera navigation during laparoscopic procedures. Simulation-trained participants showed superiority in surgical performance in comparison with untrained surgeons. The operation time, accuracy, incidence of intraoperative errors, and postoperative complications were statistically better in the simulation-trained group in comparison with the conventional-trained group.

Conclusion

Simulation provides a safe, effective, and ethical way for residents to acquire surgical skills before entering the operating room.

Assessment of training and selected factors on speed and quality of performing different tasks on the endoscopic simulator

Introduction

One of the most significant challenges nowadays is to educate and predict the predispositions of young surgeons taking into consideration that every ability has its own learning curve.

Aim

To determine the influence of selected factors and examine the shape and the length of the learning curve in performing simple tasks on an endoscopic simulator.

Material and methods

Twenty students took part in 4 training sessions with a one-week break between sessions. They were training 12 min and performed three tasks at every session on the endoscopic simulator. To identify whether selected factors influence the time of completing tasks, the participants were asked to fill in questionnaires. All participants also completed the Minnesota Manual Dexterity Test (MMDT) to assess hand-eye coordination.

Results

Our research reveals that regardless of activities performed in free time, the shape of the learning curve was logarithmic. Improvement after the fourth session ranged from 50% to 75%. Performing specific activities in the free time did not influence the results achieved on the simulator. No statistically significant correlation between MMDT results and the time to accomplish each task was found.

Conclusions

This study has shown that the length of the learning curve of performing simple tasks is quite short and the shape is logarithmic. It suggests that more complex exercises should be included in the training programme.

The effect of simulator fidelity on procedure skill training: a literature review

OBJECTIVES

To evaluate the effect of simulator fidelity on procedure skill training through a review of existing studies.

METHODS

MEDLINE, OVID and EMBASE databases were searched between January 1990 and January 2019. Search terms included "simulator fidelity and comparison" and "low fidelity" and "high fidelity" and "comparison" and "simulator". Author classification of low- and high-fidelity was used for non-laparoscopic procedures. Laparoscopic simulators are classified using a proposed schema. All included studies used a randomized methodology with two or more groups and were written in English. Data was abstracted to a standard data sheet and critically appraised from 17 eligible full papers.

RESULTS

Of 17 studies, eight were for laparoscopic and nine for other skill training. Studies employed evaluation methodologies, including subjective and objective measures. The evaluation was conducted once in 13/17 studies and before-after in 4/17. Didactic training only or control groups were used in 5/17 studies, while 10/17 studies included two groups only. Skill acquisition and simulator fidelity were different for the level of training in 1/17 studies. Simulation training was followed by clinical evaluation or a live animal evaluation in 3/17 studies. Low-fidelity training was not inferior to training with a high-fidelity simulator in 15/17 studies.

CONCLUSIONS

Procedure skill after training with low fidelity simulators was not inferior to skill after training with high fidelity simulators in 15/17 studies. Some data suggest that the effectiveness of different fidelity simulators depends on the level of training of participants and requires further study.

Large-Field-of-View Visualization with Small Blind Spots Utilizing Tilted Micro-Camera Array for Laparoscopic Surgery

Existing laparoscopic surgery systems use a single laparoscope to visualize the surgical area with a limited field of view (FoV), necessitating maneuvering the laparoscope to search a target region. In some cases, the laparoscope needs to be moved from one surgical port to another one to detect target organs. These maneuvers would cause longer surgical time and degrade the efficiency of operation. We hypothesize that if an array of cameras can be deployed to provide a stitched video with an expanded FoV and small blind spots, the time required to perform multiple tasks at different sites can be significantly reduced. We developed a micro-camera array that can enlarge the FoV and reduce blind spots between the cameras by optimizing the angle of cameras. The video stream of this micro-camera array was designed to be processed in real-time to provide a stitched video with the expanded FoV. We mounted this micro-camera array to a Fundamentals of Laparoscopic Surgery (FLS) laparoscopic trainer box and designed an experiment to validate the hypothesis above. Surgeons, residents, and a medical student were recruited to perform a modified bean drop task, and the completion time was compared against that measured using a traditional single-camera laparoscope. It was observed that utilizing the micro-camera array, the completion time of the modified bean drop task was 203±55 s while using the laparoscope, the completion time was 245±114 s, with a p-value of 0.00097. It is also observed that the benefit of using an FoV-expanded camera array does not diminish for subjects who are more experienced. This test provides convincing evidence and validates the hypothesis that expanded FoV with small blind spots can reduce the operation time for laparoscopic surgical tasks.

Virtual reality simulation to enhance laparoscopic salpingectomy skills

BACKGROUND

To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning.

METHODS

A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series.

RESULTS

26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased.

CONCLUSIONS

The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.

