Laparoscopy Simulators

Learning of Intracorporal Knot Tying in Minimally Invasive Surgery by Video or Expert Instruction

INTRODUCTION

 Minimally invasive surgery skill laboratories are indispensable in training, especially for complex procedural skills such as intracorporal suturing and knot tying (ICKT). However, maintaining a laboratory is expensive, and specially trained teachers are in short supply. During the COVID-19 pandemic, in-person instruction has reduced to almost zero, while model learning via video instruction (VID) has become an integral part of medical education. The aim of this study was to compare the learning effectiveness and efficiency of ICKT by laparoscopically inexperienced medical students through video versus direct expert instruction.

MATERIALS AND METHODS

 A secondary analysis of two randomized controlled trials was performed. We drew data from students who were trained in ICKT with expert instruction (EXP, n = 30) and from students who were trained via VID, n = 30). A laparoscopic box trainer including laparoscope was used for ICKT. Objective Structured Assessment of Technical Skills (OSATS), knot quality, and total ICKT time were the parameters for the assessment in this study. Proficiency criteria were also defined for these parameters.

RESULTS

 Students in the EXP group performed significantly better in OSATS-procedure-specific checklist (PSC) and knot quality compared with students in the VID group, with no difference in task time. Of the students who reached the proficiency criteria for OSATS-PSC and knot quality, those in the EXP group required fewer attempts to do so than those in the VID group. Students in both groups improved significantly in all parameters over the first hour of evaluation.

CONCLUSION

 For the laparoscopically inexperienced, training in ICKT through expert instruction presents an advantage compared with video-based self-study in the form of faster understanding of the procedure and the associated consistent implementation of good knot quality. Both teaching methods significantly improved participants' ICKT skills.

A cost-effective IoT learning environment for the training and assessment of surgical technical skills with visual learning analytics

BACKGROUND

Surgeons need to train and certify their technical skills. This is usually done with the intervention of experts who monitor and assess trainees. Nevertheless, this is a time-consuming task that is subject to variations among evaluators. In recent decades, subjectivity has been significantly reduced through 1) the introduction of standard curricula, such as the Fundamentals of Laparoscopic Surgery (FLS) program, which measures students' performance in specific exercises, and 2) rubrics, which are widely accepted in the literature and serve to provide feedback about the overall technical skills of the trainees. Although these two elements reduce subjectivity, they do not, however, eliminate the figure of the expert evaluator, and so the process remains time consuming.

OBJECTIVES

The objective of this work is to automate those parts of the work of the expert evaluator that the technology can measure objectively, using sensors to collect evidence, and visualizations to provide feedback. We designed and developed 1) a cost-effective IoT (Internet of Things) learning environment for the training and assessment of surgical technical skills and 2) visualizations supported by the literature on visual learning analytics (VLA) to provide feedback about the exercises (in real time) and overall performance (at the end of the training) of the trainee.

METHODS

A hybrid approach was followed based on previous research for the design of the sensor based IoT learning environment. Previous studies were used as the basis for getting best practices on the tracking of surgical instruments and on the detection of the force applied to the tissue, with a focus on reducing the costs of data collection. The monitoring of the specific exercises required the design of sensors and collection mechanisms from scratch as there is little existing research on this subject. Moreover, it was necessary to design the overall architecture to collect, process, synchronize and communicate the data coming from the different sensors to provide high-level information relevant to the end user. The information to be presented was already validated by the literature and the focus was on how to visualize this information and the optimal time for its presentation to end users. The visualizations were validated with 18 VLA experts assessing the technical aspects of the visualizations and 4 medical experts assessing their functional aspects.

RESULTS

This IoT learning environment amplifies the evaluation mechanisms already validated by the literature, allowing automatic data collection. First, it uses IoT sensors to automatically correct two of the exercises defined in the FLS (peg transfer and precision cutting), providing real-time visualizations. Second it monitors the movement of the surgical instruments and the force applied to the tissues during the exercise, computing 6 of the high-level indicators used by expert evaluators in their rubrics (efficiency, economy of movement, hand tremor, depth perception, bimanual dexterity, and respect for tissue), providing feedback about the technical skills of the trainee using a radar chart with these six indicators at the end of the training (summative visualizations).

