Surgery: Urological laparoscopic training--practice makes perfect

Training of Brazilian Urology residents in laparoscopy: results of a national survey

Objectives

To evaluate the familiarity of Brazilian urology residents with laparoscopy, methods of training and perspectives.

Material and methods

a questionnaire with 23 questions was sent by e-mail to all urological residents of 86 Urology Residence Programs certified by the Brazilian Society of Urology (BSU).

Results

225 valid answers (85% of all residents) responded. Most residences belong to academic hospitals mainly in the Southeast region of Brazil. Women account for 5% of residents and 82% of programs perform less than 100 procedures per year. Residents have access to LESS, RAL and 98% to surgical laparoscopy and 87% of these participate actively at the surgery, but 84.9% do not have access to RAL. The most common laparoscopic procedure is radical nephrectomy (73.2%), but only 28.8% of residents acted as surgeons, and third year residents (R3) are those that mainly performed this procedure (statistical significance, p <0.05). 61% of residents do not participate in hands-on courses or fellowship in laparoscopy, among those who attended these fellowships, 23.47% were sponsored by BSU in equal regions of the country. Although there are several opportunities of training in laparoscopy, 42% of residents do not have access to any kind of preparation and 52% have no structured specific program. R3 perception of laparoscopy experience is significantly higher than R2 and R1 residents. Almost 30% of them affirms that they are prepared for professional life regarding urologic laparoscopy.

Conclusion

Brazilian urologic residents have access to laparoscopy and actively participate in the learning process. Robotic surgery is expanding in the country, although still very far from residents. Brazilian resident, at the end of medical residency, is motivated to perform laparoscopic procedures.

Achieving Interface and Environment Fidelity in the Virtual Basic Laparoscopic Surgical Trainer

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.