Three-Dimensional Peripheral Bloodstream Model of the Uterus for Laparoscopic Radical Hysterectomy

Trainees require extensive experience to perform radical hysterectomy. Before starting training during an actual operation, trainees should be familiar with the pelvic anatomy and should simulate surgical procedures. Many simulators are available for virtual reality training of laparoscopic operations, but they are very expensive. The materials required to construct our model included sponges and colored wires sold in home improvement stores that allowed for superior cost effectiveness. The model represented almost all peripheral vessels and nerves around the uterus, including the minor vessels. Attaching and detaching the vessels was easy, facilitating reconstruction of the dissected vessels. The wires were easy to bend, ensuring high operability. This model allows for the simulation of laparoscopic radical hysterectomy in a dry box. Our model was superior to a 2-dimensional picture for the memorization of branching and positional relationships of the blood vessels. Comparison of our model with actual operative videos showed that the dry box provided an identical surgical view of an actual laparoscopic radical hysterectomy. We developed a peripheral bloodstream model of the uterus for repeated simulation of laparoscopic radical hysterectomy with an actual surgical view using a dry box.

Different cognitive styles can affect performance in laparoscopic surgery skill training

BACKGROUND

The lack of depth cues and haptic feedback makes minimally invasive surgery a cognitive challenge. It is therefore important to know which individuals are expected to perform well in minimally invasive surgery. In cognitive psychology, methods are available with which one can measure different cognitive thinking styles. It is well known that these cognitive styles correlate with many different tasks. We investigated whether this method can also predict performance on a box trainer (Lübeck Toolbox^®), a device for training laparoscopic surgery. If so, the method might help to select and train those people who will most likely develop high skills in minimally invasive surgery.

METHODS

Thirty medical students and thirty non-medical students performed five laparoscopic surgical tasks on a box trainer. We measured the time required and the errors participants made on each task. Their cognitive style was measured with a method from cognitive psychology that distinguishes between people who think visually, spatially, or verbally. Furthermore, all students completed a subset of a standard intelligence test (Wechsler Adult Intelligence Scale) and three subtests of the German Medical University Admission Test (TMS).

RESULTS

Participants with spatial thinking styles performed best on the box trainer. Visual and verbal cognitive styles impeded box trainer performance. Performance on the box trainer could also be predicted by the TMS and IQ scores.

CONCLUSIONS

The study shows for the first time that a standard method from cognitive psychology can be used to distinguish between different cognitive styles in surgical education and that these different cognitive styles affect performance on a box trainer. Since the correlation between box trainer performance and surgical proficiency is well documented, the method might be an efficient way to reduce errors and to elevate patient safety in laparoscopic surgery.

Characterizing the learning curve of a virtual intracorporeal suturing simulator VBLaST-SS©

BACKGROUND

The virtual basic laparoscopic skill trainer suturing simulator (VBLaST-SS©) was developed to simulate the intracorporeal suturing task in the FLS program. The purpose of this study was to evaluate the training effectiveness and participants' learning curves on the VBLaST-SS© and to assess whether the skills were retained after 2 weeks without training.

METHODS

Fourteen medical students participated in the study. Participants were randomly assigned to two training groups (7 per group): VBLaST-SS© or FLS, based on the modality of training. Participants practiced on their assigned system for one session (30 min or up to ten repetitions) a day, 5 days a week for three consecutive weeks. Their baseline, post-test, and retention (after 2 weeks) performance were also analyzed. Participants' performance scores were calculated based on the original FLS scoring system. The cumulative summation (CUSUM) method was used to evaluate learning. Two-way mixed factorial ANOVA was used to compare the effects of group, time point (baseline, post-test, and retention), and their interaction on performance.

RESULTS

Six out of seven participants in each group reached the predefined proficiency level after 7 days of training. Participants' performance improved significantly (p < 0.001) after training within their assigned group. The CUSUM learning curve shows that one participant in each group achieved 5% failure rate by the end of the training period. Twelve out of fourteen participants' CUSUM curves showed a negative trend toward achieving the 5% failure rate after further training.

CONCLUSION

The VBLaST-SS© is effective in training laparoscopic suturing skill. Participants' performance of intracorporeal suturing was significantly improved after training on both systems and was retained after 2 weeks of no training.

Evaluating a Solely Mechanical Articulating Laparoscopic Device: A Prospective Randomized Crossover Study

BACKGROUND

The FlexDex^® (FD) is a solely mechanical articulating device that combines the functionality of robotic surgery with the relative low cost and simplicity of laparoscopy. We sought to evaluate the performance of first-time FD users while performing a simple suture task at locations of varying degrees of difficulty.

STUDY DESIGN

A prospective, randomized crossover study was performed comparing the FD to standard laparoscopy (SL). Two specific groups were evaluated; Group 1 consisted of complete novices, and Group 2 consisted of surgical trainees. Participants performed a simple suture with both FD and SL locations of varying degrees of difficulty (Easy, Moderate, and Hard). The following outcomes were evaluated: Instrument Function and Ergonomics (Comfort/Ergonomics survey), Task Difficulty (National Aeronautics and Space Administration Task Load Index [NASA-TLX]), Task Performance Quality (Objective Structured Assessment of Technical Skills [OSATS]), and Time (seconds).