CONCLUSIONS

The proposed IoT learning environment is a promising and cost-effective alternative to help in the training and assessment of surgical technical skills. The system shows the trainees' progress and presents new indicators about the correctness of each specific exercise through real-time visualizations, as well as their general technical skills through summative visualizations, aligned with the 6 more frequent indicators in standardized scales. Early results suggest that although both types of visualizations are useful, it is necessary to reduce the cognitive load of the graphs presented in real time during training. Nevertheless, an additional evaluation is needed to confirm these results.

Validity of a Novel Chicken and Porcine Model for Laparoscopic Neobladder Reconstruction

Introduction: Simulation-based training in laparoscopic urology is essential, as these surgeries require a skill set different from routine urologic procedures. We aim to describe and validate the chicken and porcine intestine model for laparoscopic neobladder reconstruction. Materials and Methods: Prospective observational study was conducted at our institute. Twenty novice and 20 trained laparoscopic surgeons were included in the study. The relevant chicken anatomy and surgical steps were described to all the surgeons. The surgeons were asked to fill a nine-point questionnaire after completing the exercise comprising bowel organization, ability to do urethroneovesical anastomosis, suturing time, suturing similarity, quality of suturing, tissue feel, integrity of anastomosis, realism, and usefulness of model after finishing the procedure, and score it on a scale of 1-5. Time taken to perform the entire exercise was noted in addition. An independent expert observer retrospectively rated the urethroneovesical anastomosis on a scale of 1-5. Results: All the participants in the study gave a mean score of 3.5 or more to all the questions asked in the questionnaire. Both the groups rated the usefulness of the model highly with a mean score of 4.6 and 4.45, respectively. The mean score of the questionnaire was 35.9 and 36, respectively, for both the groups. The quality of urethroneovesical anastomosis as observed by an expert was better in the expert group (p = 0.001). Conclusion: The chicken and porcine model for laparoscopic neobladder reconstruction is a useful and effective training tool. This model has face, content, and construct validity to be used as a teaching and training tool in laparoscopic urology.

One or two trainees per workplace for laparoscopic surgery training courses: results from a randomized controlled trial

BACKGROUND

There are no standards for optimal utilization of workplaces in laparoscopic training. This study aimed to define whether laparoscopy training should be done alone or in pairs (known as dyad training).

METHODS

This was a three-arm randomized controlled trial with laparoscopically naïve medical students (n = 100). Intervention groups participated alone (n = 40) or as dyad (n = 40) in a multimodality training curriculum with e-learning, basic, and procedural skills training using box and VR trainers. The control group (n = 20) had no training. Post-performance of a cadaveric porcine laparoscopic cholecystectomy (LC) was measured as the primary outcome by blinded raters using the objective structured assessment of technical skills (OSATS). Global operative assessment of laparoscopic skills (GOALS), time for LC, and VR performances were secondary outcomes.

RESULTS

There were no differences between groups for performance scores [OSATS: alone (40.2 ± 9.8) vs. dyad (39.8 ± 8.6), p = 0.995; alone vs. control (37.1 ± 7.4), p = 0.548; or dyad vs. control, p = 0.590; and GOALS score: alone (10.6 ± 3.0) vs. dyad (10.0 ± 2.7), p = 0.599; alone vs. control (10.1 ± 3.0), p = 0.748; or dyad vs. control, p = 0.998]. Dyad finished LC faster than control [median = 62.5 min (CI 58.0-73.0) vs. 76.5 min (CI 72.0-80+); p = 0.042], while there were no inter-group differences between alone vs. control [median = 69.0 min (CI 62.0-76.0) vs. control; p = 0.099] or alone vs. dyad (p = 0.840). Dyad and alone showed superior performance on the VR trainer vs. control for time, number of movements, and path length, but not for complications and application of cautery.

CONCLUSIONS

The curriculum provided trainees with the laparoscopic skills needed to perform LC safely, irrespective of the number of trainees per workplace. Dyad training reduced the operation time needed for LC. Therefore, dyad training seems to be a promising alternative, especially if training time is limited and resources must be used as efficiently as possible. Trial registration German Clinical Trials Register: DRKS00004675.

