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

Comparison of laparoscopic performance using low-cost laparoscopy simulators versus state-of-the-art simulators: a multi-center prospective, randomized crossover trial

INTRODUCTION

Simulator training is an efficient method for the development of basic laparoscopic skills. We aimed to investigate if low-cost simulators are comparable to more expensive box trainers regarding surgeons usability, likability, and performance.

METHODS

This multi-center, randomized crossover study included 16 medical students, seven abdominal surgeons, and seven urological surgeons. Participants performed four laparoscopic tasks (peg transfer, circle cutting, balloon resection, suture and knot) on both, a "Low cost trainer" (LCT) or a "high cost trainer" (HCT) in a randomized order. The primary endpoint was the subjective rating of both training simulators in terms of camera view, depth perception, movement of instruments, pricing, and usability for training. Secondary endpoints were force parameters, task completion time, surgical errors, and psychological workload.

RESULTS

Participants rated the LCT better concerning view (p < 0.001), depth perception (p = 0.003), pricing (p < 0.001), and usability for digital training (p < 0.001), but worse in terms of instrument movement (p = 0.004). Overall, the LCT was rated better than the HCT (p = 0.015). Regarding force parameters, participants showed a significantly lower force exertion on the HCT during the peg transfer task (p = 0.008). The force exertion in the other tasks were comparable between both trainers. Participants were significantly faster using the HCT during the peg transfer (p = 0.049) and significantly slower in balloon resection (p = 0.049) and suture and knot task (p = 0.026). The assessment of the participants' workload showed no differences.

CONCLUSION

The LCT was generally rated better than the HCT. The differences concerning force exertion and task completion time showed better results during peg transfer at the HCT but were generally inconclusive and without systemic advantage for either trainer. However, the LCT could be a promising and cost-effective augmentation for modern laparoscopic training.

Advancing laparoscopic skills training in Namibia: Implementation of the Global Laparoscopic Advancement Program (GLAP) of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

BACKGROUND

In low- and middle-income countries (LMICs), laparoscopic surgery is challenging to implement due to limited resources and lack of expert surgeons as teachers. The Global Laparoscopic Advancement Program (GLAP) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to deliver sustainable and effective methods for teaching safe laparoscopic surgery. GLAP aims to train surgical leaders and trainees with the goal of eventual in-country replication of GLAP programming. After successful implementation in Mexico and Costa Rica, this study evaluates the feasibility of a pilot training course in Namibia, Southern Africa.

METHODS

In December 2022 and September 2023, GLAP partnered with the Namibian Surgical Society and the College of Surgeons of East, Central, and Southern Africa (COSECSA) to administer 2 GLAP courses, with hands-on simulation practice and lectures on surgical education, training, and curriculum development. Participants completed surveys assessing their surgical background and experiences, their experience with simulation, and interest in curriculum development at their home institutions. Participants were also evaluated on their time to completion for the five FLS tasks during the initial and final days of the program.

RESULTS

Over two GLAP courses, there were a total of 31 practicing general, gynecologic, and urologic surgeons from Namibia, Ethiopia, Malawi, Somali, and Zambia, taught by 5-7 GLAP faculty members. Overall, 35.5% had formal laparoscopic training during residency or fellowship, 16.13% had no experience with laparoscopy, and 77.42% learned laparoscopy through observation. Fifty-three percent of respondents had never practiced laparoscopy on a simulator before and 45% of respondents noted they did not have mentors to help them learn laparoscopic skills. Eighty percent of participants noted lack of equipment as the most important factor limiting the use of laparoscopy, followed by 76% noting lack of trained surgeons and 73% noting lack of formal training. The majority of respondents noted a very strong desire for formal training (61%), including additional short-term courses in laparoscopy (58%) and FLS skills testing opportunities (63%) in the future. For skills acquisition, there was a statistically significant reduction in the time to complete the circle cut task at the end of the course (359.2 s vs 206 s, p-value 0.016) across both years.

CONCLUSIONS

There is limited adoption of laparoscopy in Namibia, hindered by lack of training, expert trainers, and equipment. Implementation of GLAP is feasible and offers an additional training opportunity to the region.

