Tablet based simulation provides a new solution to accessing laparoscopic skills training

Face, Content, and Construct Validity Evaluation of Simulation Models in General Surgery Laparoscopic Training and Education: A Systematic Review

BACKGROUND

Laparoscopic technical surgical skills (LTS) are considered a fundamental competence for General Surgery residents. Several simulation tools (ST) have been explored to develop LTS. Although a plethora of systematic reviews evaluate the translation of LTS developed in simulation to real surgery, there is a lack of evidence that clarifies effectiveness of different validated ST in acquisition of LTS in surgical residents. The aim of this systematic review (SR) is to summarize published evidence on ST validation used for surgery education and training.

METHODS

A protocol was published in PROSPERO. A SR was carried out following PRISMA guidelines. Complete published articles in English or Spanish that validate either content or construct, plus another form of validation of ST to acquire LTS in general surgery were included. Articles that used only one validation or did not validate an ST were excluded.

RESULTS

1052 publications were initially identified across all searched databases. Title review identified 204 studies eligible for full text screening. 10 studies were included for final review. Two studies assessed both face and content, 4 face and construct, and 4 face, content and construct validity. None of the studies presented comparable outcomes due to metrics variation and scores used for the validation strategies.

CONCLUSIONS

This study assessed validated laparoscopic simulation models, particularly in content and construct validity. Articles reported an increased use of simulation models in laparoscopic training with positive feedback from trainees, but few studies reported validation of training model. Validation strategies are not standardized, limiting comparability between them.

Development and Validation of a Homemade and Low-Cost Three-Dimensional Laparoscopic Simulator for Novices

Background: The aim of this study was to design a low-cost three-dimensional (3D) laparoscopic simulator and validate its training effectiveness. Materials and Methods: We designed a low-cost 3D laparoscopic simulator using magnifying glass and cardboard box. Thirty-two laparoscopic novices were randomly divided into 3D group and two-dimensional (2D) group. The 3D group was trained on 3D simulator four times with 24 hours interval, and the 2D group was trained on 2D simulator. Five standardized laparoscopic tasks were performed by novices in each training. In the second part, subjects were transferred to the opposite simulator for one test after 24 hours of the fourth training. The completing time and errors for each task were recorded to assess the construct validity of simulator. Finally, the face validity and the content validity were evaluated through a closed-ended questionnaire. Results: There was no significant difference between the two groups in demographic or psychometric variables (P > .05). Compared with the 2D group, novices using 3D simulator had a better performance in five laparoscopic tasks, including a faster completing time (P < .001) and lower errors during training (P < .05). Additionally, the increased laparoscopic skill involved with our 3D simulator could be transferred to subsequent performance in 2D simulator (P < .05). Meanwhile, the score of face validity and content validity in our 3D simulator was significantly higher than that in 2D simulator (P < .05). Conclusion: Our 3D laparoscopic simulator effectively improved laparoscopic skills of novice surgeons, suggesting that the low-cost 3D simulator had satisfactory performance to satisfy requirement for novice training.

Effectiveness of the world's first 1-Day online hands-on laparoscopic suturing training during COVID-19 pandemic

We aimed to investigate the effectiveness of an online laparoscopic suturing training course conducted via an online meeting program. The mean needle loading, stitching, and knot-tying times were 77.3 s, 63.0 s, and 140.3 s, respectively on the initial test. Total laparoscopic suture time before the course was 273.8 s. After the course, time measures across all parameters decreased significantly (p < .001). The mean needle loading, suture passing, and knot tying times were 25.0 s, 31.0 s, and 34.6 s on the final test. The total intracorporeal suture time after the course was 90.0 s. The Objective and Structured Assessment of Technical Skills Scores significantly increased from 16.8 at the initial test to 25.4 at the final test (p < .001).IMPACT STATEMENTWhat is already known on this subject? Training models like box trainers and virtual reality simulators have frequently been shown to significantly improve laparoscopic skills.What the results of this study add? A 1-day online laparoscopic suturing course significantly reduces the intracorporeal suturing time.What the implications are of these findings for clinical practice and/or further research? Basis the results, online laparoscopic suturing training might become the new norm for training over conventional training given the benefits of cost and time savings.