Skill Acquisition, Assessment, and Simulation in Minimal Access Surgery: An Evolution of Technical Training in Surgery

Diminishing resources and expanding technologies, such as minimal access surgery, have complicated the acquisition and assessment of technical skills in surgical training programs. However, these challenges have been met with both innovation and an evolution in our understanding of how learners develop technical competence and how to better measure it. As these skills continue to grow in breadth and complexity, so too must the surgical education systems’ ability. This literature review examines and describes the pressures placed on surgical education programs and the development of methods to ameliorate them with a focus on surgical simulation.

Halsted's "See One, Do One, and Teach One" versus Peyton's Four-Step Approach: A Randomized Trial for Training of Laparoscopic Suturing and Knot Tying

BACKGROUND

This study aimed to compare the effectiveness of Halsted's method "see one, do one, and teach one" with Peyton's Four-Step Approach for teaching intracorporal suturing and knot tying (ICKT).

METHODS

Laparoscopically naïve medical students (n = 60) were randomized to teaching of ICKT with either Halsted's (n = 30) or Peyton's method (n = 30) for 60 minutes. Each student's first 3 and final sutures were evaluated using Objective Structured Assessment of Technical Skills (OSATS), procedural implementation, knot quality, total time, and suture placement accuracy.

RESULTS

Performance score and OSATS-PSC always differed significantly in favor of Peyton's group (p = 0.001). OSATS-GRS (p = 0.01) and task time (p = 0.03) differed only in the summary of the first 3 sutures in favor of Peyton's group. There were no significant intergroup differences in knot quality and accuracy.

CONCLUSIONS

Peyton's Four-Step Approach is the preferable method for learning complex laparoscopic skills like ICKT.

Face, content, and construct validity of a novel chicken model for laparoscopic ureteric reimplantation

Introduction:

Simulation-based training in laparoscopic urology is essential, as these surgeries require a different skill set. We validated a chicken model for laparoscopic left modified Lich Gregoir type of ureteric reimplantation.

Materials and Methods:

Prospective observational study was conducted from August 2016 till February 2017. Thirty novice surgeons and 20 trained laparoscopic surgeons were included in the study. The relevant chicken anatomy and surgical steps were described to all the surgeons. The surgeons were asked to fill an eight-point questionnaire after finishing the procedure and score it on a scale of 1–5. The trainee's performance was also recorded by an investigator on a proforma. The investigator recorded dissection time, suturing time, quality of dissection, quality of suturing, and integrity of anastomosis on a scale of 1–5.

Results:

All the participants in the study gave a mean score of 3 or more to all the questions asked, except for one question pertaining to tissue feel. Both the groups rated the usefulness of the model very highly with a mean score of 4.20 and 4.15, respectively. Difference in the time taken for dissection and suturing along with the quality of suturing was statistically significant in favor of the expert group.

Conclusions:

The chicken model for laparoscopic left modified Lich Gregoir type of ureteric reimplantation is a useful, effective, cognitive training tool. This model has a face, content, and construct validity to be used as a teaching and learning tool in laparoscopic urology.

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.

Face validity of the pulsatile organ perfusion trainer for laparoscopic cholecystectomy

BACKGROUND

The pulsatile organ perfusion (POP) trainer provides training of minimally invasive surgery (MIS) with real instruments and cadaveric organs. It provides training of full procedures with simulation of bleeding. Although widely used, the face validity has not yet been evaluated. This study aimed to establish face validity of the POP trainer for laparoscopic cholecystectomy (LC) and its usefulness compared with other training modalities.

MATERIALS AND METHODS

During MIS courses, the participants (n = 52) used the POP trainer to perform LC. Face validity was assessed with questionnaires for realism and usefulness on a five-point Likert scale. Participants were divided into two groups: experts (n = 15) who had performed more than 50 laparoscopic procedures and novices (n = 37) with less than 50 procedures. Secondary aims included the ranking of training modalities, as well as exploration of their specific advantages and disadvantages.

RESULTS

The POP trainer was found to be realistic (3.8 ± 0.9) and useful (4.6 ± 0.9). Differences between experts and novices were only found for "The training modality resembles reality" (3.1 ± 0.8 vs. 3.8 ± 0.7; p = 0.010), "The operation on the POP trainer is realistic" (3.4 ± 1.1 vs. 4.5 ± 0.8; p = 0.003), and "It would be desirable to have a POP trainer at my own hospital" (4.2 ± 1.1 vs. 4.8 ± 0.8; p = 0.040). In the ranking, the animal training (1.1 ± 0.3) placed first, the POP trainer (2.3 ± 0.9) second, and the VR trainer (2.8 ± 0.9) and box trainer (2.8 ± 1.1) third. The realistic simulation of animal training was named as an advantage most often, while the unrealistic simulation of the VR trainer was the most often named disadvantage.