A Novel Do-It-Yourself Approach to Simulating Minimally Invasive Laparoscopic Surgery

In 2008, the American Board of Surgery required residents to pass a laparoscopic fundamentals examination to sit for the boards. As such, minimally invasive surgery became the newest addition as a requisite skill for surgical trainees. To assist in preparing trainees for future surgery, simulation devices have been integrated into training programs to develop proficiency with laparoscopic and arthroscopic techniques. While effective, one of the biggest obstacles to accessing these devices is the thousands of dollars required for the equipment. Many commercial and do-it-yourself (DIY) iterations of low-cost, portable, laparoscopic simulators have been described to address this. While the price point ranges from 300 to 400 dollars, these DIY simulators primarily utilize webcams, iPhones, and tablet cameras in a fixed position. This presents an inherent limitation in the simulator's accuracy as current laparoscopy surgery utilizes camera motion. This study presents a novel DIY simulator that portrays a more realistic view of the operative field using camera motion and positioning, costing approximately 200 dollars. This proposed simulator uses a Universal Serial Bus (USB) endoscope with interchangeable side mirrors. We inserted an endoscope with built-in light-emitting diode (LED) lights into a seamless stainless tube for the laparoscope and attached it to a computer for configuration. To simulate the abdominal cavity, holes were drilled into a ½ torso hollow mannequin at the standard port locations for laparoscopic cholecystectomy, and rubber grommets were inserted into the drilled holes. Trocars were constructed using cross-linked polyethylene (PEX) tubing and #8 rubber stoppers. By creating a more affordable and easily constructed model, acquiring laparoscopic skills is more accessible. Simulators are becoming an essential part of medical training. Affordable simulators like ours allow trainees to develop their laparoscopic skill set at their own pace and convenience. More research into this can potentially lead to increased exposure to more accurate simulators and facilitate more accessible training for performing minimally invasive surgery in any surgical specialty.

The feasibility and benefit of unsupervised at-home training of minimally invasive surgical skills

BACKGROUND

Simulation-based training may be used to acquire MIS skills. While mostly done in a simulation center, it is proposed that this training can be undertaken at-home as well. The aim of this study is to evaluate whether unsupervised at-home training and assessment of MIS skills is feasible and results in increased MIS skills.

METHODS

Medical doctors and senior medical students were tested on their innate abilities by performing a pre-test on a take-home simulator. Henceforth, they followed a two-week interval training practicing two advanced MIS skills (an interrupted suture with knot tying task and a precise peg transfer task) and subsequently performed a post-test. Both tests and all training moments were performed at home. Performance was measured using motion analysis software (SurgTrac) and by expert-assessment and self-assessment using a competency assessment tool for MIS suturing (LS-CAT).

RESULTS

A total of 38 participants enrolled in the study. Participants improved significantly between the pre-test and the post-test for both tasks. They were faster (632 s vs. 213 s, p < 0.001) and more efficient (distance of instrument tips: 9.8 m vs. 3.4 m, p = 0.001) in the suturing task. Total LS-CAT scores, rated by an expert, improved significantly with a decrease from 36 at the pre-test to 20 at the post-test (p < 0.001) and showed a strong correlation with self-assessment scores (R 0.771, p < 0.001). The precise peg transfer task was completed faster (300 s vs. 163 s, p < 0.001) and more efficient as well (14.8 m vs. 5.7 m, p = 0.005). Additionally, they placed more rings correctly (7 vs. 12, p = 0.010).

CONCLUSION

Unsupervised at-home training and assessment of MIS skills is feasible and resulted in an evident increase in skills. Especially in times of less exposure in the clinical setting and less education on training locations this can aid in improving MIS skills.

Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) - Observational feasibility study

BACKGROUND

Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India.

METHODS

A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated.

RESULTS

Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers.

CONCLUSION

Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.

A Systematic Review and Meta-analysis on the Impact of Proficiency-based Progression Simulation Training on Performance Outcomes

OBJECTIVE

To analyze all published prospective, randomized, and blinded clinical studies on the proficiency-based progression (PBP) training using objective performance metrics.

BACKGROUND

The benefit of PBP methodology to learning clinical skills in comparison to conventional training is not settled.

METHODS

Search of PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases, from inception to 1st March 2020. Two independent reviewers extracted the data. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess the methodological quality of included studies. Results were pooled using biased corrected standardized mean difference and ratio-of-means. Summary effects were evaluated using a series of fixed and random effects models. The primary outcome was the number of procedural errors performed comparing PBP and non-PBP-based training pathways. Secondary outcomes were the number of procedural steps completed and the time to complete the task/procedure.

RESULTS

From the initial pool of 468 studies, 12 randomized clinical studies with a total of 239 participants were included in the analysis. In comparison to the non-PBP training, ratio-of-means results showed that PBP training reduced the number of performance errors by 60% (P < 0.001) and procedural time by 15% (P = 0.003) and increased the number of steps performed by 47% (P < 0.001).

CONCLUSIONS AND RELEVANCE

Our systematic review and meta-analysis confirms that PBP training in comparison to conventional or quality assured training improved trainees' performances, by decreasing procedural errors and procedural time, while increasing the number of correct steps taken when compared to standard simulation-based training.