RESULTS

Twenty-two participants were enrolled with 12 participants in Group 1 and 10 participants in Group 2. Group 1-FD participants experienced overall less shoulder strain (1.2 ± 0.40 versus 1.9 ± 0.90, P = .01), and Group 2-FD participants experienced less shoulder (2.5 ± 0.66 versus 4.0 ± 0.50, P = .01), back (1.1 ± 0.32 versus 1.9 ± 0.74, P = .01), and forearm strain (1.9 ± 0.88 versus 2.5 ± 1.1, P = .04). Group 1 participants using the FD experienced higher mental demand (73 ± 17 versus 48 ± 27, P < .01) and perceived effort (70 ± 20 versus 54 ± 23, P < .001). Both Group 1 and Group 2 FD participants performed tasks at the Hard location more effectively. Both Group 1 (70 versus 87, P = .21) and Group 2 (53 versus 60, P = .55) performed tasks at the Hard location in similar times, while Group 1 (80 versus 177, P = .03) and Group 2 (33 versus 70, P = .001) performed tasks at the Easy location in shorter times using SL.

CONCLUSIONS

This study demonstrates the first assessment of the FD, a mechanically articulating laparoscopic tool. First-time FD users demonstrated improved ergonomics and effectiveness suturing at difficult locations. Future studies will focus on comparison to robotic surgery and translation into clinical applications.

Virtual reality simulator versus box-trainer to teach minimally invasive procedures: A meta-analysis

BACKGROUND

To evaluate the effectiveness of virtual reality simulator (VRS) training compared to box-trainer training (BT) for learning outcomes in minimally invasive surgery (MIS) techniques.

MATERIALS AND METHODS

A systematic review of the literature was performed using CENTRAL, MEDLINE, EMBASE, Scopus, CINAHL, LILACS. The primary outcomes were time to perform MIS and performance score in MIS. After being selected, the articles were evaluated for methodological quality and risk of bias. The results were evaluated for quality of evidence and meta-analysis was performed.

RESULTS

20 randomized clinical trials were included in the qualitative analysis and 14 were used in the meta-analysis. VRS training was more efficient than BT training (P < 0.00001, 95% CI: 35.08 to -25.01) when evaluating participant time needed to complete the peg task. In descriptive analysis, VRS training was better than BT training in participant performance score to perform MIS. There was no statistical difference in the meta-analysis in the time needed to perform surgery, time to complete basic or advanced tasks and performance score for basic or advanced tasks.

CONCLUSIONS

VRS training was better than BT training in participant performance scores when performing MIS and in the time needed to complete the basic task of peg transfer. In all other outcomes, regardless of the student's level of experience or type of activity, the two forms of training were equivalent.

Validation of a virtual intracorporeal suturing simulator

BACKGROUND

Intracorporeal suturing is one of the most important and difficult procedures in laparoscopic surgery. Practicing on a FLS trainer box is effective but requires large number of consumables, and the scoring is somewhat subjective and not immediate. A virtualbasic laparoscopic skill trainer (VBLaST©) was developed to simulate the five tasks of the FLS Trainer Box. The purpose of this study is to evaluate the face and content validity of the VBLaST suturing simulator (VBLaST-SS©).

METHODS

Twenty-five medical students and residents completed an evaluation of the simulator. The participants were asked to perform the standard intracorporeal suturing task on both VBLaST-SS© and the traditional FLS box trainer. The performance scores on each system were calculated based on time (s), deviations to the black dots (mm), and incision gap (mm). The participants were then asked to finish a 13-item questionnaire with ratings from 1 (not realistic/useful) to 5 (very realistic/useful) regarding the face validity of the simulator. A Wilcoxon signed rank test was performed to identify differences in performance on the VBLaST-SS© compared to that of the traditional FLS box trainer.

RESULTS

Three questions from the face validity questionnaire were excluded due to lack of response. Ratings to 8 of the remaining 10 questions (80%) averaged above 3.0 out of 5. Average intracorporeal suturing completion time on the VBLaST-SS© was 421 (SD = 168 s) seconds compared to 406 (175 s) seconds on the box trainer (p = 0.620). There was a significant difference between systems for the incision gap (p = 0.048). Deviation in needle insertion from the black dot was smaller for the box trainer than the virtual simulator (1.68 vs. 7.12, p < 0.001).

CONCLUSION

Participants showed comparable performance on the VBLaST-SS© and traditional box trainer. Overall, the VBLaST-SS© system showed face validity and has the potential to support training for the suturing skills.

Comparative Effectiveness of Teaching Obstetrics and Gynaecological Procedural Skills on Patients versus Models: A randomized trial

Objective:

To compare the effectiveness of learning procedural skills on patients versus mannequins and models.

Methods:

Seventy four interns from two consecutive batches at the Department of Obstetrics and Gynaecolgy Unit-I at Jinnah Postgraduate Medical Center Karachi participated in the study between April and September 2014. Five basic skills; taking a cervical (Pap) smear, intrauterine contraceptive device insertion, manual vacuum aspiration, making/ suturing an episiotomy and active management of the third stage of labour were identified. Interns were randomly allocated to two training groups (Group-1 and 2 of thirty eight and thirty six trainees respectively), with Group-I received training on the five procedural skills on models and mannequins for four weeks while Group-II trained on patients initially. After an evaluation at four weeks the groups crossed over with a final evaluation at eight weeks. The evaluation was through identical objective structured assessment of technical skills on models and mannequins for both groups with standard checklists.