CONCLUSIONS

The POP trainer was rated a highly realistic and useful training modality with face validity for LC. Differences between experts and novices existed concerning realism and desirability. Future studies should evaluate the POP trainer for more advanced surgical procedures. The POP trainer widens the spectrum of modalities for training of MIS in a safe environment outside the operating room.

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.

Device model for training of laparoscopic surgical skills

The authors present a especially constructed, lightweight, collapsible, portable and low cost model device for skills training in laparoscopic.

Sequential learning of psychomotor and visuospatial skills for laparoscopic suturing and knot tying - study protocol for a randomized controlled trial "The shoebox study"

BACKGROUND

Laparoscopy training has become an integral part of surgical education. Suturing and knot tying is a basic, yet inherent part of many laparoscopic operations, and should be mastered prior to operating on patients. One common and standardized suturing technique is the C-loop technique. In the standard training setting, on a box trainer, the trainee learns the psychomotor movements of the task and the laparoscopic visuospatial orientation simultaneously. Learning the psychomotor and visuospatial skills separately and sequentially may offer a more time-efficient alternative to the current standard of training.

METHODS

This is a monocentric, two-arm randomized controlled trial. The participants are medical students in their clinical years (third to sixth year) at Heidelberg University who have not previously partaken in a laparoscopic training course lasting more than 2 hours. A total of 54 students are randomized into one of two arms in a 1:1 ratio to sequential learning (group 1) or control (group 2). Both groups receive a standardized introduction to the training center, laparoscopic instruments, and C-loop technique. Group 1 learn the C-loop using a transparent shoebox, thus only learning the psychomotor skills. Once they reach proficiency, they then perform the same knot tying procedure on a box trainer with standard laparoscopic view, where they combine their psychomotor skills with the visuospatial orientation inherent to laparoscopy. Group 2 learn the C-loop using solely a box trainer with standard laparoscopic view until they reach proficiency. Trainees work in pairs and time is recorded for each attempt. The primary outcome is mean total training time for each group. Secondary endpoints include procedural and knot quality subscore differences. Tertiary endpoints include studying the influence of gender and video game experience on performance.

DISCUSSION

This study addresses whether the learning of the psychomotor and visuospatial aspects of laparoscopic suturing and knot tying is optimal sequentially or simultaneously, by assessing total training time, procedural, and knot quality differences between the two groups. It will improve the efficiency of future laparoscopic suturing courses and may serve as an indicator for laparoscopic training in a broader context, i.e., not only for suturing and knot tying.

TRIAL REGISTRATION

This trial was registered on 12 August 2015 with the trial registration number DRKS00008668 .

Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices

This study compared virtual reality (VR) training with low cost-blended learning (BL) in a structured training program.Training of laparoscopic skills outside the operating room is mandatory to reduce operative times and risks.Laparoscopy-naïve medical students were randomized in 2 groups stratified for sex. The BL group (n = 42) used E-learning for laparoscopic cholecystectomy (LC) and practiced basic skills with box trainers. The VR group (n = 42) trained basic skills and LC on the LAP Mentor II (Simbionix, Cleveland, OH). Each group trained 3 × 4 hours followed by a knowledge test concerning LC. Blinded raters assessed the operative performance of cadaveric porcine LC using the Objective Structured Assessment of Technical Skills (OSATS). The LC was discontinued when it was not completed within 80 min. Students evaluated their training modality with questionnaires.The VR group completed the LC significantly faster and more often within 80 min than BL (45% v 21%, P = .02). The BL group scored higher than the VR group in the knowledge test (13.3 ± 1.3 vs 11.0 ± 1.7, P < 0.001). Both groups showed equal operative performance of LC in the OSATS score (49.4 ± 10.5 vs 49.7 ± 12.0, P = 0.90). Students generally liked training and felt well prepared for assisting in laparoscopic surgery. The efficiency of the training was judged higher by the VR group than by the BL group.VR and BL can both be applied for training the basics of LC. Multimodality training programs should be developed that combine the advantages of both approaches.

