Integrating technical competency into the surgical curriculum: doing more with less

Ergonomic evaluation and performance of a new handle for laparoscopic tools in surgery

This paper presents a new handle for instruments used in laparoscopic surgery. This new handle has been designed to provide the best ergonomic and usability features required in this kind of surgical interventions. The main novelty of this handle is that the opening and closing motion of the end-effector is operated with the thumb using a lever located on the top of the handle. This enables the surgeon to reach the patient's organs without adopting extremely awkward postures. In order to demonstrate its advantages, the handle has been tested and compared with another commercial handle in terms of efficiency, effectiveness, and satisfaction. To this end, volunteers have been selected for participation in the experimental evaluation, which comprised two types of surveys: objective and subjective. Electromyography and goniometric studies provide objective parameters for evaluation. Questionnaires are used for the subjective assessment. Outstanding results include the lower level of pain reported by the individuals working with the new handle, as well as the reduction in the hyperflexion of the wrist. Compared with the conventional handle, electromyography reveals that no muscle load is increased when working with the new handle. The results of the subjective survey show that volunteers expressed a significant preference for the new handle, demonstrating an improvement in the ergonomic characteristics.

Design and evaluation of a new ergonomic handle for instruments in minimally invasive surgery

BACKGROUND

Laparoscopic surgery techniques have been demonstrated to provide massive benefits to patients. However, surgeons are subjected to hardworking conditions because of the poor ergonomic design of the instruments. In this article, a new ergonomic handle design is presented. This handle is designed using ergonomic principles, trying to provide both more intuitive manipulation of the instrument and a shape that reduces the high-pressure zones in the contact with the surgeon's hand.

MATERIALS AND METHODS

The ergonomic characteristics of the new handle were evaluated using objective and subjective studies. The experimental evaluation was performed using 28 volunteers by means of the comparison of the new handle with the ring-handle (RH) concept in an instrument available on the market. The volunteers' muscle activation and motions of the hand, wrist, and arm were studied while they performed different tasks. The data measured in the experiment include electromyography and goniometry values.

RESULTS

The results obtained from the subjective analysis reveal that most volunteers (64%) preferred the new prototype to the RH, reporting less pain and less difficulty to complete the tasks. The results from the objective study reveal that the hyperflexion of the wrist required for the manipulation of the instrument is strongly reduced.

CONCLUSIONS

The new ergonomic handle not only provides important ergonomic advantages but also improves the efficiency when completing the tasks. Compared with RH instruments, the new prototype reduced the high-pressure areas and the extreme motions of the wrist.

Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance

BACKGROUND

The purpose of this study was to determine 2-year performance retention and certification exam pass rate after completion of a proficiency-based fundamental laparoscopic skills (FLS) curriculum and subsequent interval training.

METHODS

Surgery residents (postgraduate year [PGY]1-5, n = 91) were enrolled in an Institutional Review Board approved protocol. All participants initially underwent proficiency-based training on all 5 FLS tasks. Subsequently, available residents were enrolled every 6 months in an ongoing training curriculum that included retention tests on tasks 4 and 5, with mandatory retraining to proficiency if the proficiency levels were not achieved. The final retention test included the actual FLS certification examination for PGY4-5 trainees.

RESULTS

A 96% participation rate was achieved for all curricular components during the 2-year study period (PGY3-5, n = 33). Skill retention at retention 1-4 was 83%, 94%, 98%, and 91% for task 4 and 85%, 95%, 96%, and 100% for task 5, respectively. All PGY4-5 (n = 20) residents passed the FLS certification examination, achieving 413 +/- 28 total score on the skills portion (passing score > or =270) and demonstrating 92% retention for all 5 tasks.

CONCLUSION

Proficiency-based training with subsequent ongoing practice results in a very high level of skill retention after 2 years and uniformly allows trainees to pass the FLS certification examination.