Telementoring of in-home real-time laparoscopy using whatsapp messenger: An innovative teaching tool during the COVID-19 pandemic. A cohort study

Background

COVID-19 pandemic has decreased worldwide surgical activity, thus impairing the training of surgical residents. As a coping strategy, we opted for laparoscopic simulation with endotrainer; however, due to social distancing rules, a face-to-face tutoring training method is unfeasible. In this context telementoring using WhatsApp® Messenger (owned by Facebook Inc., Menlo Park, CA) with a Smartphone aims to train surgical residents in laparoscopy from their homes during the pandemic.

Methods

Trainers and surgical residents who were at home participated in this study. They used endotrainers with Smartphone cameras and were trained by video calls using WhatsApp. The baseline and final score of intracorporeal knotting was measured, according to the Fundamentals of Laparoscopic Surgery (FLS) methodology, measuring the difference in means with the paired t-test. Recommendations for virtual surgical tutoring were followed and user satisfaction was measured using the Likert scale.

Results

40 surgical residents participated. The average distance between the mentor and the trainee was 12.87 km. Average bandwidth was 32.5 Megabits per second (Mbits/s), latency was 424.5 ms (ms), good quality image with immediate feedback was achieved. The statistically significant difference between basal and final measurement was 23.7 points (p < 0.001). All participants found telementoring a good educational tool.

Conclusion

Smartphone telementoring using WhatsApp® Messenger is an effective educational tool for acquiring laparoscopic skills with a statistically significant difference. This type of training represents a new teaching resource in the light of the recommendations of social distancing during a pandemic.

Take-Home Laparoscopy Simulators in Pediatric Surgery: Is More Expensive Better?

Background: To increase complex minimally invasive skills (MIS), frequent training outside the clinical setting is of uttermost importance. This study compares two low-cost pediatric MIS simulators, which can easily be used preclinically. Materials and Methods: The LaparoscopyBoxx is a portable simulator without a tracking system, with costs ranging from €90 to €315. The EoSim simulator has a built-in camera and tracking system and costs range from €780 to €1800. During several pediatric surgical conferences and workshops (January 2017-December 2018), participants were asked to use both simulators. Afterward, they completed a questionnaire regarding their opinion on realism and didactic value, scored on a five-point Likert scale. Results: A total of 50 participants (24 experts and 25 target group, one unknown) evaluated one or both simulators. Both simulators scored well on the questionnaire. The LaparoscopyBoxx scored significantly better regarding the "on screen representation of the instrument actions" (mean 4.2 versus 3.5, P = .001), "training tool for pediatric surgery" (mean 4.4 versus 3.9, P = .005), and "appealing take-home simulator" (mean 4.6 versus 4.0, P = .002). Conclusion: The simulators tested in this study were both regarded an appealing take-home simulator. The LaparoscopyBoxx scored significantly better than the EoSim, even though this is a low budget simulator without tracking capabilities.

Home Surgical Skill Training Resources for Obstetrics and Gynecology Trainees During a Pandemic

Resources are available for remote laparoscopic and basic surgical training, including core skills, psychomotor, visual–spatial, and cognitive, to improve gaps in surgical training during the coronavirus disease 2019 (COVID-19) pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created a unique educational circumstance in which medical students, residents, and fellows find themselves with a gap in their surgical training. We reviewed the literature, and nine categories of resources were identified that may benefit trainees in preventing skill decay: laparoscopic box trainers, virtual reality trainers, homemade simulation models, video games, online surgical simulations, webinars, surgical videos, smartphone applications, and hobbies including mental imagery. We report data regarding effectiveness, limitations, skills incorporated, cost, accessibility, and feasibility. Although the cost and accessibility of these resources vary, they all may be considered in the design of remote surgical training curricula during this unprecedented time of the COVID-19 pandemic.