Results:

There was no significant difference in skills between the two groups at the four weeks assessment. However at the end of training, Group-1 trainees performed significantly better than Group 2 with higher overall tests scores (86.7 ± 2.7 versus 80.4 ± 4.8, p< 0.001). This difference was more marked in skills of intrauterine contraceptive device insertion, making and suturing an episiotomy and active management of third stage of labour.

Conclusion:

Our findings suggest that simulations using models and mannequins for developing procedural skills can be readily incorporated in training programs with potential benefits for teaching infrequently performed or more difficult procedures. Our data suggest potential benefits of initiation of trainings on simulations and mannequins followed by human subject exposure.

Development of a Laparoscopic Box Trainer Based on Open Source Hardware and Artificial Intelligence for Objective Assessment of Surgical Psychomotor Skills

Background. A trainer for online laparoscopic surgical skills assessment based on the performance of experts and nonexperts is presented. The system uses computer vision, augmented reality, and artificial intelligence algorithms, implemented into a Raspberry Pi board with Python programming language. Methods. Two training tasks were evaluated by the laparoscopic system: transferring and pattern cutting. Computer vision libraries were used to obtain the number of transferred points and simulated pattern cutting trace by means of tracking of the laparoscopic instrument. An artificial neural network (ANN) was trained to learn from experts and nonexperts’ behavior for pattern cutting task, whereas the assessment of transferring task was performed using a preestablished threshold. Four expert surgeons in laparoscopic surgery, from hospital “Raymundo Abarca Alarcón,” constituted the experienced class for the ANN. Sixteen trainees (10 medical students and 6 residents) without laparoscopic surgical skills and limited experience in minimal invasive techniques from School of Medicine at Universidad Autónoma de Guerrero constituted the nonexperienced class. Data from participants performing 5 daily repetitions for each task during 5 days were used to build the ANN. Results. The participants tend to improve their learning curve and dexterity with this laparoscopic training system. The classifier shows mean accuracy and receiver operating characteristic curve of 90.98% and 0.93, respectively. Moreover, the ANN was able to evaluate the psychomotor skills of users into 2 classes: experienced or nonexperienced. Conclusion. We constructed and evaluated an affordable laparoscopic trainer system using computer vision, augmented reality, and an artificial intelligence algorithm. The proposed trainer has the potential to increase the self-confidence of trainees and to be applied to programs with limited resources.

The laparoscopic inguinal and diaphragmatic defect (LIDD) model: a validation study of a novel box trainer model

BACKGROUND

Paediatric laparoscopic procedures are now becoming routine practice. Therefore, there is a need for simulated laparoscopic models to acquire part-procedural competency prior to direct patient contact in a safe learning environment. For this reason, we chose two paediatric conditions; inguinal hernia (IH) and congenital diaphragmatic hernia (CDH), which were combined to create the laparoscopic inguinal and diaphragmatic defect (LIDD) model. Our aim was to assess this novel surgical simulation model by determining its construct and content validity.

METHODS

A total of 107 participants completed the validation study: volunteer medical students (novices), surgical trainees (intermediate) and consultant surgeons (experts). Basic demographic data were collected. Subjects were shown a pre-recorded video of both exercises. The assessment exercise involved closing both the simulated inguinal or diaphragmatic hernial orifice. The task was assessed using a novel scoring system with a maximum score of 21 for IH model and 15 for the CDH. The content validity was assessed by a 6-point Likert scale of the expert group.

RESULTS

105/107 participants successfully completed the two exercises. Both aspects of the LIDD model revealed a statistical significance between the scores obtained by the three groups of subjects. Experts scored 20.3/21 for the IH and 14.8/15 for the CDH models which significantly higher than medical students (6.3/21 and 5.3/15; p < 0.05 for both) and trainees (11.2/21 and 9.3/15; p < 0.05 for both). Similarly, trainees performed significantly better than medical students in both models (p < 0.05). Therefore, the LIDD model was found to have a good construct validity. It was, however, unable to differentiate between the various levels of trainees in the intermediate group. Content validity from the experts revealed that there was a high score for the potential of both aspects of LIDD (4.8 and 4.8). There was also a high level of functional fidelity for task completion (4.0 and 4.0).

CONCLUSIONS

We have demonstrated both the construct and content validity of the LIDD model for both laparoscopic IH and CDH repair. It was able to successfully differentiate between the expert, trainees and inexperienced laparoscopic surgeons.

Validation of the Simulated Vaginal Hysterectomy Trainer

STUDY OBJECTIVE

To establish construct validity of the simulated vaginal hysterectomy trainer (SimVaHT).

DESIGN

A cross-sectional validation study (Canadian Task Force classification II-2).

SETTING

A single academic medical center in the United States.

SUBJECTS

Fourteen residents in obstetrics and gynecology (4 postgraduate year [PGY] 1, 4 PGY-2, 3 PGY-3 and 3 PGY-4). PGY-1 and PGY-2 residents were grouped to form the "junior level" cohort, whereas PGY-3 and PGY-4 residents comprised the "senior level" cohort.

