Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial

Development and validation of a simulation training platform for the ligation of deep dorsal vein complex in radical prostatectomy

Objective

This study aimed to design a low-cost, simulation training platform for the ligation of deep dorsal vein (DVC) complex in radical prostatectomy and validate its training effectiveness.

Methods

A simplified prostate urethra model was produced by 0-degree silica gel and pulse pressure banding. This model was placed on a slope of about 30 degrees using cardboard to thus creating a narrow environment of the pelvis. The DVC ligation was performed by a 2D laparoscopy simulator. A total of 27 participants completed the study include 13 novices, 10 surgical residents and 4 urology experts. The novices were trained five trails with 24 hours interval, the residents and experts completed the DVC ligation once. The construct validity of this simulation training platform was performed by completing time, the GOALS (Global Operative Assessment of Laparoscopic Skills) and TSA (i.e. Task Specific Assessments) score. The face validity and content validity were performed by a specific closed-ended questionnaire.

Results

There was no significant difference among three groups in demographic or psychometric variables (p > 0.05). Compared to the novices, the residents spend a shorter time to complete the DVC ligation (p < 0.05) and had higher GOALS scores (p < 0.05), but had no significant difference in TSA scores (p > 0.05). Additionally, the experts groups had a better performance compared to residents group in the completing time (p < 0.05), GOALS score (p < 0.05) and TSA score (p < 0.05). The learning curve of novices significantly promoted along with the increased times of training. Almost 90 percent of subjects considered that this simulator had a good performance in the realism and practicability.

Conclusion

We developed a novel low-cost a simulation training platform for the ligation of deep dorsal vein complex in radical prostatectomy, and this simulator had a good performance in the construct validity, face validity and content validity.

Teaching With the GlobalSurgBox: Trainer Perceptions of a Portable Surgical Simulator

OBJECTIVES

Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation.

DESIGN

An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers.

SETTING

Academic medical training centers or conferences in the United States, Rwanda and Kenya.

PARTICIPANTS

10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident.

RESULTS

The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox.

CONCLUSION

The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room.

Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents

OBJECTIVE

Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills.

DESIGN

Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence).

SETTING

The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center.

RESULTS

Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction.

CONCLUSION

This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.

Validation of a novel, low-fidelity virtual reality simulator and an artificial intelligence assessment approach for peg transfer laparoscopic training

Simulators are widely used in medical education, but objective and automatic assessment is not feasible with low-fidelity simulators, which can be solved with artificial intelligence (AI) and virtual reality (VR) solutions. The effectiveness of a custom-made VR simulator and an AI-based evaluator of a laparoscopic peg transfer exercise was investigated. Sixty medical students were involved in a single-blinded randomised controlled study to compare the VR simulator with the traditional box trainer. A total of 240 peg transfer exercises from the Fundamentals of Laparoscopic Surgery programme were analysed. The experts and AI-based software used the same criteria for evaluation. The algorithm detected pitfalls and measured exercise duration. Skill improvement showed no significant difference between the VR and control groups. The AI-based evaluator exhibited 95% agreement with the manual assessment. The average difference between the exercise durations measured by the two evaluation methods was 2.61 s. The duration of the algorithmic assessment was 59.47 s faster than the manual assessment. The VR simulator was an effective alternative practice compared with the training box simulator. The AI-based evaluation produced similar results compared with the manual assessment, and it could significantly reduce the evaluation time. AI and VR could improve the effectiveness of basic laparoscopic training.

Laparoscopic training workshop to assess medical students' skill acquisition and interest in surgical careers

BACKGROUND

With its minimally invasive approach, laparoscopic surgery has transformed the medical landscape. As the demand for these procedures escalates, there is a pressing need for adept surgeons trained in laparoscopic techniques. However, current training often falls short of catering to medical school education. This study evaluates the impact of a custom-designed laparoscopic training workshop on medical students' surgical skills and career aspirations.

METHODS

This prospective experimental study was conducted at the E-Da hospital in Kaohsiung City, Taiwan. Medical students from Taiwanese medical schools undergoing Clerk 5, Clerk 6, and Postgraduate Year 1 and 2 were invited to participate. Medical students (n = 44) underwent an endoscopic skill training workshop consisting of lectures, box training, and live tissue training. The trainees performed multiple tasks before and after training using our objective evaluation system. The primary outcome was assessed before and after training through a questionnaire assessing the influence of training on students' interest in surgery as a career. The secondary outcome measured improvement in skill acquisition, comparing the task completion time pre- and post-workshop. For the primary outcome, descriptive statistics were used to summarize the questionnaire responses, and paired t-tests were performed to determine significant changes in interest levels post-workshop. For the secondary outcome, paired t-tests were used to compare the time recorded pre- and post-training.

RESULTS

Post-training, participants exhibited significant proficiency gains, with task completion times reducing notably: 97 s (p = 0.0015) for Precision Beads Placement, 88.5 s (p < 0.0001) for Beads Transfer Exercise, 95 s (p < 0.0001) for Precision Balloon Cutting, and 137.8 s (p < 0.0001) for Intracorporeal Suture. The primary outcome showcased an increased mean score from 8.15 pre-workshop to 9.3 post-workshop, indicating a bolstered interest in surgery as a career. Additionally, post-training sentiment analysis underscored a predominant inclination toward surgery among 88% of participants.

CONCLUSION

The custom-designed laparoscopic workshop significantly improved technical skills and positively influenced students' career aspirations toward surgery. Such hands-on training workshops can play a crucial role in medical education, bridging the gap between theoretical knowledge and practical skills and potentially shaping the future of budding medical professionals.

Original Training for Laparoscopic Surgery by Making an Origami Paper Crane

INTRODUCTION

The training box is an effective tool used by surgical trainees. Suturing training is the common method of practicing laparoscopic surgery; however, the cost of needles and threads for long-term practice remains a problem. In this study, we incorporated the original Japanese training for laparoscopic surgery by making an origami paper crane (laparoscopic origami training (LOT)) and evaluated its effect on the clinical results as a long-term practice.

METHODS

LOT was performed using a single 7.5 × 7.5 cm origami paper in the training box of laparoscopic surgery. In the bench-top study, the total time required to make one paper crane was measured and evaluated, and a self-efficacy questionnaire was designed to analyze the efficacy of LOT. In clinical practice, we retrospectively compared two resident groups, one that had previously trained on LOT (trained group) and the other that did not (less-trained group), by analyzing the pneumoperitoneum time (PT) for 10 cases.

RESULTS

After making paper cranes in approximately 100 cases, the making time was reduced to approximately 10 min. Long-term results analyzing up to 1500 cases revealed that in addition to shortening the time required to make a paper crane, the shape of the crane also improved. Consequently, the median PT was significantly shorter in the trained group than in the less-trained group (129.0 (62-287) versus 208.5 (127-343) min; p<0.001).

CONCLUSION

LOT contributed to introducing safe laparoscopic surgery to residents and improved their laparoscopic outcomes. We believe that this is a useful practice methodology that can be recommended to general physicians who wish to practice laparoscopic surgeries.

Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents

OBJECTIVE

This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times.

DESIGN

Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10.

SETTING

Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care.

PARTICIPANTS

Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents.

RESULTS

159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases.