Impact of animated instruction on tablets and hands-on training in applying bimanual perineal support on episiotomy rates: an intervention study

INTRODUCTION AND HYPOTHESIS

In Palestine, episiotomy is frequently used among primiparous women.This study assesses the effect of training birth attendants in applying bimanual perineal support during delivery by either animated instruction on tablets or hands-on training on episiotomy rates among primiparous women.

METHODS

An interventional cohort study was performed from 15 October 2015 to 31 January 2017, including all primiparous women with singletons and noninstrumental vaginal deliveries at six Palestinian hospitals. Intervention 1 (animated instructions on tablets) was conducted in Hospitals 1, 2, 3, and 4. Intervention 2 (bedside hands-on training) was applied in Hospitals 1 and 2 only. Hospitals 5 and 6 did not receive interventions. Differences in episiotomy rates in intervention and nonintervention hospitals were assessed before and after the interventions and presented as p values using chi-square test, and odds ratios (OR) with 95% confidence intervals (CI). Differences in the demographic and obstetric characteristics were presented as p values using the Kruskal-Wallis test.

RESULTS

Of 46,709 women, 12,841 were included. The overall episiotomy rate in the intervention hospitals did not change significantly after intervention 1, from 63.1 to 62.1% (OR = 0.96, 95% CI 0.84-1.08), but did so after intervention 2, from 61.1 to 38.1% (OR = 0.39, 95% CI 0.33-0.47). Rates after Intervention 2 changed from 65.0 to 47.3% (OR = 0.52, 95% CI 0.40-0.67) in Hospital 1 and from 39.4 to 25.1% (OR = 0.49, 95% CI 0.35-0.68) in Hospital 2.

CONCLUSIONS

Hands-on training of bimanual perineal support during delivery of primiparous women was significantly more effective in reducing episiotomy rates than animated instruction videos alone.

Simulation platforms to assess laparoscopic suturing skills: a scoping review

BACKGROUND

Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted.

METHODS

A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence."

RESULTS

Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies.

CONCLUSION

We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Simulation-based training in laparoscopic urology - Pros and cons

Surgery is traditionally taught by using Halsteadian principle, which includes “see one, do one, teach one”. This principle relies on sheer volume of surgical exposure rather than a specific course structure. Simulation in minimally invasive surgery allows the learner to practice new motor skills in a safe and stress free environment outside the operating room, thereby decreasing the learning curve.

A non-structured exhaustive MEDLINE search was done using MeSH words: “Simulation, Urological Training, Training Models, Laparoscopy Urology, Laparoscopic Skill, Endotrainer, Surgical Simulators, Simulator Validation”. The “ Pros and Cons of simulation based training in laparoscopic urology” were studied.

Results were discussed along the following lines : 1. How does skill acquisition occur? 2. Factors affecting simulator-based training. 3. Description of types of simulators and models. 4. Validating a simulator. 5. Task analysis after training on a simulator. 6. How effectively does simulation based training, translate into improved surgical performance in real time?

Pros: Simulators have the ability to teach a novice basic psychomotor skills. Supervision and feedback enhance learning in a simulation-based training. They are supplements to and not a substitution for traditional method of teaching. These models can be used as a part of most of the surgical training curriculum.

Cons: Cost and availability are the key issues. The cost will determine the availability of the simulators at a center and the availability in turn would determine whether a trainee will get the opportunity to use the simulator. Also, teacher training is an important aspect which would help teachers to understand the importance of simulation in student training. The domains in which it would improve and the extent to which simulation will improve surgical skills is dependent on various factors. Most simulators cannot train a surgeon to deal with anatomical and physiological variations. At present, it is not possible to re-validate all the surgeons in terms of their surgical skills, using simulators.