INTERVENTIONS

Each participant underwent surgical skill simulation by performing a simulated vaginal hysterectomy on a practical, inexpensive vaginal hysterectomy trainer.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was resident surgical skill as assessed by the Objective Structured Assessment of Technical Skills Global Rating Scale (GRS). All obstetrics and gynecology residents were videotaped performing a simulated vaginal hysterectomy on the SimVaHT. The tapes were reviewed independently by 2 blinded urogynecology experts, each of whom provided a GRS score. The primary outcome was overall GRS scores. The secondary outcome was time to complete the exercise. GRS scores were compared between junior- and senior-level residents. Senior-level residents scored significantly higher on the GRS overall compared with junior-level residents (p = .008).

CONCLUSION

Construct validity was demonstrated for the SimVaHT. The SimVaHT is a practical and inexpensive tool that may improve resident vaginal surgical skills before their first case in the operating room.

Effect of Continuous Motion Parameter Feedback on Laparoscopic Simulation Training: A Prospective Randomized Controlled Trial on Skill Acquisition and Retention

OBJECTIVE

To investigate the effect of motion parameter feedback on laparoscopic basic skill acquisition and retention during a standardized box training curriculum.

DESIGN

A Lap-X Hybrid laparoscopic simulator was designed to provide individual and continuous motion parameter feedback in a dry box trainer setting. In a prospective controlled trial, surgical novices were randomized into 2 groups (regular box group, n = 18, and Hybrid group, n = 18) to undergo an identical 5-day training program. In each group, 7 standardized tasks on laparoscopic basic skills were completed twice a day on 4 consecutive days in fixed pairs. Additionally, each participant performed a simulated standard laparoscopic cholecystectomy before (day 1) and after training (day 5) on a LAP Mentor II virtual reality (VR) trainer, allowing an independent control of skill progress in both groups. A follow-up assessment of skill retention was performed after 6 weeks with repetition of both the box tasks and VR cholecystectomy.

SETTING

Muenster University Hospital Training Center, Muenster, Germany.

PARTICIPANTS

Medical students without previous surgical experience.

RESULTS

Laparoscopic skills in both groups improved significantly during the training period, measured by the overall task performance time. The 6 week follow-up showed comparable skill retention in both groups. Evaluation of the VR cholecystectomies demonstrated significant decrease of operation time (p < 0.01), path length of the left and right instrument, and the number of movements of the left and right instruments for the Hybrid group (all p < 0.001), compared to the box group. Similar results were found at the assessment of skill retention.

CONCLUSION

Simulation training on both trainers enables reliable acquisition of laparoscopic basic skills. Furthermore, individual and continuous motion feedback improves laparoscopic skill enhancement significantly in several aspects. Thus, training systems with feedback of motion parameters should be considered to achieve long-term improvement of motion economy among surgical trainees.

LapTrain: multi-modality training curriculum for laparoscopic cholecystectomy-results of a randomized controlled trial

BACKGROUND

Multiple training modalities for laparoscopy have different advantages, but little research has been conducted on the benefit of a training program that includes multiple different training methods compared to one method only. This study aimed to evaluate benefits of a combined multi-modality training program for surgical residents.

METHODS

Laparoscopic cholecystectomy (LC) was performed on a porcine liver as the pre-test. Randomization was stratified for experience to the multi-modality Training group (12 h of training on Virtual Reality (VR) and box trainer) or Control group (no training). The post-test consisted of a VR LC and porcine LC. Performance was rated with the Global Operative Assessment of Laparoscopic Skills (GOALS) score by blinded experts.

RESULTS

Training (n = 33) and Control (n = 31) were similar in the pre-test (GOALS: 13.7 ± 3.4 vs. 14.7 ± 2.6; p = 0.198; operation time 57.0 ± 18.1 vs. 63.4 ± 17.5 min; p = 0.191). In the post-test porcine LC, Training had improved GOALS scores (+ 2.84 ± 2.85 points, p < 0.001), while Control did not (+ 0.55 ± 2.34 points, p = 0.154). Operation time in the post-test was shorter for Training vs. Control (40.0 ± 17.0 vs. 55.0 ± 22.2 min; p = 0.012). Junior residents improved GOALS scores to the level of senior residents (pre-test: 13.7 ± 2.7 vs. 18.3 ± 2.9; p = 0.010; post-test: 15.5 ± 3.4 vs. 18.8 ± 3.8; p = 0.120) but senior residents remained faster (50.1 ± 20.6 vs. 25.0 ± 1.9 min; p < 0.001). No differences were found between groups on the post-test VR trainer.

CONCLUSIONS

Structured multi-modality training is beneficial for novices to improve basics and overcome the initial learning curve in laparoscopy as well as to decrease operation time for LCs in different stages of experience. Future studies should evaluate multi-modality training in comparison with single modalities.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00011040.

