Commercial Video Laparoscopic Trainers versus Less Expensive, Simple Laparoscopic Trainers: A Systematic Review and Meta-Analysis

The effects of unilateral transcranial direct current stimulation on unimanual laparoscopic peg-transfer task

INTRODUCTION

Efficient training methods are required for laparoscopic surgical skills training to reduce the time needed for proficiency. Transcranial direct current stimulation (tDCS) is widely used to enhance motor skill acquisition and can be used to supplement the training of laparoscopic surgical skill acquisition. The aim of this study was to investigate the effect of anodal tDCS over the primary motor cortex (M1) on the performance of a unimanual variant of the laparoscopic peg-transfer task.

METHODS

Fifteen healthy subjects participated in this randomized, double-blinded crossover study involving an anodal tDCS and a sham tDCS intervention separated by 48 h. On each intervention day, subjects performed a unimanual variant of laparoscopic peg-transfer task in three sessions (baseline, tDCS, post-tDCS). The tDCS session consisted of 10 min of offline tDCS followed by 10 min of online tDCS. The scores based on the task completion time and the number of errors in each session were used as a primary outcome measure. A linear mixed-effects model was used for the analysis.

RESULTS

We found that the scores increased over sessions (p < 0.01). However, we found no effects of stimulation (anodal tDCS vs. sham tDCS) and no interaction of stimulation and sessions.

CONCLUSION

This study suggests that irrespective of the type of current stimulation (anodal and sham) over M1, there was an improvement in the performance of the unimanual peg-transfer task, implying that there was motor learning over time. The results would be useful in designing efficient training paradigms and further investigating the effects of tDCS on laparoscopic peg-transfer tasks.

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.

Changing Education Paradigms: Training Transplant Fellows for High Stake Procedures

OBJECTIVE

Living kidney donation is a unique operation, as healthy patients are placed at risks inherent with major surgery without physical benefit. The ethical implications associated with any morbidity make it a high-stakes procedure. Fellowships are faced with the dilemma of optimizing fellow training in this demanding procedure while providing safe outcomes to donors. The Laparoscopic Living Donor Nephrectomy (LDN) Workshop is a resource that can provide intense instruction to help bridge the training deficit. Our aim was to examine the course's effectiveness in improving fellows' skill and confidence related to implementing LDN into future practice.

METHODS

From 2017 to 2018, 36 abdominal transplant surgery fellows participated in a 2-day workshop consisting of live surgery observation, cadaver lab, and didactic sessions. Surveys were completed precourse, postcourse, and at 3-month postcourse follow-up.

RESULTS

Preworkshop, 61% of participants reported less than 50% confidence in independent performance of LDN. Following workshop completion, 95% reported improved confidence. At 3-month follow-up, there was a 30% (p < 0.05) increase in median confidence level. Immediately following the course, 67% reported improved ability to analyze kidneys prior to donation, 74% changed the way donor candidates were evaluated, and 67% reported enhanced ability to risk stratify donors. Eighty-five percent felt it strengthened operative techniques with 70% implementing new diagnostic treatments and surgical strategies. Seventy percent of participants felt it improved their communication with colleagues and 67% had enhanced communication with patients. These trends were maintained at 3-month follow-up.

CONCLUSION

These results indicated that the LDN Workshop improves confidence and increases fellows' skillset in a high-stakes procedure. The LDN Workshop is a useful adjunct to fellowship training to optimize successful, efficient, and safe performance of a demanding procedure in a uniquely healthy donor population.

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.

Do 'standard laparoscopic box trainers' represent real-life conditions during transperitoneal laparoscopical interventions of the upper tract?

BACKGROUND

The purpose of this study is to investigate the representativeness of the conventional laparoscopic standard box trainers in terms of real-life circumstances in transperitoneal laparoscopical interventions of the upper tract, using questionnaire inquiries with experienced surgeons.

MATERIALS AND METHODS

The study was conducted with 44 laparoscopists, whose level of renal surgery experience was either high (primary surgeon in >100 cases), moderate (primary surgeon in >50 cases) or basic (primary surgeon in >20 cases). We used the box widely preferred in international training courses, which consists of a 10-mm 30° laparoscope, real endoscopic instruments, light source, monitor and chicken bone materials. Participants were asked whether they represent real-life situations while performing tasks by means of standard box trainers.