Ensuring Competency of Novice Laparoscopic Surgeons-Exploring Standard Setting Methods and their Consequences

OBJECTIVE

Simulation-based assessment tools have been developed to allow for proficiency-based simulator training in laparoscopy. However, few studies have examined the consequences of different standard setting methods or examined what level of proficiency is considered adequate for trainees. The objectives of the present study were to explore the consequences of different standard setting methods and to examine the proficiency level that surgical trainees are expected to reach, before performing supervised surgery on patients.

DESIGN

Study participants undertook the Training and Assessment of Basic Laparoscopic Techniques test. The tests were video-recorded and rated using a simple scoring system based on number of errors and time. Participants were then asked to assess how high a score a novice should reach before performing supervised surgery on a patient. We then compared 3 methods of standard setting: expert performance level, contrasting groups method, and a modified Angoff method.

SETTING

The study was conducted at the Copenhagen Academy for Medical Education and Simulation. The academy provides surgical simulation training in laparoscopy for trainees at the hospitals in the Capital Region and the Zealand Region of Denmark.

PARTICIPANTS

Participants were recruited among surgical trainees in their first year of specialty training from surgery, gynecology, and urology departments. A total of 40 participants were included and completed the trial.

RESULTS

The different standard setting methods resulted in different pass/fail levels. At the expert performance level, the pass/fail level was 474 points-the contrasting groups method resulted in 358 points and the modified Angoff method resulted in 311 points among experienced surgeons, and 386 points among trainees. The different proficiency levels resulted in a failure rate of 0% to 50% of experienced surgeons and a pass rate of 0% to 25% of novices. Novice laparoscopic surgeons set a higher pass/fail level than experienced surgeons did (p = 0.008).

CONCLUSION

Required proficiency levels varies depending on the standard setting method used, which highlights the importance of using an established standard setting method to set the pass/fail level.

Take-home training in a simulation-based laparoscopy course

BACKGROUND

Simulation training can prepare trainees for clinical practice in laparoscopic surgery. Training on box trainers allows for simulation training at home, which studies have shown to be a feasible method of training. However, little research has been conducted into how to make it a more efficient method of training. Our aim was to investigate how box trainers are used in take-home training to help guide the design of take-home training courses.

METHODS

This study was designed using a mixed methods approach. Junior doctors participating in a laparoscopy curriculum, which included practising at home on box trainers, were invited. Quantitative data on training patterns was collected from logbooks. Qualitative data on the use of box trainers was retrieved from focus groups and individual interviews.

RESULTS

From logbooks, we found that 14 out of 18 junior doctors mixed their training modalities, and four practised first on box trainers then on virtual reality simulators. Twelve practised only at home, while five practised at both places and one practised solely at the simulation centre. After a delayed start, most practised for some time, then had a period without training and then started training again towards the end of the course. We found that the themes of the interviews were: training method, training pattern, feedback and self-regulation. Participants identified the lack of feedback as challenging but described how self-rating provided direction during unsupervised training. Mandatory training elements affected when and how much participants practised.

CONCLUSIONS

When participants practised at home, they took an individualised approach to training. They mixed their training at home with training at the simulation centre. Participants practised at the beginning and towards the end of the course. Self-rating helped to guide unsupervised training where feedback was not accessible. Curricular requirements and testing determined when and how much participants practised.

Simulation-based training for burr hole surgery instrument recognition

BACKGROUND

The use of simulation training in postgraduate medical education is an area of rapidly growing popularity and research. This study was designed to assess the impact of simulation training for instrument knowledge and recognition among neurosurgery residents.

METHODS

This was a randomized control trial of first year residents from neurosurgery residency training programs across Canada. Eighteen neurosurgery trainees were recruited to test two simulation-based applications: PeriopSim™ Instrument Trainer and PeriopSim™ for Burr Hole Surgery. The intervention was game-based simulation training for learning neurosurgical instruments and applying this knowledge to identify correct instruments during a simulated burr hole surgery procedure.