A randomized control trial to evaluate the importance of pre-training basic laparoscopic psychomotor skills upon the learning curve of laparoscopic intra-corporeal knot tying

Background

Training of basic laparoscopic psychomotor skills improves the acquisition of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial was designed to evaluate whether pre-training of basic skills, as laparoscopic camera navigation (LCN), hand-eye coordination (HEC), and bimanual coordination (BMC), and the combination of the three of them, has any beneficial effect upon the learning curve of LICK. The study was carried out in a private center in Asunción, Paraguay, by 80 medical students without any experience in surgery. Four laparoscopic tasks were performed in the ENCILAP model (LCN, HEC, BMC, and LICK). Participants were allocated to 5 groups (G1-G5). The study was structured in 5 phases. In phase 1, they underwent a base-line test (T₁) for all tasks (1 repetition of each task in consecutive order). In phase 2, participants underwent different training programs (30 consecutive repetitions) for basic tasks according to the group they belong to (G1: none; G2: LCN; G3: HEC; G4: BMC; and G5: LCN, HEC, and BMC). In phase 3, they were tested again (T₂) in the same manner than at T₁. In phase 4, they underwent a standardized training program for LICK (30 consecutive repetitions). In phase 5, they were tested again (T₃) in the same manner than at T₁ and T₂. At each repetition, scoring was based on the time taken for task completion system.

Results

The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). The LICK group learning curves fitted better to the two-phase exponential decay model. From these curves, the starting points (Y0), the point after HEC training/before LICK training (Y1), the Plateau, and the rate constants (K) were calculated. All groups, except for G4, started from a similar point (Y0). At Y1, G5 scored already better than the others (G1 p = .004; G2 p = .04; G3 p < .0001; G4 NS). Although all groups reached a similar Plateau, G5 has a quicker learning than the others, demonstrated by a higher K (G1 p < 0.0001; G2 p < 0.0001; G3 p < 0.0001; and G4 p < 0.0001).

Conclusions

Our data confirms that training improves laparoscopic skills and demonstrates that pre-training of all basic skills (i.e., LCN, HEC, and BMC) shortens the LICK learning curve.

Robotic Pancreatoduodenectomy Biotissue Curriculum has Validity and Improves Technical Performance for Surgical Oncology Fellows

OBJECTIVE

Obtaining the proficiency on the robotic platform necessary to safely perform a robotic pancreatoduodenectomy is particularly challenging. We hypothesize that by instituting a proficiency-based robotic training curriculum we can enhance novice surgeons' skills outside of the operating room, leading to a shorter learning curve.

DESIGN

A biotissue curriculum was designed consisting of sewing artificial organs to simulate a hepaticojejunostomy (HJ), gastrojejunostomy (GJ), and pancreaticojejunostomy (PJ). Three master robotic surgeons performed each biotissue anastomosis to assess validity. Using video review, trainee performance on biotissue drills was evaluated for time, errors and objective structured assessment of technical skills (OSATS) by 2 blinded graders.

SETTING

This study is conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital.

PARTICIPANTS

In total, 14 surgical oncology fellows completed the biotissue curriculum.

RESULTS

Fourteen fellows performed 196 anastomotic drills during the first year: 66 (HJ), 64 (GJ), and 66 (PJ). The fellows' performances were analyzed as a group by attempt. The attendings' first attempt outperformed the fellows' first attempt in all metrics for every drill (all p < 0.05). More than 5 analyzed attempts of the HJ, there was improvement in time, errors, and OSATS (all p < 0.01); however, no metric reached attending performance. For the GJ, time, errors, and OSATS all improved more than 5 attempts (all p < 0.01), whereas only errors and OSATS reached proficiency. For the PJ, errors and OSATS both improved over attempts (p < 0.01) and reached proficiency; however, time did not statistically improve nor reach proficiency. The graders scoring correlated for errors and OSATS (p < 0.0001).

CONCLUSION

A pancreatoduodenectomy biotissue curriculum has face and construct validity. The curriculum is feasible and improves errors and technical performance. Time is the most difficult technical parameter to improve. This curriculum is a valid tool for teaching robotic pancreatoduodenectomies with established milestones for reaching optimum performance.

Incorporating simulation into gynecologic surgical training

Today's educational environment has made it more difficult to rely on the Halstedian model of "see one, do one, teach one" in gynecologic surgical training. There is decreased surgical volume, but an increased number of surgical modalities. Fortunately, surgical simulation has evolved to fill the educational void. Whether it is through skill generalization or skill transfer, surgical simulation has shifted learning from the operating room back to the classroom. This article explores the principles of surgical education and ways to introduce simulation as an adjunct to residency training. We review high- and low-fidelity surgical simulators, discuss the progression of surgical skills, and provide options for skills competency assessment. Time and money are major hurdles when designing a simulation curriculum, but low-fidelity models, intradepartmental cost sharing, and utilizing local experts for simulation proctoring can aid in developing a simulation program.

Dominant hand, non-dominant hand, or both? The effect of pre-training in hand-eye coordination upon the learning curve of laparoscopic intra-corporeal knot tying

Background

Training of basic laparoscopic psychomotor skills improves both acquisition and retention of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial (RCT) was performed to evaluate the effect of different pre-training programs in hand-eye coordination (HEC) upon the learning curve of LICK.