Computer-assisted abdominal surgery: new technologies

BACKGROUND

Computer-assisted surgery is a wide field of technologies with the potential to enable the surgeon to improve efficiency and efficacy of diagnosis, treatment, and clinical management.

PURPOSE

This review provides an overview of the most important new technologies and their applications.

METHODS

A MEDLINE database search was performed revealing a total of 1702 references. All references were considered for information on six main topics, namely image guidance and navigation, robot-assisted surgery, human-machine interface, surgical processes and clinical pathways, computer-assisted surgical training, and clinical decision support. Further references were obtained through cross-referencing the bibliography cited in each work. Based on their respective field of expertise, the authors chose 64 publications relevant for the purpose of this review.

CONCLUSION

Computer-assisted systems are increasingly used not only in experimental studies but also in clinical studies. Although computer-assisted abdominal surgery is still in its infancy, the number of studies is constantly increasing, and clinical studies start showing the benefits of computers used not only as tools of documentation and accounting but also for directly assisting surgeons during diagnosis and treatment of patients. Further developments in the field of clinical decision support even have the potential of causing a paradigm shift in how patients are diagnosed and treated.

The influence of dexamethasone on postoperative nausea and vomiting in patients undergoing gynecologic laparoscopic surgeries: A randomised, controlled, double blind trial

OBJECTIVE

Dexamethasone, as a part of multimodal approach, can decrease nausea and vomiting following laparoscopy in high risk patients. We performed this study to find out whether the dexamethasone can improve postoperative nausea and vomiting (PONV) in patients undergoing gynecology laparoscopic surgeries.

MATERIALS AND METHODS

In this double-blind randomized clinical trial, 91 patients who underwent gynecologic laparoscopic surgery in Rasool Akram hospital in Tehran during 2011-2014 were enrolled. Fourty-four patients received 8 mg dexamethasone (study group) and 47 patients received 10 mg metochlopramide (control group) intravenously after intubation. Outcome parameters including age, weight, height, cause of hospitalization, drugs, Last Menstrual Period (LMP), Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR) and oxygen saturation, Visual Analogue Scale (VAS) score, nausea and vomiting were entered to SPSS (v.16) and were analyzed.

RESULTS

Eighyt-eight American Society of Anesthesiology (ASA) class 1-2 patients between 25-39 years old were analyzed. There was no difference in vital signs during and post operation (BP, HR, RR and O₂ saturation) between these two groups (p value>0.05). There was no significant difference between VAS score at 4 and 24 hours after the operation (14% vs. 17.8% and 7% vs. 6.7%, respectively, p>0.05). Incidence of PONV in 4 hours was significantly lower in dexamethasone group (11.6% vs. 55.6% p<0.0001), while there was no significant difference in 24 hours (23.3% vs. 22.2%, p>0.05) and also need to anti-emetic drugs wasn't significantly lower in study group (p>0.05).

CONCLUSION

We conclude that dexamethasone can relieve PONV after gynecologic laparoscopic surgery.

One or two trainees per workplace in a structured multimodality training curriculum for laparoscopic surgery? Study protocol for a randomized controlled trial - DRKS00004675

BACKGROUND

Laparoscopy training courses have been established in many centers worldwide to ensure adequate skill learning before performing operations on patients. Different training modalities and their combinations have been compared regarding training effects. Multimodality training combines different approaches for optimal training outcome. However, no standards currently exist for the number of trainees assigned per workplace.

METHODS

This is a monocentric, open, three-arm randomized controlled trial. The participants are laparoscopically-naive medical students from Heidelberg University. After a standardized introduction to laparoscopic cholecystectomy (LC) with online learning modules, the participants perform a baseline test for basic skills and LC performance on a virtual reality (VR) trainer. A total of 100 students will be randomized into three study arms, in a 2:2:1 ratio. The intervention groups participate individually (Group 1) or in pairs (Group 2) in a standardized and structured multimodality training curriculum. Basic skills are trained on the box and VR trainers. Procedural skills and LC modules are trained on the VR trainer. The control group (Group C) does not receive training between tests. A post-test is performed to reassess basic skills and LC performance on the VR trainer. The performance of a cadaveric porcine LC is then measured as the primary outcome using standardized and validated ratings by blinded experts with the Objective Structured Assessment of Technical Skills. The Global Operative Assessment of Laparoscopic Surgical skills score and the time taken for completion are used as secondary outcome measures as well as the improvement of skills and VR LC performance between baseline and post-test. Cognitive tests and questionnaires are used to identify individual factors that might exert influence on training outcome.