RESULTS

Participants showed significant overall improvement in total score (p < 0.0005), number of errors (p = 0.019) and time saved (p < 0.0005), over three testing sessions when using the PeriopSim™ Instrument Trainer. Participants demonstrated further performance-trained improvements when using PeriopSim™ Burr Hole Surgery.

CONCLUSIONS

Training in the recognition and utilization of simulated surgical instruments by neurosurgery residents improved significantly with repetition when using PeriopSim™ Instrument Trainer and PeriopSim™ for Burr Hole Surgery.

A systematic review of low-cost laparoscopic simulators

BACKGROUND

Opportunities for surgical skills practice using high-fidelity simulation in the workplace are limited due to cost, time and geographical constraints, and accessibility to junior trainees. An alternative is needed to practise laparoscopic skills at home. Our objective was to undertake a systematic review of low-cost laparoscopic simulators.

METHOD

A systematic review was undertaken according to PRISMA guidelines. MEDLINE/EMBASE was searched for articles between 1990 and 2014. We included articles describing portable and low-cost laparoscopic simulators that were ready-made or suitable for assembly; articles not in English, with inadequate descriptions of the simulator, and costs >£1500 were excluded. Validation, equipment needed, cost, and ease of assembly were examined.

RESULTS

Seventy-three unique simulators were identified (60 non-commercial, 13 commercial); 55 % (33) of non-commercial trainers were subject to at least one type of validation compared with 92 % (12) of commercial trainers. Commercial simulators had better face validation compared with non-commercial. The cost ranged from £3 to £216 for non-commercial and £60 to £1007 for commercial simulators. Key components of simulator construction were identified as abdominal cavity and wall, port site, light source, visualisation, and camera monitor. Laptop computers were prerequisite where direct vision was not used. Non-commercial models commonly utilised retail off-the-shelf components, which allowed reduction in costs and greater ease of construction.

CONCLUSION

The models described provide simple and affordable options for self-assembly, although a significant proportion have not been subject to any validation. Portable simulators may be the most equitable solution to allow regular basic skills practice (e.g. suturing, knot-tying) for junior surgical trainees.

Construction and validation of a low-cost surgical trainer based on iPhone technology for training laparoscopic skills

In this article, we describe the construction and validation of a laparoscopic trainer using an iPhone 5 and a plastic document holder case. The abdominal cavity was simulated with a clear plastic document holder case. On 1 side of the case, 2 holes for entry of laparoscopic instruments were drilled. We added a window to place the camera of the iPhone, which works as our camera of the trainer. Twenty residents carried out 4 tasks using the iPhone Trainer and a physical laparoscopic trainer. The time of all tasks were analyzed with a simple paired t test. The construction of the trainer took 1 hour, with a cost of <US$90. Results showed no significant differences in time for the 4 tasks performed in both the trainers. iPhone Trainer is a reusable and fully functional device that allows surgeons to practice their skills anywhere and at their own pace.

Comparison between Training Models to Teach Veterinary Medical Students Basic Laparoscopic Surgery Skills

The objective of this study was to compare the effectiveness of two different laparoscopic training models in preparing veterinary students to perform basic laparoscopic skills. Sixteen first- and second-year veterinary students were randomly assigned to a box trainer (Group B) or tablet trainer (Group T). Training and assessment for both groups included two tasks, "peg transfer" and "pattern cutting," derived from the well-validated McGill University Inanimate System for Training and Evaluation of Laparoscopic Skills. Confidence levels were compared by evaluating pre- and post-training questionnaires. Performance of laparoscopic tasks was scored pre- and post-training using a rubric for precision and speed. Results revealed a significant improvement in student confidence for basic laparoscopic skills (p<.05) and significantly higher scores for both groups in both laparoscopic tasks (p<.05). No significant differences were found between the groups regarding their assessment of the video quality, lighting, and simplicity of setup (p=.34, p=.15, and p=.43, respectively). In conclusion, the low-cost tablet trainer and the more expensive box trainer were similarly effective in preparing pre-clinical veterinary students to perform basic laparoscopic skills on a model.