Results

The study was performed in a private center in Asunción, Paraguay, by 60 residents/specialists in gynaecology with no experience in laparoscopic surgery. Participants were allocated in three groups. In phase ₁, a baseline test was performed (T₁, three repetitions). In phase 2, participants underwent different training programs for HEC (60 repetitions): G1 with both the dominant hand (DH) and the non-dominant hand (NDH), G2 with the DH only, G3 none. In phase 3, a post HEC/pre LICK training test was performed (T₂, three repetitions). In phase 4, participants underwent a standardized training program for LICK (60 repetitions). In phase 5, a final test was performed (T₃, three repetitions). The score was based on the time taken for task completion system. The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). For both HEC and LICK, the group learning curves fitted better to the two-phase exponential decay model. For HEC with the DH, G1 and G2 started from a similar point, but G1 reached a lower plateau at a higher speed. In G1, the DH curve started from a lower point than the NDH curve, but both curves reached a similar plateau at comparable speeds. For LICK, all groups started from a similar point, but immediately after HEC training and before LICK training, G1 scored better than the others. All groups reached a similar plateau but with a different decay, G1 reaching this plateau faster than the others groups.

Conclusions

This study demonstrates that pre-training in HEC with both the DH and the NDH shortens the LICK learning curve.

Box- or Virtual-Reality Trainer: Which Tool Results in Better Transfer of Laparoscopic Basic Skills?-A Prospective Randomized Trial

OBJECTIVE

Simulation training improves laparoscopic performance. Laparoscopic basic skills can be learned in simulators as box- or virtual-reality (VR) trainers. However, there is no clear recommendation for either box or VR trainers as the most appropriate tool for the transfer of acquired laparoscopic basic skills into a surgical procedure.

DESIGN

Both training tools were compared, using validated and well-established curricula in the acquirement of basic skills, in a prospective randomized trial in a 5-day structured laparoscopic training course. Participants completed either a box- or VR-trainer curriculum and then applied the learned skills performing an ex situ laparoscopic cholecystectomy on a pig liver. The performance was recorded on video and evaluated offline by 4 blinded observers using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. Learning curves of the various exercises included in the training course were compared and the improvement in each exercise was analyzed.

SETTING

Surgical Skills Lab of the Department of General and Visceral Surgery, University Hospital Muenster.

PARTICIPANTS

Surgical novices without prior surgical experience (medical students, n = 36).

RESULTS

Posttraining evaluation showed significant improvement compared with baseline in both groups, indicating acquisition of laparoscopic basic skills. Learning curves showed almost the same progression with no significant differences. In simulated laparoscopic cholecystectomy, total GOALS score was significantly higher for the box-trained group than the VR-trained group (box: 15.31 ± 3.61 vs. VR: 12.92 ± 3.06; p = 0.039; Hedge׳s g* = 0.699), indicating higher technical skill levels.

CONCLUSIONS

Despite both systems having advantages and disadvantages, they can both be used for simulation training for laparoscopic skills. In the setting with 2 structured, validated and almost identical curricula, the box-trained group appears to be superior in the better transfer of basic skills into an experimental but structured surgical procedure.

Cost Comparison of Fundamentals of Laparoscopic Surgery Training Completed With Standard Fundamentals of Laparoscopic Surgery Equipment versus Low-Cost Equipment

OBJECTIVE

Training for the Fundamentals of Laparoscopic Surgery (FLS) skills test can be expensive. Previous work demonstrated that training on an ergonomically different, low-cost platform does not affect FLS skills test outcomes. This study compares the average training cost with standard FLS equipment and medical-grade consumables versus training on a lower cost platform with non-medical-grade consumables.

DESIGN

Subjects were prospectively randomized to either the standard FLS training platform (n = 19) with medical-grade consumables (S-FLS), or the low-cost platform (n = 20) with training-grade products (LC-FLS). Both groups trained to proficiency using previously established mastery learning standards on the 5 FLS tasks. The fixed and consumable cost differences were compared.

SETTING

Training occurred in a surgical simulation center.

PARTICIPANTS

Laparoscopic novice medical student and resident physician health care professionals who had not completed the national FLS proficiency curriculum and who had performed less than 10 laparoscopic cases.

RESULTS

The fixed cost of the platform was considerably higher in the S-FLS group (S-FLS, $3360; LC-FLS, $879), and the average consumable training cost was significantly higher for the S-FLS group (S-FLS, $1384.52; LC-FLS, $153.79; p < 0.001). The LC-FLS group had a statistically discernable cost reduction for each consumable (Gauze $9.24 vs. $0.39, p = 0.002; EndoLoop $540.00 vs. $40.60, p < 0.001; extracorporeal suture $216.45 vs. $25.20, p < 0.001; intracorporeal suture $618.83 vs. $87.60, p < 0.001). The annual fixed and consumable cost to train 5 residents is $10,282.60 in the S-FLS group versus $1647.95 in the LC-FLS group.

CONCLUSIONS

This study shows that the average cost to train a single trainee to proficiency using a lower fixed-cost platform and non-medical-grade equipment results in significant financial savings. A 5-resident program will save approximately $8500 annually. Residency programs should consider adopting this strategy to reduce the cost of FLS training.