CONCLUSIONS

Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.

Magnitude and predictors of unfavorable management outcome in surgically treated patients with intestinal obstruction in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Unless an emergency surgical intervention is conducted, intestinal obstruction may result in high morbidity and mortality. In Ethiopia, the magnitude and predictors of unfavorable management outcomes in surgically treated patients with intestinal obstruction are highly variable and inconsistent. The aim of this study was; therefore, to estimate the overall prevalence of unfavorable management outcome and its predictors among surgically treated patients with intestinal obstruction in Ethiopia.

METHOD

We searched articles from databases from June 1, 2022, to August 30, 2022. Cochrane Q test statistics and I² tests were applied. We used a random-effect meta-analysis model to overcome the impact of heterogeneity among the included studies. In addition, the association between risk factors and unfavorable management outcome in surgically treated patients with intestinal obstruction was investigated.

RESULTS

This study included a total of twelve articles. The pooled prevalence of unfavorable management outcome in surgically treated patients with intestinal obstruction was 20.22% (95% CI: 17.48-22.96). According to a sub-group analysis by region, Tigray region had the highest prevalence of poor management outcome, which was 25.78% (95% CI: 15.69-35.87). Surgical site infection was the most commonly reported symptom of poor management outcome (8.63%; 95% CI: 5.62, 11.64). The length of postoperative hospital stays (95% CI: 3.02, 29.08), duration of illness (95% CI: 2.44, 6.12), presence of comorbidity (95% CI: 2.38, 10.11), dehydration (95% CI: 2.07, 17.40), and type of intraoperative procedure (95% CI: 2.12, 6.97) were all significantly associated with unfavorable management outcome of intestinal obstruction among surgically treated patients in Ethiopia.

CONCLUSION

According to this study, the magnitude of unfavorable management outcome was high among surgically treated patients in Ethiopia. Unfavorable management outcome was significantly associated with the length of postoperative hospital stays, duration of illness, comorbidity, dehydration, and type of intraoperative procedure. Medical, surgical and public health measures are pivotal to reduce unfavorable management outcome in surgically treated intestinal obstruction patients in Ethiopia.

Development and evaluation of a portable and soft 3D-printed cast for laparoscopic choledochojejunostomy model in surgical training

BACKGROUND

Laparoscopic choledochojejunostomy (LCJ) is an essential basic skill for biliary surgeons. Therefore, we established a convenient and effective LCJ 3D printing model to evaluate whether the model could simulate the actual operation situation and determine its effectiveness and validity in surgical training.

METHODS

A 3D printing dry laboratory model was established to simulate LCJ. The face and content validity of the model were evaluated by six experienced biliary surgeons based on 5-point Likert scale questionnaires. A total of 15 surgeons with different levels of experience performed LCJ on the model and evaluated the structural validity of the model using the objective structured assessment of technical skills (OSATS). Simultaneously, the operation time of each surgery was also recorded. A study was also performed to further evaluate the learning curve of residents.

RESULTS

The operating space score of the model was 4.83 ± 0.41 points. The impression score of bile duct and intestinal canal was 4.33 ± 0.52 and 4.17 ± 0.41 points, respectively. The tactile sensation score of bile duct suture and intestinal canal suture was 4.00 ± 0.63 and 3.83 ± 0.41points, respectively. The OSATS score for model operation in the attending group was 29.20 ± 0.45 points, which was significantly higher than that in the fellow group (26.80 ± 1.10, P = 0.007) and the resident group (19.80 ± 1.30, P < 0.001). In addition, there was a statistical difference in operation time among surgeons of different experience levels (P < 0.05). Residents could significantly improve the surgical score and shorten the time of LCJ through repeated training.

CONCLUSIONS

The 3D printing LCJ model can simulate the real operation scenes and distinguish surgeons with different levels of experience. The model is expected to be one of the training methods for biliary tract surgery in the future.

Patterns of Skills Acquisition in Anesthesiologists During Simulated Interscalene Block Training on a Soft Embalmed Thiel Cadaver: Cohort Study

BACKGROUND

The demand for regional anesthesia for major surgery has increased considerably, but only a small number of anesthesiologists can provide such care. Simulations may improve clinical performance. However, opportunities to rehearse procedures are limited, and the clinical educational outcomes prescribed by the Royal College of Anesthesiologists training curriculum 2021 are difficult to attain. Educational paradigms, such as mastery learning and dedicated practice, are increasingly being used to teach technical skills to enhance skills acquisition. Moreover, high-fidelity, resilient cadaver simulators are now available: the soft embalmed Thiel cadaver shows physical characteristics and functional alignment similar to those of patients. Tissue elasticity allows tissues to expand and relax, fluid to drain away, and hundreds of repeated injections to be tolerated without causing damage. Learning curves and their intra- and interindividual dynamics have not hitherto been measured on the Thiel cadaver simulator using the mastery learning and dedicated practice educational paradigm coupled with validated, quantitative metrics, such as checklists, eye tracking metrics, and self-rating scores.

OBJECTIVE

Our primary objective was to measure the learning slopes of the scanning and needling phases of an interscalene block conducted repeatedly on a soft embalmed Thiel cadaver over a 3-hour period of training.

METHODS

A total of 30 anesthesiologists, with a wide range of experience, conducted up to 60 ultrasound-guided interscalene blocks over 3 hours on the left side of 2 soft embalmed Thiel cadavers. The duration of the scanning and needling phases was defined as the time taken to perform all the steps correctly. The primary outcome was the best-fit linear slope of the log-log transformed time to complete each phase. Our secondary objectives were to measure preprocedural psychometrics, describe deviations from the learning slope, correlate scanning and needling phase data, characterize skills according to clinical grade, measure learning curves using objective eye gaze tracking and subjective self-rating measures, and use cluster analysis to categorize performance irrespective of grade.

RESULTS

The median (IQR; range) log-log learning slopes were -0.47 (-0.62 to -0.32; -0.96 to 0.30) and -0.23 (-0.34 to -0.19; -0.71 to 0.27) during the scanning and needling phases, respectively. Locally Weighted Scatterplot Smoother curves showed wide variability in within-participant performance. The learning slopes of the scanning and needling phases correlated: ρ=0.55 (0.23-0.76), P<.001, and ρ=-0.72 (-0.46 to -0.87), P<.001, respectively. Eye gaze fixation count and glance count during the scanning and needling phases best reflected block duration. Using clustering techniques, fixation count and glance were used to identify 4 distinct patterns of learning behavior.

CONCLUSIONS

We quantified learning slopes by log-log transformation of the time taken to complete the scanning and needling phases of interscalene blocks and identified intraindividual and interindividual patterns of variability.

The impact of virtual reality simulation training on operative performance in laparoscopic cholecystectomy: meta-analysis of randomized clinical trials

BACKGROUND

Simulation training can improve the learning curve of surgical trainees. This research aimed to systematically review randomized clinical trials (RCT) evaluating the performance of junior surgical trainees following virtual reality training (VRT) and other training methods in laparoscopic cholecystectomy.