DISCUSSION

This study aims to assess whether workplaces in laparoscopy training courses for beginners should be used by one trainee or two trainees simultaneously, by measuring the impact on operative performance and learning curves. Possible factors of influence, such as the role of observing the training partner, exchange of thoughts, active reflection, model learning, motivation, pauses, and sympathy will be explored in the data analysis. This study will help optimize the efficiency of laparoscopy training courses.

TRIAL REGISTRATION NUMBER

DRKS00004675.

A systematic review on low-cost box models to achieve basic and advanced laparoscopic skills during modern surgical training

INTRODUCTION

Low-cost box models (BMs) are a valuable tool alternative to virtual-reality simulators. We aim to provide surgical trainees with a description of most common BMs and to present their validity to achieve basic and advanced laparoscopic skills.

MATERIALS AND METHODS

A literature search was undertaken for all studies focusing on BMs, excluded were those presenting data on virtual-reality simulators only. Databases were screened up to December 2011.

RESULTS

Numerous studies focused on various BMs to improve generic tasks (ie, instrument navigation, coordination, and cutting). Only fewer articles described models specific for peculiar operations. All studies showed a significant improvement of basic laparoscopic skills after training with BMs. Furthermore, their low costs make them easily available to most surgical trainees.

CONCLUSIONS

BMs should be developed by all surgical trainees during their training. Fields for future improvement regard endoscopy and complex laparoscopic operations for which ad hoc BMs are not available.

Is laboratory training essential for beginners in learning laparoscopic adrenalectomy?

The aim is to develop a staged clinical laparoscopic training program (without laboratory trainings) for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility. Five beginners with no previous experience in adrenalectomy were randomly selected to receive the staged clinical laparoscopic training, including open retroperitoneal adrenalectomy or radical nephrectomy and mentor-initiated clinical laparoscopic training. The clinical data of the 15 LAs performed by each the trainees were collected and compared with the data from the initial 15 LAs of the mentor. All LAs were completed successfully, and no procedure required conversion to open surgery. The median operative time of the trainees was obviously less than the mentor's. The learning curve of the trainees was shorter compared with that of the mentor. The perioperative complication rate was similar between trainees and mentor. Beginners without laboratory trainings could perform LA safely and effectively after they participated in staged clinical laparoscopic training.

Virtual reality does not meet expectations in a pilot study on multimodal laparoscopic surgery training

BACKGROUND

The purpose of the present study was to determine the value of virtual reality (VR) training for a multimodality training program of basic laparoscopic surgery.

MATERIALS AND METHODS

Participants in a two-day multimodality training for laparoscopic surgery used box trainers, live animal training, and cadaveric training on the pulsating organ perfusion (POP) trainer in a structured and standardized training program. The participants were divided into two groups. The VR group (n = 13) also practiced with VR training during the program, whereas the control group (n = 14) did not use VR training. The training modalities were assessed using questionnaires with a five-point Likert scale after the program. Concerning VR training, members of the control group assessed their expectations, whereas the VR group assessed the actual experience of using it. Skills performance was evaluated with five standardized test tasks in a live porcine model before (pre-test) and after (post-test) the training program. Laparoscopic skills were measured by task completion time and a general performance score for each task. Baseline tests were compared with laparoscopic experience of all participants for construct validity of the skills test.

RESULTS

The expected benefit from VR training of the control group was higher than the experienced benefit of the VR group. Box and POP training received better ratings from the VR group than from the control group for some purposes. Both groups improved their skill parameters significantly from pre-training to post-training tests [score +17 % (P < 0.01), time -29 % (P < 0.01)]. No significant difference was found between the two groups for laparoscopic skills improvement except for the score in the instrument coordination task. Construct validity of the skills test was significant for both time and score.

CONCLUSIONS

At its current level of performance, VR training does not meet expectations. No additional benefit was observed from VR training in our multimodality training program.

Learning basic laparoscopic skills: a randomized controlled study comparing box trainer, virtual reality simulator, and mental training

OBJECTIVES

The objectives of this study were (1) to compare different methods of learning basic laparoscopic skills using box trainer (BT), virtual reality simulator (VRS) and mental training (MT); and (2) to determine the most effective method of learning laparoscopic skills.