Association of gender and specialty interest with video-gaming, three-dimensional spatial analysis, and entry-level laparoscopic skills in third-year veterinary students

OBJECTIVE To determine whether gender or interest in pursuing specialty certification in internal medicine or surgery was associated with video-gaming, 3-D spatial analysis, or entry-level laparoscopic skills in third-year veterinary students. DESIGN Cross-sectional study. SAMPLE A convenience sample of 68 (42 female and 26 male) third-year veterinary students. PROCEDURES Participants completed a survey asking about their interest in pursuing specialty certification in internal medicine or surgery. Subsequently, participants' entry-level laparoscopic skills were assessed with 3 procedures performed in box trainers, their video-gaming skills were tested with 3 video games, and their 3-D spatial analysis skills were evaluated with the Purdue University Visualization of Rotations Spatial Test. Scores were assigned for laparoscopic, video-gaming, and 3-D spatial analysis skills. RESULTS Significantly more female than male students were interested in pursuing specialty certification in internal medicine (23/42 vs 7/26), and significantly more male than female students were interested in pursuing specialty certification in surgery (19/26 vs 19/42). Males had significantly higher video-gaming skills scores than did females, but spatial analysis and laparoscopic skills scores did not differ between males and females. Students interested in pursuing specialty certification in surgery had higher video-gaming and spatial analysis skills scores than did students interested in pursuing specialty certification in internal medicine, but laparoscopic skills scores did not differ between these 2 groups. CONCLUSIONS AND CLINICAL RELEVANCE For this group of students, neither gender nor interest in specialty certification in internal medicine versus surgery was associated with entry-level laparoscopy skills.

"Take-home" box trainers are an effective alternative to virtual reality simulators

BACKGROUND

Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS.

METHODS

After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared.

RESULTS

The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups.

CONCLUSIONS

This study suggests that a basic "take-home" BT is a suitable alternative to VRS.

Perceptions About the Present and Future of Surgical Simulation: A National Study of Mixed Qualitative and Quantitative Methodology

OBJECTIVES

Assess expert opinion on the current and future role of simulation in surgical education.

DESIGN

Expert opinion was sought through an externally validated questionnaire that was disseminated electronically.

PARTICIPANTS

Heads of Schools of Surgery (HoS) (and deputies) and Training Program Directors (TPD) (and deputies).

RESULTS

Simulation was considered a good training tool (HoS: 15/15, TPD: 21/21). The concept that simulation is useful mostly to novices and for basic skills acquisition was rejected (HoS: 15/15, TPDs: 21/21; HoS: 13/15, TPDs: 18/21). Further, simulation is considered suitable for teaching nontechnical skills (HoS: 13/15, TPDs: 20/21) and re-enacting stressful situations (HoS: 14/15, TPDs: 15/21). Most respondents also felt that education centers should be formally accredited (HoS: 12/15, TPDs: 16/21) and that consultant mentors should be appointed by every trust (HoS: 12/15, TPDs: 19/21). In contrast, there were mixed views on its use for trainee assessment (HoS: 6/15, TPDs: 14/21) and whether it should be compulsory (HoS: 8/15, TPDs: 11/21).

CONCLUSION

The use of simulation for the acquirement of both technical and nontechnical skills is strongly supported while views on other applications (e.g., assessment) are conflicting. Further, the need for center accreditation and supervised, consultant-led teaching is highlighted.

Development of a novel simulation model for assessment of laparoscopic camera navigation

BACKGROUND

Laparoscopic camera navigation is vital to laparoscopic surgery, yet often falls to the most junior member of the surgical team who has limited laparoscopic operating experience. Previously published reports on simulation models fail to address qualitative scoring of movement, method of communication and correct physician location with respect to patient position. The purpose of this study was to develop and evaluate a novel laparoscopic camera navigation simulation model that addresses these deficiencies.

METHODS

A novel, low-cost laparoscopic camera navigational maze was constructed from pliable foam for use in a standard laparoscopic surgery box trainer. Participants (n = 37) completed a camera navigation exercise by following a pre-recorded set of verbal instructions using correct anatomic terminology that is used in the operating room, to simulate an actual operating room experience of receiving verbal cues from senior surgeons. The sample group consisted of participants at various levels of Obstetrics and Gynecology training, representing novice to expert laparoscopists. Each trial was recorded with a multi-channel video camera. Performances were scored by a blinded evaluator for excess gross and fine camera movements as well as overt errors, including camera collisions and failure to follow directions.

RESULTS

Our model demonstrated evidence of validity by discriminating performance by level of laparoscopic experience with a statistically significant decrease in number of movements and errors in experts compared to novices. A trend emerged toward improvement with each additional year of training, with reduced variability among performances in more experienced participants.

CONCLUSIONS

This novel, low-cost box-trainer simulation model for laparoscopic camera navigation offers a mechanism for assessment of laparoscopic camera operation skills. Moreover, this model closely replicates operating room logistics and communication. Given the necessity for improved laparoscopic camera operation education, our model represents a unique, complementary tool to other laparoscopic simulation curricula.