METHODS

MEDLINE (PubMed), Embase (Ovid SP), Web of Science, Scopus and LILACS were searched for trials randomizing participants to VRT or no additional training (NAT) or simulation training (ST). Outcomes of interest were the reported performance using global rating scores (GRS), the Objective Structured Assessment of Technical Skill (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS), error counts and time to completion of task during laparoscopic cholecystectomy on either porcine models or humans. Study quality was assessed using the Cochrane Risk of Bias Tool. PROSPERO ID: CRD42020208499.

RESULTS

A total of 351 titles/abstracts were screened and 96 full texts were reviewed. Eighteen RCT were included and 15 manuscripts had data available for meta-analysis. Thirteen studies compared VRT and NAT, and 4 studies compared VRT and ST. One study compared VRT with NAT and ST and reported GRS only. Meta-analysis showed OSATS score (mean difference (MD) 6.22, 95%CI 3.81 to 8.36, P < 0.001) and time to completion of task (MD -8.35 min, 95%CI 13.10 to 3.60, P = <0.001) significantly improved after VRT compared with NAT. No significant difference was found in GOALS score. No significant differences were found between VRT and ST groups. Intraoperative errors were reported as reduced in VRT groups compared with NAT but were not suitable for meta-analysis.

CONCLUSION

Meta-analysis suggests that performance measured by OSATS and time to completion of task is improved with VRT compared with NAT for junior trainee in laparoscopic cholecystectomy. However, conclusions are limited by methodological heterogeneity and more research is needed to quantify the potential benefit to surgical training.

The role of virtual reality simulation in surgical training in the light of COVID-19 pandemic: Visual spatial ability as a predictor for improved surgical performance: a randomized trial

INTRODUCTION

Due to the current COVID-19 pandemic, surgical training has become increasingly challenging due to required social distancing. Therefore, the use of virtual reality (VR)-simulation could be a helpful tool for imparting surgical skills, especially in minimally invasive environments. Visual spatial ability (VSA) might influence the learning curve for laparoscopic surgical skills. However, little is known about the influence of VSA for surgical novices on VR-simulator training regarding the complexity of different tasks over a long-term training period. Our study evaluated prior VSA and VSA development in surgical trainees during VR-simulator training, and its influence on surgical performance in simulator training.

METHODS

In our single-center prospective two-arm randomized trial, VSA was measured with a tube figure test before curriculum training. After 1:1 randomization, the training group (TG) participated in the entire curriculum training consisting of 48 different VR-simulator tasks with varying difficulty over a continuous nine-day training session. The control group (CG) performed two of these tasks on day 1 and 9. Correlation and regression analyses were used to assess the influence of VSA on VR-related surgical skills and to measure procedural abilities.

RESULTS

Sixty students (33 women) were included. Significant improvements in the TG in surgical performance and faster completion times were observed from days 1 to 9 for the scope orientation 30° right-handed (SOR), and cholecystectomy dissection tasks after the structured 9-day training program. After training, the TG with pre-existing low VSA scores achieved performance levels similar to those with pre-existing high VSA scores for the two VR simulator tasks. Significant correlations between VSA and surgical performance on complex laparoscopic camera navigation SOR tasks were found before training.

CONCLUSIONS

Our study revealed that that all trainees improved their surgical skills irrespective of previous VSA during structured VR simulator training. An increase in VSA resulted in improvements in surgical performance and training progress, which was more distinct in complex simulator tasks. Further, we demonstrated a positive relationship between VSA and surgical performance of the TG, especially at the beginning of training. Our results identified pre-existing levels of VSA as a predictor of surgical performance.

Proficiency Based Progression (PBP) training- the future model for dental operative skills training?: A systematic review and meta-analysis of existing literature

OBJECTIVE

To evaluate the effectiveness of Proficiency-Based Progression (PBP) operative training using validated performance metrics, by comparing this to standard, conventional training methods.

DATA

This systematic review was conducted in accordance with the guidelines of the Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA). Study quality was assessed using the MERSQI tool and the Cochrane Risk of Bias tool. Results were pooled using biased corrected standardized mean difference and ratio-of-means (ROM). 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. In quantitative synthesis testing for procedural errors, a pooled meta-analysis on 87 trainees was conducted using random-effects models. In a ROM analysis, PBP was estimated to reduce the mean rate of errors by 62%, when compared to standard training (ROM 0.38, 95% CI: 0.25; 0.58; p < 0.001) Sources: The electronic databases of PubMed, Embase, Web of Science, MEDLINE and Cochrane library's CENTRAL were searched from inception to 8/11/2021. Filters activated were Randomized Controlled trials, clinical trial.

STUDY SELECTION

13 studies were included for review with 11 included in the quantitative synthesis from 174 potentially relevant publications identified by the search strategy. Main inclusion criteria were studies comparing standard surgical/operative training with proficiency-based simulation training using validated metrics based on expert performance.

CONCLUSIONS

Our meta-analysis found that PBP training improved trainees' performances, by decreasing procedural errors. There is sufficient evidence to explore PBP training for use in dental skills training. PBP training was estimated to reduce the mean rate of operative errors by 62%, when compared to standard training. Given that there is a direct correlation between operative skill and patient outcomes, these data suggest that there is sufficient evidence to explore PBP training for use in dental skills training.

Investigation of Objectivity in Scoring and Evaluating Microvascular Anastomosis Simulation Training

The increase in minimally invasive surgery has led to a decrease in surgical experience. To date, there is only limited research examining whether skills are evaluated objectively and equally in simulation training, especially in microsurgery. The purpose of this study was to analyze the objectivity and equality of simulation evaluation results conducted in a contest format. A nationwide recruitment process was conducted to select study participants. Participants were recruited from a pool of qualified physicians with less than 10 years of experience. In this study, the simulation procedure consisted of incising a 1 mm thick blood vessel and suturing it with a 10-0 thread using a microscope. Initially, we planned to have the neurosurgical supervisors score the simulation procedure by direct observation. However, due to COVID-19, some study participants were unable to attend. Thus requiring some simulation procedures to be scored by video review. A total of 14 trainees participated in the study. The Cronbach’s alpha coefficient among the scorers was 0.99, indicating a strong correlation. There was no statistically significant difference between the scores from the video review and direct observation judgments. There was a statistically significant difference (p <0.001) between the scores for some criteria. For the eight criteria, individual scorers assigned scores in a consistent pattern. However, this pattern differed between scorers indicating that some scorers were more lenient than others. The results indicate that both video review and direct observation methods are highly objective techniques evaluate simulation procedures.

Comparison of a practice-based versus theory-based training program for conducting vacuum-assisted deliveries: a randomized-controlled trial

PURPOSE

Vacuum-assisted deliveries (VAD) are complex procedures that require training and experience to be performed proficiently. We aimed to evaluate if a more resource intensive practice-based training program for conducting VAD is more efficient compared to a purely theory-based training program, with respect to immediate training effects and persistence of skills 4-8 weeks after the initial training.

METHODS

In this randomized-controlled study conducted in maternity staff, participants performed a simulated low-cavity non-rotational vacuum delivery before (baseline test) and immediately after the training (first post-training test) as well as 4-8 weeks thereafter (second post-training test). The study's primary endpoint was to compare training effectiveness between the two study groups using a validated objective structured assessment of technical skills (OSATS) rating scale.