Robotic hypospadias surgery: a new evolution

The dictum that "there is nothing new in surgery not previously described," is quoted regularly and is particularly true of hypospadias. There is an ongoing search for solutions to many troublesome issues concerning surgical treatment of hypospadias, such as what age is the most appropriate to apply surgery, or in how many stages surgery should be performed. We present a case report of the first robotic hypospadias surgery to propose a departure from the standard practice, in the hope of expanding medical expertise and teaching globally. The use of a robot for reconstructive surgery is not novel; its use for extracorporeal surgery is, but we contend that there is no difference in the surgical steps to carry out a hypospadias repair. In addition, we envision that the benefits of applying robotic surgery for extracorporeal reconstructive procedures will greatly impact the current paradigm of surgery and surgical education. For those surgeons who already possess comfort with robotic skills, reconstructive procedures outside of a major cavity are feasible, and time will provide safety and efficacy data. Our hope is that others will join in the advancement of telesurgery and its applications and appreciate the potential expansion of surgical knowledge that will be afforded by this change in how we teach and operate.

Patient safety, competency, and the future of surgical simulation

Despite its relatively short track record, simulation has been successfully introduced into the surgical arena in an effort to augment training. Initially a fringe endeavor at isolated centers, simulation has now become a mainstream component of surgical education. The surgical community is now aware that the old adage, "see one, do one, and teach one" is no longer acceptable from the ethical standpoint of practicing procedures on patients. Moreover, financial and time constraints have made teaching outside of the operating room an attractive proposition. Coupled with the growing body of validation, new procedures can now be practiced and proficiency can be acquired on a multitude of simulation platforms. Importantly, simulation standards are being established and there is an unprecedented national acceptance and endorsement of simulation as an invaluable educational tool; in fact, simulation is being mandated for surgical residency programs. Team training will likely expand the impact of surgical simulation considerably and help assure multidimensional competency verification. For both surgery residents and surgeons in practice, simulation holds great promise as a safe, effective, and efficient means of acquiring new skills.

A systematic review of skills transfer after surgical simulation training

OBJECTIVE

To determine whether skills acquired by simulation-based training transfer to the operative setting.

SUMMARY BACKGROUND DATA

The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance.

METHODS

A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulation-based training for surgical skills training, and the transferability of these skills to the operative setting, were included.

RESULTS

Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters.

CONCLUSIONS

Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs.

Certification pass rate of 100% for fundamentals of laparoscopic surgery skills after proficiency-based training

BACKGROUND

The fundamentals of laparoscopic surgery (FLS) program has been extensively validated for use as a high-stakes examination for certification purposes, but optimal methods for its use in skills training have not been described. This study aimed to investigate the feasibility of implementing a proficiency-based FLS skills training curriculum and to evaluate its effectiveness in preparing trainees for certification.

METHODS

For this study, 21 novice medical students at two institutions viewed video tutorials, then performed one repetition of the five FLS tasks as a pretest. The pretests were scored using standard testing metrics. The trainees next practiced the tasks over a 2-month period until they achieved proficiency for all the tasks. A modified on-the-fly scoring system based on expert-derived performance was used. The trainees were posttested using the high-stakes examination format.

RESULTS

No trainee passed the certification examination at pretesting. The trainees achieved proficiency for 96% of the five tasks during training, which required 9.7 +/- 2.4 h (range, 6-14 h) and 119 +/- 31 repetitions (range, 66-161 repetitions). The trainees rated the proficiency levels as "moderately difficult" (3.0 +/- 0.7 on a 5-point scale) and "highly appropriate" (4.7 +/- 0.1 on a 5-point scale). At posttesting, 100% of the trainees passed the certification examination and demonstrated significant improvement compared with pretesting for normalized score (468 +/- 24 vs 126 +/- 75; p < 0.001), self-rated laparoscopic comfort (89.4% vs 4.8%; p < 0.001), and skill level (3.6 +/- 0.9 vs 1.2 +/- 0.5; p < 0.001, 5-point scale).

CONCLUSIONS

This proficiency-based curriculum is feasible for training novices and uniformly allows sufficient skill acquisition for FLS certification. Endorsed by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), this curriculum is available for use as an optimal method for FLS skills training. More widespread adoption of this curriculum is encouraged.