Training Laparoscopic Skills at Home: Residents' Opinion of a New Portable Tablet Box Trainer

OBJECTIVE

To determine residents' opinion about a new portable box trainer, to see if they would be interested in using this for training at home, and to give an overview of the box trainers that could be used at home.

METHODS

An expert opinion study was performed among 27 gynecology residents to determine the value of the portable box trainer in training their laparoscopic skills and the value of using it at home. Their opinions were scored on a 5-point Likert scale.

RESULTS

Gynecology residents very much appreciated the portable box trainer in its design, size, visualization, light source, ability to record, and instruments (all median 4). They felt that the portable box trainer would be effective in training laparoscopic skills in general; in training hand-eye coordination, 3D perception, and tying knots (all median 4); and especially in training basic skills (median 5). Almost all residents would use the portable box trainer if they had one at home (median 5). The literature supports the hypothesis that training laparoscopic skills at home using a box trainer may be effective in acquiring and maintaining laparoscopic skills.

CONCLUSIONS

Training laparoscopic skills at home using a portable box trainer may be of added value in the laparoscopic training of surgical residents. Residents feel positive about using the new portable box trainer that is presented and appreciate the possibility of training at home.

Validity of a cross-specialty test in basic laparoscopic techniques (TABLT)

Background

Box trainer systems have been developed that include advanced skills such as suturing. There is still a need for a portable, cheap training and testing system for basic laparoscopic techniques that can be used across different specialties before performing supervised surgery on patients. The aim of this study was to establish validity evidence for the Training and Assessment of Basic Laparoscopic Techniques (TABLT) test, a tablet‐based training system.

Methods

Laparoscopic surgeons and trainees were recruited from departments of general surgery, gynaecology and urology. Participants included novice, intermediate and experienced surgeons. All participants performed the TABLT test. Performance scores were calculated based on time taken and errors made. Evidence of validity was explored using a contemporary framework of validity.

Results

Some 60 individuals participated. The TABLT was shown to be reliable, with an intraclass correlation coefficient of 0·99 (P < 0·001). ANOVA showed a difference between the groups with different level of experience (P < 0·001). The Bonferroni correction was used to confirm this finding. A Pearson's r value of 0·73 (P < 0·001) signified a good positive correlation between the level of laparoscopic experience and performance score. A reasonable pass–fail standard was established using contrasting groups methods.

Conclusion

TABLT can be used for the assessment of basic laparoscopic skills and can help novice surgical trainees in different specialties gain basic laparoscopic competencies.

Simple, cheap and valid

mHealth in Urology: A Review of Experts' Involvement in App Development

INTRODUCTION

Smartphones are increasingly playing a role in healthcare and previous studies assessing medical applications (apps) have raised concerns about lack of expert involvement and low content accuracy. However, there are no such studies in Urology. We reviewed Urology apps with the aim of assessing the level of participation of healthcare professionals (HCP) and scientific Urology associations in their development.

MATERIAL AND METHODS

A systematic search was performed on PubMed, Apple's App Store and Google's Play Store, for Urology apps, available in English. Apps were reviewed by three graders to determine the app's platform, target customer, developer, app type, app category, price and the participation of a HCP or a scientific Urology association in the development.

RESULTS

The search yielded 372 apps, of which 150 were specific for Urology. A fifth of all apps had no HCP involvement (20.7%) and only a third had been developed with a scientific Urology association (34.7%). The lowest percentage of HCP (13.4%) and urological association (1.9%) involvement was in apps designed for the general population. Furthermore, there was no contribution from an Urology society in "Electronic Medical Record" nor in "Patient Information" apps. A limitation of the study is that only Android and iOS apps were reviewed.