RESULTS

Sixty-two participants were randomized to either the theory-based group (n = 31) or the practice-based group (n = 31). Total global and specific OSATS scores, as well as distance of cup application to the flexion point improved significantly from baseline test to the first post-training test in both groups (p_all < 0.007). Skill deterioration after 4-8 weeks was only found in the theory-based group, whereas skills remained stable in the practice-based group.

CONCLUSION

A practice-based training program for conducting VAD results in comparable immediate improvement of skills compared to a theory-based training program, but the retention of skills 4-8 weeks after training is superior in a practice-based program. Future studies need to evaluate, whether VAD simulation training improves maternal and neonatal outcome after VAD.

Application of technology to educational needs in surgery

Innovations in surgical education follow advancing clinical technology. New surgical methods have prompted demand for systematic methods to leverage computing power and internet tools to achieve proficiency-based training goals. Virtual reality, high-fidelity patient simulation, web-based resources to facilitate performance assessment, and telementoring have become mainstream practices, although patient outcomes benefits are not well studied. Remote virtual meeting and mentoring have had transformative effects on resident experiences, the full effects of which remain to be seen.

The impact of virtual reality training on laparoscopic surgical skills; A prospective blinded controlled trial

Background. Laparoscopic surgery has gained popularity in the last few decades replacing open standard techniques in several procedures. While its use and scope expand, a standardized method of training and assessment in laparoscopic skills is lacking. Aim. To assess the effect of virtual reality (VR) training on laparoscopic surgical skills. Materials and Methods. It is a prospective, controlled study conducted at Sagar Hospital’s skill lab and Shanthi Hospital and Research Centre (SHRC). We included 27 post graduates in general surgery. They were divided into two groups. One group underwent training in VR Simulator for one week, 30 minutes each day. The second group received no training. Their proficiency while mobilizing the Gallbladder from its liver bed was assessed using a validated scale by a single blinded observer. Results. The statistical analysis was done using a non-parametric test (Mann-Whitney U test). Residents who underwent training in VR simulator got better scores in Overall rating and also in individual parameters when compared with the control group (P = <0.05). Conclusions. Laparoscopic surgical skills can be increased by using proficiency-based VR simulator training and it can be transferred to actual operations. VR simulators are a valid tool for laparoscopic surgical skills training.

Automation of surgical skill assessment using a three-stage machine learning algorithm

Surgical skills are associated with clinical outcomes. To improve surgical skills and thereby reduce adverse outcomes, continuous surgical training and feedback is required. Currently, assessment of surgical skills is a manual and time-consuming process which is prone to subjective interpretation. This study aims to automate surgical skill assessment in laparoscopic cholecystectomy videos using machine learning algorithms. To address this, a three-stage machine learning method is proposed: first, a Convolutional Neural Network was trained to identify and localize surgical instruments. Second, motion features were extracted from the detected instrument localizations throughout time. Third, a linear regression model was trained based on the extracted motion features to predict surgical skills. This three-stage modeling approach achieved an accuracy of 87 ± 0.2% in distinguishing good versus poor surgical skill. While the technique cannot reliably quantify the degree of surgical skill yet it represents an important advance towards automation of surgical skill assessment.

The ILLS Laparoscopic Liver Surgery Fellow Skills Curriculum

INTRODUCTION

Laparoscopy is becoming the standard approach in liver surgery. As the degree of difficulty varies greatly from core skills to advanced procedures, strategies for teaching young surgeons need to be reconsidered. We here aimed to design a skills curriculum for LLR.

METHODS

Using the nominal group technique, 22 substeps of LLR were identified by 61 hepatobiliary surgeons. The raters were asked to rate (1) the difficulty of substeps and (2) the minimum number of times that the substep must be performed for mastery of the technique. According to the frequency of defined substeps, being estimated on the basis of high volume center experiences (n = 222 LLR; 1/2017-12/2018), the center's training capacity and defined goals for a 2-year fellowship were calculated.

RESULTS

Ten surgical substeps (45%) are routinely performed and can thus be taught sufficiently at centers carrying out ≥50 LLR in 2 years. As the mobilization of the right liver lobe and the dissection of the hepatic artery or portal vein is performed in only 27% and 28% of all LLR, respectively, sufficient training can only be provided at centers with ≥100 LLRs in 2 years. Mastery of complex parenchymal dissection (19%) and hilar lymphadenectomy (8%) can only be achieved in center performing ≥200 LLR in 2 years.

CONCLUSION

We here suggest a stepwise approach for training of hepatobiliary fellows in LLR. Based on the estimated complexity of the substeps and the size of the center, not every substep can be learned within 2 years.

Simulation-Based Arthroscopic Skills Using a Spaced Retraining Schedule Reduces Short-Term Task Completion Time and Camera Path Length

PURPOSE

To investigate whether acquiring basic knee arthroscopic skills via a spaced retraining schedule could prevent skills deterioration and achieve further skills improvement.

METHODS

In the learning phase, 16 residents with no previous hands-on experience in practicing arthroscopic skills were asked to perform basic arthroscopic tasks on a simulator until they attained perfect scores in each task. Immediately after completing the learning phase, a pretest was performed to assess their performance. Next, they were randomly assigned into 2 groups. The spaced retraining group, which undertook a spaced repetitive training phase with a fixed-time interval, returned on days 2, 4 and 6 to repeat the same tasks for 20 minutes per day, whereas the control group did nothing. On day 7, all participants performed a posttest. A 2 × 2 mixed analysis of variance model was used for statistical analysis.

RESULTS

Significant differences between the 2 groups were found in task completion time (P = .003) and camera path length (P = .043) but not cartilage injury (P = .186). Residents in the spaced retraining group decreased their task completion time (163.2 ± 23.9 seconds) whereas the task time in the control group increased (351.3 ± 25.5 seconds). The same pattern was found with the camera path length.

CONCLUSIONS

Implementing a spaced retraining schedule in 1 week resulted in a reduced task completion time and camera path length but no significant reduction in cartilage injury. It appears that introducing a spaced retraining schedule to retain arthroscopic skills acquired through massed learning may be advantageous.

CLINICAL RELEVANCE

In consideration of the training time available to residents and the trend toward massed learning, this spaced retraining schedule may offer a cost-effective and convenient way for residents to maintain and improve their basic arthroscopic skills with no significant increase in time invested.

Transferability of Simulation-Based Training in Laparoscopic Surgeries: A Systematic Review

Objective

The implementation of simulation-based training in residency programs has been increased, but the transferability of surgical skills in the real operating room is not well documented. In our survey, the role of simulation in surgical training will be evaluated. Study Design. In this systemic review, randomized control trials, which assessed the transferability of acquired skills through simulation in the real operating setting, were included. A systematic search strategy was undertaken using a predetermined protocol.

Results

Eighteen randomized clinical trials were included in this survey. Two studies investigated inguinal hernia repair, six laparoscopic cholecystectomy, five gynecologic procedures, two laparoscopic suturing, and two camera navigation during laparoscopic procedures. Simulation-trained participants showed superiority in surgical performance in comparison with untrained surgeons. The operation time, accuracy, incidence of intraoperative errors, and postoperative complications were statistically better in the simulation-trained group in comparison with the conventional-trained group.

Conclusion

Simulation provides a safe, effective, and ethical way for residents to acquire surgical skills before entering the operating room.