Piloting the FIRE: A Novel Error Management Training Simulation Curriculum for Fasciotomy Instruction

BACKGROUND

Multiple studies have demonstrated poor performance of lower extremity fasciotomy (LEF), highlighted by missed and/or inadequately released compartments. Incorporating error management training (EMT) into surgical simulation has been promoted as a way to gain deeper understanding of procedural errors and overall performance. The purpose of this study was to evaluate LEF performance using a Fasciotomy Improvement through Recognition of Errors (FIRE) simulation training curriculum to train novice surgical trainees.

METHODS

A mastery learning-based EMT curriculum was developed, and surgical residents were enrolled and pretested with a multiple-choice question (MCQ) written test, and a simulated fasciotomy using a lower leg model. Each trainee then watched a 15-minute narrated presentation followed by 2 rounds of fasciotomy error recognition and management training exercises to a mastery standard. During each round, trainees performed hands-on assessment of unique premade fasciotomy leg models containing a variable number of procedural errors. They were required to identify and propose corrective action for all errors. Serial rounds of remediation were implemented until the mastery standard was attained on both error identification rounds. All trainees were post-tested with the same MCQ and another simulated fasciotomy.

RESULTS

All 14 residents had minimal experience with only 0.3 ± 0.6 fasciotomies performed prior to instruction. There were 3 ± 1.6 missed or inadequately released compartments on the pretest. Residents examined 14 ± 2.5 legs, including 2 ± 2.5 legs during remediation to attain mastery. All residents demonstrated significant improvement following the FIRE of Error curriculum for the MCQ (57% ± 16% vs 78% ± 13%; p = 0.01; Cohen's d = 1.4), fasciotomy score (10 ± 7.1 vs 28 ± 1.9; p < 0.001; Cohen's d = 3.6), and achieving a complete fasciotomy (14% ± 36% vs 93% ± 27%; p < 0.001; Cohen's d = 2.5). Only a single cumulative compartment was missed on post-testing.

CONCLUSIONS

Implementation of a mastery learning-based EMT curriculum for fasciotomy simulation training results in significant improvement in fasciotomy technique without reliance on repeated procedure performance nor clinical fasciotomy exposure. This curriculum is a highly effective option for surgical trainees lacking fasciotomy training during residency.

An early introduction to surgical skills: Validating a low-cost laparoscopic skill training program purpose built for undergraduate medical education

BACKGROUND

Medical student exposure to laparoscopy is limited to observation despite the prevalence of minimally invasive techniques in practice. The high cost of laparoscopic simulation equipment, commonly called "box trainers", limits undergraduate exposure to skill training.

METHODS

Students at a Midwestern medical school were recruited to participate in an experimental laparoscopic skill training program. One cohort (n = 17) used a DIY box trainer design freely available on MedEdPORTAL. A second cohort (n = 17) used a commercially available equivalent. Pre- and post-training attempts for four tasks were scored and the difference was calculated. The average differences for each cohort were then contrasted statistically.

RESULTS

Significant performance improvements (pre- and post-training) were demonstrated regardless of group allocation. The difference in performance between the cohorts was not significant for any task (p > 0.05).

CONCLUSIONS

This low-cost training program using DIY box trainers is as effective as commercially available equivalent box trainers for introducing laparoscopic skills to medical students.

Perceptions and experience of veterinary surgery residents with minimally invasive surgery simulation training

OBJECTIVE

To determine access to and use of minimally invasive surgery (MIS) simulators among American College of Veterinary Surgeons (ACVS) small animal residents and to identify barriers to simulator use and perceptions of simulator training.

STUDY DESIGN

Voluntary online survey.

SAMPLE POPULATION

One hundred forty-one ACVS small animal residents.

METHODS

American College of Veterinary Surgeons residents were identified by contacting ACVS residency program directors. An emailed online survey was sent to residents along with a reminder email 2 weeks later. All surveys were collected within 1 month. Participation was voluntary but incentivized.

RESULTS

Response rate to the survey was 79 of 141 (56%) residents. Twenty-eight of 77 (36%) residents have access to a simulator, with box simulators being most common. Lack of time was the most frequent reason for not using the simulator more. Sixty-eight of 77 (88%) and 65 of 77 (65%) residents agreed or strongly agreed that simulator-based training improves laparoscopic skills and that simulator skills are transferable to the operating room, respectively. Residents with access to a simulator were more comfortable with basic laparoscopic surgeries at the end of their residency than those without such access (P = .04).

CONCLUSION

There is substantial room for improved access to and use of MIS simulator training in ACVS residency programs. Despite lack of simulator access, residents believed that simulator training improved their skill and comfort level with basic laparoscopic procedures.