CONCLUSIONS

Despite the increasing Mobile Health (mHealth) market, this is the first study that demonstrates the lack of expert participation in the design of Urology apps, particularly in apps designed for the general public. Until clear regulation is enforced, the urological community should help regulate app development. Maintaining a register of certified apps or issuing an official scientific seal of approval could improve overall app quality. We propose that urologists become stakeholders in mHealth, shaping future app design and promoting peer-review app validation.

Development of a novel iPad-based laparoscopic trainer and comparison with a standard laparoscopic trainer for basic laparoscopic skills testing

INTRODUCTION

We developed the iTrainer (iT) as a portable laparoscopic trainer, which incorporates the iPad tablet. We then compared the iT with a standard pelvic trainer (SPT) to assess surgical skills as well as its image quality, resolution, brightness, comfort, and overall performance.

MATERIALS AND METHODS

We designed and constructed the iT to be compatible with the Apple iPad 3 and standard laparoscopic instruments. Participants were assigned to perform the thread-the-loops task on both trainers and were prospectively randomized to start on either the iT or the SPT. Each participant was allowed a 2-minute warm-up before the 2-minute testing period. We scored participants using the product of skill quality (0-4 scale) and quantity of loops threaded (0-10 scale). Participants then rated each trainer on image quality, resolution, brightness, comfort, and overall performance on a 5-point Likert scale.

RESULTS

A total of 45 subjects including 10 undergraduates, 10 medical students, 10 general surgery and urology residents, and 15 experts (fellows and attending surgeons) participated in this study. There was no significant difference between thread-the-loops task scores completed on the iT when compared with the SPT for all groups tested (p > 0.05) with the exception of the medical student group, who performed better on the SPT (p < 0.05). On evaluation of each trainer, participants rated the iT as having superior image quality and resolution when compared with the SPT (p < 0.05) but rated the SPT higher in overall performance (p < 0.05). Brightness and comfort were rated similarly for both trainers.

CONCLUSIONS

We have demonstrated face validity and criterion validity for the thread-the-loops task on the iT. The iT rated superior in image quality and resolution but inferior in overall performance compared with the SPT. The iT provides trainees a unique advantage over SPT as an additional resource to laparoscopic training as it is inexpensive, portable, and can be readily available for training.

Mobile medical and health apps: state of the art, concerns, regulatory control and certification

This paper examines the state of the art in mobile clinical and health-related apps. A 2012 estimate puts the number of health-related apps at no fewer than 40,000, as healthcare professionals and consumers continue to express concerns about the quality of many apps, calling for some form of app regulatory control or certification to be put in place. We describe the range of apps on offer as of 2013, and then present a brief survey of evaluation studies of medical and health-related apps that have been conducted to date, covering a range of clinical disciplines and topics. Our survey includes studies that highlighted risks, negative issues and worrying deficiencies in existing apps. We discuss the concept of ‘apps as a medical device’ and the relevant regulatory controls that apply in USA and Europe, offering examples of apps that have been formally approved using these mechanisms. We describe the online Health Apps Library run by the National Health Service in England and the calls for a vetted medical and health app store. We discuss the ingredients for successful apps beyond the rather narrow definition of ‘apps as a medical device’. These ingredients cover app content quality, usability, the need to match apps to consumers’ general and health literacy levels, device connectivity standards (for apps that connect to glucometers, blood pressure monitors, etc.), as well as app security and user privacy. ‘Happtique Health App Certification Program’ (HACP), a voluntary app certification scheme, successfully captures most of these desiderata, but is solely focused on apps targeting the US market. HACP, while very welcome, is in ways reminiscent of the early days of the Web, when many “similar” quality benchmarking tools and codes of conduct for information publishers were proposed to appraise and rate online medical and health information. It is probably impossible to rate and police every app on offer today, much like in those early days of the Web, when people quickly realised the same regarding informational Web pages. The best first line of defence was, is, and will always be to educate consumers regarding the potentially harmful content of (some) apps.