Virtual reality training compared with apprenticeship training in laparoscopic surgery: a meta-analysis

INTRODUCTION

Since its inception, laparoscopic surgery has evolved and new techniques have been developed due to technological advances. This requires a different and more complex skill set in comparison with open surgery. Reduced working hours, less training time and patient safety factors demand that such skills need to be achieved outside the operating theatre environment. Several studies have been published and have determined the effectiveness of virtual reality training. We aimed to compare virtual reality training with the traditional apprenticeship method of training and determine whether it can supplement or replace the traditional apprenticeship model. We also aimed to perform a meta-analysis of the literature and develop conclusions with respect to the benefits achieved by adding virtual reality training on a regular basis to surgical training programmes.

METHODS

A literature search was carried out on PubMed, MEDLINE, EMBASE and Google Scholar academic search engines using the MESH terms 'randomised controlled trials', 'virtual reality', 'laparoscopy', 'surgical education' and 'surgical training'. All randomised controlled trials published to January 2018 comparing virtual reality training to apprenticeship training were included. Data were collected on improved dexterity, operative performance and operating times. Each outcome was calculated with 95% confidence intervals and with intention-to-treat analysis; 24 randomised controlled trials were analysed.

FINDINGS

Meta-analytical data were extracted for time, path length, instrument handling, tissue handling, error scores and objective structure assessment of technical skills scoring. There was significant improvement in individual trainee skill in all meta-analyses (p < 0.0002).

CONCLUSION

This meta-analysis shows that virtual reality not only improves efficiency in the trainee's surgical practice but also improves quality with reduced error rates and improved tissue handling.

Surgical apprenticeship in the era of simulation

The new tools for transmission of knowledge and skills (simulation, surgery broadcast, virtual reality, augmented reality…) offer novel opportunities for training through mentoring. The peer network is widened; the dissemination of knowledge is accelerated. The new ways of teaching bring benefit to each aspect of the surgical profession: clinical reasoning, performance of technical procedures, stress management, communication and management of severe or exceptional adverse events. Previously, confined to surgical teams, mentoring has been extended to simulation centers, which are becoming virtual hospitals, and it has been prolonged on the Internet via social networks. In the sphere of digital mentoring, objectives are henceforth more structured, skills assessment is more standardized, phases of apprenticeship are redefined, and individualized training contracts are formalized.

Efficacy of goal-directed minimally invasive surgery simulation training with the Lübeck Toolbox-Curriculum prior to first operations on patients: Study protocol for a multi-centre randomized controlled validation trial (NOVICE)

•

Laparoscopic surgery (MIS) requires additional psychomotoric skills (basic skills)

•

Acquisition of MIS basic skills by the video box trainer Lübecker Toolbox.

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Simulation of laparoscopic demands outside the operation room.

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MIS training outside the operation room prior to first operations on patients.

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Implementation of MIS training into the surgical residency curriculum.

Background

Minimally invasive surgery (MIS) procedures require special psychomotoric skills. Learning of these MIS basic skills is often performed in the operating room (OR). This is economically inefficient and could be improved in terms of patient safety. Against the background of this problem, various MIS simulators have been developed to train MIS basic skills outside the OR. Aim of this study is to evaluate to what extent MIS training programs and simulators improve the residents’ skills in performing their first MIS procedures on patients.

Method

The current multicentric RCT will be performed with surgical residents without prior active experience in MIS (n = 14). After the participants have completed their first laparoscopic cholecystectomy as baseline evaluation (CHE I), they will be randomized into two groups: 1) The intervention group will perform the Lübeck Toolbox curriculum, whereas 2) the control group will not undergo any MIS training. After 6 weeks, both groups will perform the second laparoscopic CHE (CHE II). Changes or improvements in operative performance (between CHE I and CHE II) will be analyzed and evaluated according to the Global Operative Assessment of Laparoscopic Skill (GOALS) Score (primary endpoint).

Discussion

The multicentric randomized controlled trial will help to determine the value of MIS training outside the operation room. Proof of effectiveness in practice transfer could be of considerable relevance with regard to an integration of MIS training programs into surgical education.

Implementation of a Medical School Elective Course Incorporating Case-Based Learning: a Pilot Study

INTRODUCTION

Case-based learning (CBL) is a pedagogical method using clinical case studies to reinforce learning topics. A pilot elective course incorporating CBL was offered for first-year medical students. The purpose of this study is to (1) describe the logistics of implementing the course and (2) evaluate its reception among medical students on its efficacy in learning basic science class material.

METHOD

An 8-week elective course was offered to medical students from 2012 to 2017. Specialists facilitated case discussions synthesizing material from didactic lectures with clinical scenarios. End-of-term surveys with multiple choice and free response questions were distributed to students and described using summary statistics.

RESULTS

There were 13 cohorts of enrollees, and the average number of students enrolled per cohort was 45.6, out of an average class size of 186 (24.5%, range 36-60). One hundred ninety-eight (64.2%) students reported that the course considerably changed or greatly expanded knowledge. Three hundred two (89.1%) students felt it met a majority of or exceeded expectations. Two hundred eighty-seven (80.2%) responses indicated interest in taking the course again or recommending it to others. One hundred six responses (27.1%) indicated preference for CBL over traditional lectures, and 177 (45.3%) were interested to see CBL integrated into the curriculum.

CONCLUSIONS

Overall, this CBL elective course was well-received and perceived as effective for better learning class material by students. Additionally, students were receptive to case-based learning and integrating this style of learning into a preclinical curriculum without entirely replacing didactic-based learning. These findings may encourage more medical schools to explore incorporating CBL in the curriculum.

Trainee Performance After Laparoscopic Simulator Training Using a Blackbox versus LapMentor

BACKGROUND

Training using laparoscopic high-fidelity simulators (LHFSs) to proficiency levels improves laparoscopic cholecystectomy skills. However, high-cost simulators and their limited availability could negatively impact residents' laparoscopic training opportunities. We aimed to assess whether motivation and surgical skill performance differ after basic skills training (BST) using a low-cost (Blackbox) versus LHFS (LapMentor) among medical students.

MATERIALS AND METHODS

Sixty-three medical students from Karolinska Institutet volunteered, completing written informed consent, questionnaire regarding expectations of the simulation training, and a visuospatial ability test. They were randomized into two groups that received BST using Blackbox (n = 32) or LapMentor (n = 31). However, seven students absence resulted in 56 participants, followed by another 9 dropouts. Subsequently, after training, 47 students took up three consecutive tests using the minimally invasive surgical trainer-virtual reality (MIST-VR) simulator, finalizing a questionnaire.

RESULTS

More Blackbox group participants completed all MIST-VR tests (29/31 versus 18/25). Students anticipated mastering LapMentor would be more difficult than Blackbox (P = 0.04). In those completing the simulation training, a trend toward an increase was noted in how well participants in the Blackbox group liked the simulator training (P = 0.07). Subgroup analysis of motivation and difficulty in liking the training regardless of simulator was found only in women (Blackbox [P = 0.02]; LapMentor [P = 0.06]). In the Blackbox group, the perceived difficulty of training, facilitation, and liking the Blackbox training (significant only in women) were significantly correlated with the students' performance in the MIST-simulator. No such correlations were found in the LapMentor group.