CLINICAL SIGNIFICANCE

The results of this study inform us about access to and perceptions of MIS simulator training among residents. This information is important to surgeons responsible for training residents and may help guide the creation of a surgical skills curriculum.

Reliability testing of a modified MISTELS score using a low-cost trainer box

BACKGROUND

Training programs such as the fundamentals of laparoscopic surgery (FLS) that are based on simulation are being currently used in several western countries. FLS allows skill acquisition and evaluation of competency in laparoscopic surgery. On the practical side, evaluation is determined by the MISTELS metrics (MISTELS is the acronym for the McGill inanimate system for training and evaluation of laparoscopic skills). This training program may be modified so that it can be implemented in countries with limited resources using a low-cost trainer box. Would the use of a low-cost trainer box alter the reliability of the MISTELS score?

OBJECTIVE OF STUDY

The aim of the study was to evaluate the reliability of a modified MISTELS using a low-cost trainer box.

METHODS

It was a prospective study carried out at Habib Thameur hospital in Tunis (Tunisia), between April 2016 and August 2016. The study involved residents from different surgical specialties in the departments of general surgery and paediatric surgery of the hospital during 2015 and 2016. This study assessed the reliability of a modified MISTELS system (Only three tasks were performed out of the five tasks used in the original MISTELS system). Evaluation was based on Cronbach's alpha and intraclass correlation coefficients (ICC). A low-cost trainer box was designed and constructed. The residents included in the study performed three series of three tasks using this trainer box. The first series was scored by two trained raters to evaluate inter-rater reliability. The two-other series were successively performed to evaluate test-retest reliability.

RESULTS

The internal consistency, assessed by Cronbach's alpha, was at 0.929 which is an acceptable score. As for inter-rater and test-retest reliabilities that were assessed by ICCs, they yielded excellent scores that were at 1 and 0.95 (95% CI, 0.891-0.978) respectively.

CONCLUSIONS

The reliability of a modified MISTELS is not altered by the use of a low-cost trainer box. The score of the modified MISTELS is a reliable score for evaluating technical skills of surgical residents using a low-cost trainer box.

Low-Cost Laparoscopic Skill Training for Medical Students Using Homemade Equipment

INTRODUCTION

Despite the increasing prevalence of minimally invasive surgery (MIS), medical students receive little training in MIS techniques like laparoscopy. Cost is perhaps the biggest obstacle, as expensive laparoscopic skill simulators (box trainers) are needed to mimic the laparoscopic environment. Low-cost, homemade box trainers have been built and described in the literature but are generally relegated to self-directed practice for surgical residents. These do-it-yourself (DIY) box trainers are uniquely capable of addressing cost as a major barrier to laparoscopic skills training for medical students but have not previously been used specifically for this purpose.

METHODS

Students from the Oakland University William Beaumont School of Medicine (n = 17) participated in a laparoscopic skills training course using DIY box trainers. Four basic laparoscopic tasks were taught using live demonstrations followed by directed practice. Learners were instructed to record their first and last attempts in order to enable self-assessment of their progress.

RESULTS

All learners were able to successfully complete each of the four laparoscopic tasks by the end of their respective sessions. Feedback from the learners in the form of a postsession survey indicated that the course provided an enjoyable and high-quality experience.

DISCUSSION

This resource is effective at providing medical students with a low-cost opportunity to experience laparoscopy and develop basic laparoscopic skills.

Impact of one-to-one tutoring on fundamentals of laparoscopic surgery (FLS) passing rate in a single center experience outside the United States: a randomized controlled trial

BACKGROUND

Outside the US, FLS certification is not required and its teaching methods are not well standardized. Even if the FLS was designed as "stand alone" training system, most of Academic Institution offer support to residents during training. We present the first systematic application of FLS in Italy. Our aim was to evaluate the role of mentoring/coaching on FLS training in terms of the passing rate and global performance in the search for resource optimization.

METHODS

Sixty residents in general surgery, obstetrics & gynecology, and urology were selected to be enrolled in a randomized controlled trial, practicing FLS with the goal of passing a simulated final exam. The control group practiced exclusively with video material from SAGES, whereas the interventional group was supported by a mentor.

RESULTS

Forty-six subjects met the requirements and completed the trial. For the other 14 subjects no results are available for comparison. One subject for each group failed the exam, resulting in a passing rate of 95.7%, with no obvious differences between groups. Subgroup analysis did not reveal any difference between the groups for FLS tasks.

CONCLUSION

We confirm that methods other than video instruction and deliberate FLS practice are not essential to pass the final exam. Based on these results, we suggest the introduction of the FLS system even where a trained tutor is not available. This trial is the first single institution application of the FLS in Italy and one of the few experiences outside the US. Trial Number: NCT02486575 ( https://www.clinicaltrials.gov ).

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.