RESULTS

The medians of 'restrained body posture of the surgeon', 'position of monitor', 'trocars entry slots', 'tissue distance and region' and 'limited field of movement and restricted working space' were analysed on their difference from the ideal value. All the variables were shown to be significantly different from the ideal value of 5 (p < 0.001). These results suggest that experienced surgeons in our study did not find the box simulation conditions similar to real surgery conditions.

CONCLUSION

Conventional laparoscopic trainer box, which is currently being used, is far from representing for the real situation in transperitoneal laparoscopical interventions of the upper tract.

Construct, content and face validity of the eoSim laparoscopic simulator on advanced suturing tasks

Background

The purpose of this study was to validate the eoSim, an affordable and mobile inanimate laparoscopic simulator with instrument tracking capabilities, regarding face, content and construct validity on complex suturing tasks.

Methods

Participants recruited for this study were novices (no laparoscopic experience), target group for this training (surgical/gynaecologic/urologic residents, > 10 basic and < 20 advanced laparoscopic procedures) and experts (> 20 advanced laparoscopic procedures). Each participant performed the intracorporeal suturing exercise (Task 1), an upside down needle transfer (Task 2, developed for this study) and an anastomosis needle transfer (Task 3). Following, the participants completed a questionnaire regarding their demographics and opinion on the eoSim in terms of realism, didactic value and usability. Measured outcome parameters were time, distance, percentage of instrument tip off-screen, working area, speed, acceleration and smoothness.

Results

In total, 104 participants completed the study, of which 60 novices, 31 residents and 13 experts. Face and content validity results showed a mean positive opinion on realism (3.9 Task 1, 3.6 Task 2 and 3.7 Task 3), didactic value (4.0, 3.4 and 3.7, respectively) and usability (4.2. 3.7 and 4.0, respectively). There were no significant differences in these outcomes between the specified expertise groups. Construct validity results showed significant differences between experts, target group or novices for Task 1 in terms of time (means 339, 607 and 1224 s, respectively, p < 0.001) and distance (means 8.1, 15.6 and 21.7 m, respectively, p < 0.001). Task 2 showed significant differences between groups regarding time (p < 0.001), distance (p 0.003), off-screen (p < 0.001) and working area (p < 0.001). Task 3 showed significant differences between groups, after subanalyses, on total number of stitches (p < 0.001), time per stitch (p < 0.001) and distance per stitch (p < 0.001).

Conclusions

The results of this study indicate that the eoSim is a potential meaningful and valuable simulator in the training of suturing tasks.

Process of medical simulator development: An approach based on personal experience

With increasing demand for simulators from the healthcare community and increasingly sophisticated technology being used in the manufacture of medical simulators, the manufacture of healthcare simulators has become a multifaceted undertaking. Based on our experience in the field and our diverse backgrounds, we explore the processes and issues related to the development of these simulators and suggest ways for the developing teams to collaborate and coordinate with each other to achieve a successful outcome.

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.

A laparoscopic simulator - maybe it is worth making it yourself

Introduction

Laparoscopic trainers have gained recognition for improving laparoscopic surgery skills and preparing for operations on humans. Unfortunately, due to their high price, commercial simulators are hard to obtain, especially for young surgeons in small medical centers. The solution might be for them to construct a device by themselves.

Aim

To make a relatively cheap and easy to construct laparoscopic trainer for residents who wish to develop their skills at home.

Material and methods

Two laparoscopic simulators were designed and constructed: 1) a box model with an optical system based on two parallel mirrors, 2) a box model with an HD webcam, a light source consisting of LED diodes placed on a camera casing, and a modeling servo between the webcam and aluminum pipe to allow electronic adjustment of the optical axis.

Results

The two self-constructed simulators were found to be effective training devices, the total cost of parts for each not exceeding $100. Advice is also given for future constructors.

Conclusions

Home made trainers are accessible to any personal budget and can be constructed with a minimum of practical skill. They allow more frequent practice at home, outside the venue and hours of surgical departments. What is more, home made trainers have been shown to be comparable to commercial trainers in facilitating the acquisition of basic laparoscopic skills.