CONCLUSIONS

Results indicate an important role for low-tech/low-cost Blackbox laparoscopic BST of students in an otherwise high-tech surrounding. Furthermore, experience of Blackbox BST procedures correlate with students' performance in the MIST-VR simulator, with some gender-specific differences.

Perfect Registration Leads to Imperfect Performance: A Randomized Trial of Multimodal Intraoperative Image Guidance

OBJECTIVE

To compare surgical safety and efficiency of 2 image guidance modalities, perfect augmented reality (AR) and side-by-side unregistered image guidance (IG), against a no guidance control (NG), when performing a simulated laparoscopic cholecystectomy (LC).

BACKGROUND

Image guidance using AR offers the potential to improve understanding of subsurface anatomy, with positive ramifications for surgical safety and efficiency. No intra-abdominal study has demonstrated any advantage for the technology. Perfect AR cannot be provided in the operative setting in a patient; however, it can be generated in the simulated setting.

METHODS

Thirty-six experienced surgeons performed a baseline LC using the LapMentor simulator before randomization to 1 of 3 study arms: AR, IG, or NG. Each performed 3 further LC. Safety and efficiency-related simulator metrics, and task workload (SURG-TLX) were collected.

RESULTS

The IG group had a shorter total instrument path length and fewer movements than NG and AR groups. Both IG and NG took a significantly shorter time than AR to complete dissection of Calot triangle. Use of IG and AR resulted in significantly fewer perforations and serious complications than the NG group. IG had significantly fewer perforations and serious complications than the AR group. Compared with IG, AR guidance was found to be significantly more distracting.

CONCLUSION

Side-by-side unregistered image guidance (IG) improved safety and surgical efficiency in a simulated setting when compared with AR or NG. IG provides a more tangible opportunity for integrating image guidance into existing surgical workflow as well as delivering the safety and efficiency benefits desired.

Construct validity of eoSim - a low-cost and portable laparoscopic simulator

Purpose: To examine the construct validity of the low-cost, portable laparoscopic simulator eoSim using motion analysis.Material and methods: Novice and experienced surgeons (≤ 100 and >100 laparoscopic procedures performed, respectively) completed four tasks on the eoSim using the SurgTrac software: intracorporeal suture and tie, tube ligation, peg capping and precision cutting. The following metrics were recorded: Time to complete task, distance traveled, handedness (left- versus right hand use), time off-screen, distance between instrument tips, speed, acceleration and motion smoothness.Results: Compared to novices (n = 22), experienced surgeons (n = 14) completed tasks in less time (p ≤ .025), except when performing peg capping (p = .052). On all tasks, they also scored lower on the distance metric (p ≤ .001). Differences in handedness (left hand compared between groups, right hand compared between groups) were found to be significant for three tasks (p ≤ .025). In general, the experienced group made greater use of their left hand than the novice group.Conclusion: The eoSim can differentiate between experienced and novice surgeons on the tasks intracorporeal suture and tie, tube ligation and precision cutting, thus providing a convenient method for surgical departments to implement testing of their surgeons' basic laparoscopic skills.

Challenges & Issues: Evidence-Based Clinical Skills Teaching and Learning: What Do We Really Know?

The recent programmatic focus on skills development in veterinary medicine means that many programs are devoting increased time to formal clinical skills teaching. This expansion makes it essential that we use the time as effectively as possible. This review examines current practices and veterinary training principles using the broader field of evidence-based motor skills learning as a lens. In many areas, current practices may be hindering learning. Proposed practices include using videos and discussions for pre-laboratory training, focusing on a single complex skill at a time, using more near-peer instructors rather than faculty, including assessments in each teaching or practice session, and encouraging supervised distributed practice by incorporating practice sessions into the formal curriculum. Ensuring mastery of a few core skills rather than exposure to many may be the new goal. Further research is urgently needed on block versus spiral curricula, optimum instructor-to-student ratios, learning and practice schedules, hours required for proficiency, and the benefits of exercise on motor skills learning.

Surgery Tutor for Computational Assessment of Technical Proficiency in Soft-Tissue Tumor Resection in a Simulated Setting

BACKGROUND

In competency-based medical education, progression between milestones requires reliable and valid methods of assessment. Surgery Tutor is an open-source motion tracking platform developed to objectively assess technical proficiency during open soft-tissue tumor resections in a simulated setting. The objective of our study was to provide evidence in support of construct validity of the scores obtained by Surgery Tutor. We hypothesized that Surgery Tutor would discriminate between novice, intermediate, and experienced operators.

METHODS

Thirty participants were assigned to novice, intermediate, or experienced groups, based on the number of prior soft-tissue resections performed. Each participant resected 2 palpable and 2 nonpalpable lesions from a soft-tissue phantom. Surgery Tutor was used to track hand and instrument motions, number of tumor breaches, and time to perform each resection. Mass of excised specimens and margin status were also recorded.

RESULTS

Surgery Tutor scores demonstrated "moderate" to "good" internal structure (test-retest reliability) for novice, intermediate, and experienced groups (interclass correlation coefficient = 0.596, 0.569, 0.737; p < 0.001). Evidence in support of construct validity (consequences) was demonstrated by comparing scores of novice, intermediate, and experienced participantsfor number of hand and instrument motions (690 ± 190, 597 ± 169, 469 ± 110; p < 0.001), number of tumor breaches (29 ± 34, 16 ± 11, 9 ± 6; p < 0.001), time per resection (677 ± 331 seconds, 561 ± 210 seconds, 449 ± 148 seconds; p < 0.001), mass of completely excised specimens (22 ± 7g, 21 ± 11g, 17 ± 6 g; p = 0.035), and rate of positive margin (68%, 50%, 28%; p < 0.001). There was "strong" and "moderate" relationships between motion scores and Objective Structured Assessment of Technical Skill scores, and time per resection and Objective Structured Assessment of Technical Skill scores respectively (r = -0.60, p < 0.001; r = -0.54, p < 0.001).

CONCLUSION

Surgery Tutor scores demonstrate evidenceof construct validity with regards to good internal structure, consequences, and relationship to other variables in the assessment of technical proficiency duringopen soft-tissue tumor resections in a simulated setting. Utilization of Surgery Tutor can provide formative feedback and objective assessment of surgical proficiency in a simulated setting.

Low-Cost Self-Made Arthroscopic Training Camera Is Equally as Effective as Commercial Camera: A Comparison Study

PURPOSE

To assess the effectiveness of a low-cost self-made arthroscopic camera (LAC) in basic arthroscopic skills training compared with a commercial arthroscopic camera (CAC).

METHODS

One hundred fifty-three orthopaedic residents were recruited and randomly assigned to either the LAC or CAC. They were allocated 2 practice sessions, with 20 minutes each, to practice 4 given arthroscopic tasks: task 1, transferring objects; task 2, stacking objects; task 3, probing numbers; and task 4, stretching rubber bands. The time taken for participants to complete the given tasks was recorded in 3 separate tests; before practice, immediately after practice, and after a period of 3 months. A comparison of the time taken between both groups to complete the given tasks in each test was measured as the primary outcome.