DESIGN

Randomized controlled trial.

SETTING

King's College, London.

METHODS

41 medical students were included in the study. After randomization, they were divided into 5 groups. Group 1 was the control group without training; group 2 was box trained; group 3 was also box trained with an additional practice session; group 4 was VRS trained; and group 5 was solely mentally trained. The task was to cut out a circle marked on a stretchable material. All groups were assessed after 1 week on both BT and VRS. Four main parameters were assessed, namely time, precision, accuracy, and performance.

RESULTS

Time: On BT assessment, the box-trained group with additional practice group 3 was the fastest, and the mental-trained group 5 was the slowest. On VRS assessment, the time difference between group 3 and the control group 1 was statistically significant. Precision: On BT assessment, the box-trained groups 2 and 3 scored high, and mental trained were low on precision. On VRS assessment, the VRS-trained group ranked at the top, and the MT group was at the bottom on precision. Accuracy: On BT assessment, the box-trained group 3 was best and the mental-trained group was last. On VRS assessment, the VRS-trained group 4 scored high closely followed by box-trained groups 2 and 3. Performance: On BT assessment, the box-trained group 3 ranked above all the other groups, and the mental-trained group ranked last. On VRS assessment, the VRS group 4 scored best, followed closely by box-trained groups 2 and 3.

CONCLUSIONS

The skills learned on box training were reproducible on both VRS and BT. However, not all the skills learned on VRS were transferable to BT. Furthermore, VRS was found to be a reliable and the most convenient method of assessment. MT alone cannot replace conventional training.

Perk Station--Percutaneous surgery training and performance measurement platform

MOTIVATION

Image-guided percutaneous (through the skin) needle-based surgery has become part of routine clinical practice in performing procedures such as biopsies, injections and therapeutic implants. A novice physician typically performs needle interventions under the supervision of a senior physician; a slow and inherently subjective training process that lacks objective, quantitative assessment of the surgical skill and performance. Shortening the learning curve and increasing procedural consistency are important factors in assuring high-quality medical care.

METHODS

This paper describes a laboratory validation system, called Perk Station, for standardized training and performance measurement under different assistance techniques for needle-based surgical guidance systems. The initial goal of the Perk Station is to assess and compare different techniques: 2D image overlay, biplane laser guide, laser protractor and conventional freehand. The main focus of this manuscript is the planning and guidance software system developed on the 3D Slicer platform, a free, open source software package designed for visualization and analysis of medical image data.

RESULTS

The prototype Perk Station has been successfully developed, the associated needle insertion phantoms were built, and the graphical user interface was fully implemented. The system was inaugurated in undergraduate teaching and a wide array of outreach activities. Initial results, experiences, ongoing activities and future plans are reported.

Training on a virtual reality laparoscopic simulator improves performance of an unfamiliar live laparoscopic procedure

PURPOSE

Virtual reality simulators provide a safe and efficient means of acquiring laparoscopic skills. We evaluated whether training on a virtual reality laparoscopic cholecystectomy simulator (Lap Mentor) improves the performance of a live, unrelated laparoscopic urological procedure.

MATERIALS AND METHODS

A total of 32 medical students with no previous laparoscopic experience were oriented to the Lap Mentor, and then performed virtual reality laparoscopic cholecystectomy which was assessed by 2 experienced laparoscopists using the previously validated Objective Structured Assessment of Technical Skills scoring. Subjects were randomized to group 1, in which participants completed 6, 30-minute virtual reality training sessions within 3 weeks, or group 2, in which participants received no training. All participants then performed live laparoscopic nephrectomy in a porcine model and performance was evaluated using Objective Structured Assessment of Technical Skills by 2 experts blinded to training status.

RESULTS

Mean total pretraining laparoscopic cholecystectomy Objective Structured Assessment of Technical Skills scores were comparable between the groups (16.9 +/- 4.3 for group 1 vs 15.4 +/- 6.2 for group 2, p = 0.4). After training total Objective Structured Assessment of Technical Skills scores for live porcine laparoscopic nephrectomy were significantly higher in group 1 compared to group 2 (21.0 +/- 6.8 vs 15.7 +/- 6.6, respectively, p = 0.03). Likewise, individual subcategory Objective Structured Assessment of Technical Skills scores were higher in group 1 than in group 2, although significant differences were noted only in the categories of instrument handling and knowledge of the procedure.