RESULTS

Significant improvements in time completion were seen in the post-practice test for both groups in all given arthroscopic tasks, each with P < .001. However, there was no significant difference between the groups for task 1 (P = .743), task 2 (P = .940), task 3 (P = .932), task 4 (P = .929), and total (P = .944). The outcomes of the tests (before practice, after practice, and at 3 months) according to repeated measures analysis of variance did not differ significantly between the groups in task 1 (P = .475), task 2 (P = .558), task 3 (P = .850), task 4 (P = .965), and total (P = .865).

CONCLUSIONS

The LAC is equally as effective as the CAC in basic arthroscopic skills training with the advantage of being cost-effective.

CLINICAL RELEVANCE

In view of the scarcity in commercial arthroscopic devices for trainees, this low-cost device, which trainees can personally own and use, may provide a less expensive and easily available way for trainees to improve their arthroscopic skills. This might also cultivate more interest in arthroscopic surgery among junior surgeons.

Refining How We Define Laparoscopic Expertise

BACKGROUND

Traditional stratification of expertise in laparoscopic simulation assigns participants to novice, intermediate, or expert groups based on case numbers. We hypothesized that expert video assessment might refine this discrimination of psychomotor expertise, especially in light of new measurable parameters.

MATERIALS AND METHODS

One hundred five participants performed a defined intracorporeal suturing task in the pediatric laparoscopic surgery simulator armed with force-sensing capabilities. Participants were stratified into novice, intermediate, and expert groups via three classification schemes: (1) number of complex laparoscopic cases, (2) self-declared level of expertise, and (3) average expert rating of participants' videos. Precision, time to task completion, and force analysis parameters (FAP = total, maximum and mean forces in three axes) were compared using one-way analysis of variance tests. P < .05 was considered significant.

RESULTS

Participants stratified on the basis of case numbers and on the basis of self-declared level of expertise had statistically significant differences in time to task completion, but no significant difference in FAP. When participants were restratified according to expert assessment of their video performance, time to task completion as well as total and mean forces in X, Y, and Z axes allowed discrimination between novices, intermediates, and experts, thus establishing construct validity for the latter. Precision did not allow discrimination in any stratification scheme.

CONCLUSION

Compared with traditional stratification, video assessment allows refined discrimination of psychomotor expertise within a simulator. Assessment of FAP may become a relevant tool for teaching and assessing laparoscopic skills.

Characteristics of participants who withdraw from surgical simulation-based educational research

Introduction

The problems associated with recruitment and retention of patients in clinical trials have been widely addressed in literature; however, similar problems associated with healthcare workers are rarely reported. The aim of this paper is to outline the factors that can impede a participant’s successful participation in a research project and to analyse the characteristics of participants that withdrew.

Methods

The Laparoscopic Simulation Skills Program (LSSP) was a prospective randomised cohort study investigating the efficacy of self-directed learning for basic laparoscopic skills acquisition. Two hundred and seven medical students, junior doctors, as well as surgical and gynaecology trainees were enrolled between June 2015 and November 2016.

Results

Fifty-six (27%) participants failed to attend the final assessment. Of these, 43 participants (77%) responded to the follow-up survey and/or phone contact regarding non-attendance. Most participants failed to attend due to lack of free time/conflicting clinical duties and university requirements. Participants who did not attend the final assessment and did not provide further responses were less motivated by a career in surgery, surgical simulation and perceived less benefits of laparoscopic simulation. The 43 participants who answered the survey and/or phone contact provided similar responses to the participants who completed the study requirements and had more intrinsic motivators to enrol.

Conclusions

Clinical duties and other educational commitments are the biggest barriers to participation in simulation based-education research.

Endosuture trainer box simulator as a tool for training and teaching in bariatric laparoscopic surgery

Background

Video surgery requires acquisition of psychomotor skills that are different from those required for open surgery. The aim of this study was to assess the EndoSuture Trainer Box Simulator (ESTBS), a new bariatric laparoscopic skills simulator, as a tool for surgical education, comparing it with a standard laparoscopic trainer (SLT).

Methods

A randomized prospective crossover study was designed to compare ESTBS versus SLT as a tool for training bariatric laparoscopic skills. Participants were assigned to perform a task simulating Nissen fundoplication operation. All subjects evaluated the simulators concerning to their performance on simulating laparoscopic procedures by the use of a questionnaire comparing: triangulation, resistance and resilience, spatial perception (stereotaxy), ergonomics and positioning, inverted movements, visibility, design, technical and technological resources for training and education. The overall score was defined as the median value obtained. A total of 37 participants were enrolled in the study, including 29 experienced surgeons (78.37%) and 08 surgical residents (21.63%).

Results

A superior performance was observed with ESTBS as compared to SLT upon 7 of the 10 items evaluated in the questionnaire. Additionally, the overall score of ESTBS (median of 4, very good) was significantly higher (P < 0.0001) than that of SLT (median of 3, good). For the items, triangulation, resistance and resilience, ergonomics, design, training, technology and teaching, the evaluation for the ESTBS was very good and excellent, which was significantly higher than obtained by SLT. Also, ESTBS was cheaper.

Conclusions

The ESTBS was shown to present excellent technical and technological performances and appears to constitute a useful cost-effective promising instrument for teaching and training bariatric surgical laparoscopic skills.

TEACHING MODEL FOR EVALUATION OF THE ABILITY AND COMPETENCE PROGRESS IN ENDOSUTURE IN SURGICAL SKILL LABORATORY

Background:

Laparoscopic manual suturing is probably the most difficult skill to be acquired in minimally invasive surgery. However, laparoscopic exercise endo-sutures can be learned with a simulator and are of great practical importance and clinical applicability, absorbing concepts that are immediately transferred to the operating room.

Aim:

To assess the progression of skills competence in endo-sutures through realistic simulation model of systematized education.

Method:

Evaluation of the progression of competence of students in three sequential stages of training in realistic simulation, pre-test (V.1), teaching concepts (V.2) and training station for absorption of video concepts in surgery - ergonomics, stereotaxia, ambidexterity, haptic touch, fucral effect, applied in the manufacture of points corresponding to a Nissen fundoplication, in endo-suture for realistic simulation.

Results:

All students who attended the course absorbed the video concepts in surgery; most participants showed steady and continued improvement and during the stages of training, obtained progression of appropriate skills, defining competence and validation of the teaching model to achieve proficiency.

Conclusions:

The teaching model was adequate, safe, revealed the profile of the student, the evolutionary powers of the endo-sutures performance and critical analysis of the training to achieve proficiency in bariatric procedures.

Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy

BACKGROUND

Endoscopy has traditionally been taught with novices practicing on real patients under the supervision of experienced endoscopists. Recently, the growing awareness of the need for patient safety has brought simulation training to the forefront. Simulation training can provide trainees with the chance to practice their skills in a learner-centred, risk-free environment. It is important to ensure that skills gained through simulation positively transfer to the clinical environment. This updated review was performed to evaluate the effectiveness of virtual reality (VR) simulation training in gastrointestinal endoscopy.

OBJECTIVES

To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy, and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience.