CONCLUSIONS

Surgical skills acquired as a result of training on a virtual reality laparoscopic simulator are not procedure specific but improve overall surgical skills, thereby translating into superior performance of an unrelated live laparoscopic urological procedure.

Virtual reality training improves simulated laparoscopic surgery performance in laparoscopy naïve medical students

PURPOSE

With the expanding role of laparoscopy in urologic practice, efficient and safe training has become paramount. Virtual reality simulation may potentially aid training, but it requires validation before it can be incorporated into training programs. The objective of this study was to assess whether training on a virtual reality (VR) laparoscopy simulator (LAP Mentor) can improve performance of virtual laparoscopic procedures.

MATERIALS AND METHODS

After a basic introduction to the LAP Mentor, 32 inexperienced medical students performed a baseline VR cholecystectomy that was observed and scored by two observers using the Objective Structured Assessment of Technical Skills (OSATS). The students were then randomized to two groups: Group 1 trained on the simulator without supervision during a total of six 30-minute sessions, and group 2 received no training. Students were then reevaluated on a second VR cholecystectomy by the same observers.

RESULTS

All 32 students completed the study. The two groups were comparable with regard to baseline OSATS scores (group 1, 16.6+/-4.3 v group 2, 15.67+/-6.3, P=0.2). On the second evaluation, the trained students (group 1) performed significantly better than the control group (group 2) (27.9+/-7.2 v 17.6+/-6.2, P<0.001). Group 1 students outperformed group 2 students in each category of the OSATS. Moreover, trained students improved their scores by at least 20% (P<0.001) in each category, while the untrained students improved only in the "knowledge of procedure" category by 25% (P=0.03).

CONCLUSION

Skills training on a LAP Mentor VR simulator improved VR surgical performance. Before incorporating this simulator into resident education, the LAP Mentor will have to undergo testing for predictive and construct validity.

A medical simulator for subcutaneous contraceptive implant insertion

New contraceptive methods like the subcutaneous implant offers a new kind of comfort for women with an efficiency similar to the contraceptive pill. Unfortunately the few numbers of unintended pregnancies that have been reported are generally due to a bad insertion of the implant. In order to give more security to patients, we have designed, in close collaboration with physicians, a new kind of medical simulator. This paper focuses on a device dedicated to a specific subcutaneous implant but it is worth noting that this simulator is relatively generic since it will be used for other subcutaneous techniques or other implant instruments. This simulator can be used for two purposes: one for training novice physicians in the correct manipulation and the other for physician certification which will help determine if they are capable of inserting the implant in vivo. This paper describes the approach which has led to the design of this simulator. It describes its functionalities, its several components but also methods used to analyze the manipulation of the implant insertion inside the patient. Finally first experimental results are reported and discussed. The system used in this paper makes possible to carry out training in a constraint-free context and provides the first mean of visualizing a maneuver that, until now, has been performed blindly.

Training in oesophageal surgery--the gold standard: a prospective study

INTRODUCTION

Competency in complex oesophagogastric surgery, within the current climate of changes to medical training and reduced hours, requires repeated, focused, hands-on training. We describe the training methods for oesophagectomy in our institution.

METHODS

All oesophageal resections under the care of one consultant surgeon are regarded as training cases. When trainees start they are shown the first resection; subsequently, the trainees then perform every case with the consultant scrubbed. Consultant input consists of retraction and tips in difficult situations. All data were collected on a prospective database.

RESULTS

Two hundred and seventy patients (215 males, median age=64 years) underwent primary oesophagectomy under the consultant, between January 2000 and May 2007. Fifteen resections (6%) were performed solely by the consultant. ASA grading was: I=15, II=154, III=95, IV=5, and unrecorded=1. In-hospital mortality and clinically apparent leak rate was 1.9% (5 deaths) and 6.2% (n=17), respectively. Reoperation was required in 15 patients (5.5%). The median length of hospital stay was 14 days (range=8-95 days). Median lymph node yield was 13 (range=0-64).

CONCLUSIONS

Trainees under supervision can competently perform an oesophagectomy without compromising patient care. An early hands-on approach leads to a rapid ascent of the learning curve and is essential in today's climate of limited training opportunity.