SEARCH METHODS

We searched the following health professions, educational, and computer databases until 12 July 2017: the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, BIOSIS Previews, CINAHL, AMED, ERIC, Education Full Text, CBCA Education, ACM Digital Library, IEEE Xplore, Abstracts in New Technology and Engineering, Computer and Information Systems Abstracts, and ProQuest Dissertations and Theses Global. We also searched the grey literature until November 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised clinical trials comparing VR endoscopy simulation training versus any other method of endoscopy training with outcomes measured on humans in the clinical setting, including conventional patient-based training, training using another form of endoscopy simulation, or no training. We also included trials comparing two different methods of VR training.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. We pooled data for meta-analysis where participant groups were similar, studies assessed the same intervention and comparator, and had similar definitions of outcome measures. We calculated risk ratio for dichotomous outcomes with 95% confidence intervals (CI). We calculated mean difference (MD) and standardised mean difference (SMD) with 95% CI for continuous outcomes when studies reported the same or different outcome measures, respectively. We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We included 18 trials (421 participants; 3817 endoscopic procedures). We judged three trials as at low risk of bias. Ten trials compared VR training with no training, five trials with conventional endoscopy training, one trial with another form of endoscopy simulation training, and two trials compared two different methods of VR training. Due to substantial clinical and methodological heterogeneity across our four comparisons, we did not perform a meta-analysis for several outcomes. We rated the quality of evidence as moderate, low, or very low due to risk of bias, imprecision, and heterogeneity.Virtual reality endoscopy simulation training versus no training: There was insufficient evidence to determine the effect on composite score of competency (MD 3.10, 95% CI -0.16 to 6.36; 1 trial, 24 procedures; low-quality evidence). Composite score of competency was based on 5-point Likert scales assessing seven domains: atraumatic technique, colonoscope advancement, use of instrument controls, flow of procedure, use of assistants, knowledge of specific procedure, and overall performance. Scoring range was from 7 to 35, a higher score representing a higher level of competence. Virtual reality training compared to no training likely provides participants with some benefit, as measured by independent procedure completion (RR 1.62, 95% CI 1.15 to 2.26; 6 trials, 815 procedures; moderate-quality evidence). We evaluated overall rating of performance (MD 0.45, 95% CI 0.15 to 0.75; 1 trial, 18 procedures), visualisation of mucosa (MD 0.60, 95% CI 0.20 to 1.00; 1 trial, 55 procedures), performance time (MD -0.20 minutes, 95% CI -0.71 to 0.30; 2 trials, 29 procedures), and patient discomfort (SMD -0.16, 95% CI -0.68 to 0.35; 2 trials, 145 procedures), all with very low-quality evidence. No trials reported procedure-related complications or critical flaws (e.g. bleeding, luminal perforation) (3 trials, 550 procedures; moderate-quality evidence).Virtual reality endoscopy simulation training versus conventional patient-based training: One trial reported composite score of competency but did not provide sufficient data for quantitative analysis. Virtual reality training compared to conventional patient-based training resulted in fewer independent procedure completions (RR 0.45, 95% CI 0.27 to 0.74; 2 trials, 174 procedures; low-quality evidence). We evaluated performance time (SMD 0.12, 95% CI -0.55 to 0.80; 2 trials, 34 procedures), overall rating of performance (MD -0.90, 95% CI -4.40 to 2.60; 1 trial, 16 procedures), and visualisation of mucosa (MD 0.0, 95% CI -6.02 to 6.02; 1 trial, 18 procedures), all with very low-quality evidence. Virtual reality training in combination with conventional training appears to be advantageous over VR training alone. No trials reported any procedure-related complications or critical flaws (3 trials, 72 procedures; very low-quality evidence).Virtual reality endoscopy simulation training versus another form of endoscopy simulation: Based on one study, there were no differences between groups with respect to composite score of competency, performance time, and visualisation of mucosa. Virtual reality training in combination with another form of endoscopy simulation training did not appear to confer any benefit compared to VR training alone.Two methods of virtual reality training: Based on one study, a structured VR simulation-based training curriculum compared to self regulated learning on a VR simulator appears to provide benefit with respect to a composite score evaluating competency. Based on another study, a progressive-learning curriculum that sequentially increases task difficulty provides benefit with respect to a composite score of competency over the structured VR training curriculum.

AUTHORS' CONCLUSIONS

VR simulation-based training can be used to supplement early conventional endoscopy training for health professions trainees with limited or no prior endoscopic experience. However, we found insufficient evidence to advise for or against the use of VR simulation-based training as a replacement for early conventional endoscopy training. The quality of the current evidence was low due to inadequate randomisation, allocation concealment, and/or blinding of outcome assessment in several trials. Further trials are needed that are at low risk of bias, utilise outcome measures with strong evidence of validity and reliability, and examine the optimal nature and duration of training.

The Impact of Simulator Size on Forces Generated in the Performance of a Defined Intracorporeal Suturing Task: A Pilot Study

Background: In pediatric minimal access surgery, the operative domain may vary from that of an adult to that of a neonate. This study aimed to quantify the impact of decreased operative domain on forces generated in the performance of a defined intracorporeal suturing task. Methods: One hundred five participants performed a defined intracorporeal suturing task in small and large simulators. Time to task completion and force analysis parameters (FAPs = total, maximum, and mean forces in X, Y, and Z axes) were measured. Expertise level was assigned based on the number of laparoscopic cases. Outcomes were analyzed using paired sample t-tests, P value of <.05. Results: Time to task completion varied significantly for experts between adult and pediatric simulators but not for intermediates or novices. Total, maximum, and mean forces in the X ("side to side") axis were significantly greater in the larger laparoscopic simulator for all levels of expertise. In the Y axis ("in and out" movement) and Z axis ("up and down" movement), total and mean forces were higher in the adult simulator regardless of the level of expertise. Differences in maximum force between the adult and pediatric simulators in the Z axis ("up and down" movement) varied significantly for novices and intermediates but not for experts. Conclusion: Forces were greater, particularly in the side-to-side plane, in the larger simulator for participants of all levels in the performance of this defined intracorporeal suturing task. Further analysis will determine the reasons for and implications of the increased force parameters in the simulator of larger domain.

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.

Building a Simulator with Life-like Realism for Teaching Abdominal Operations

OBJECTIVE

The objective of this communication is to provide an evolutionary description of an attempt to replicate the success of the Rampahl Cardiac Simulator using perfused abdominal organ blocks the way that the Rampahl Simulator uses ex vivo porcine hearts.

DESIGN

This descriptive paper makes no attempt to prove the effectiveness of the described educational tool, but rather, outlines the successes and failures in development. The proven value of a perfused organ teaching tool, as the Rampahl Simulator, suggests that others can build upon the work described in this paper so that, in the future, perfused abdominal organs will be available to students of general surgery as a routine part of their pre-operative preparation.

SETTING

The Animal Resource Facility of the University of Utah, under the oversight of the University Institutional Animal Use and Care Committee (IACUC), provided the animals, operating suites and technical support.

PARTICIPANTS

During each development phase, General Surgery Residents and Medical Students from all levels participated. In addition, operating room staff with an interest in either medical school or perfusion were invited to participate.

RESULTS

The efforts described in this paper eventually resulted in a reliable teaching tool for abdominal procedures in that viability of the porcine abdominal organs for up to three hours after euthanasia was regularly achieved.

CONCLUSIONS

General Surgery Teaching Programs of a size similar to the University of Utah may have access to the resources necessary to replicate this teaching tool in a cost-effective manner. However smaller teaching programs, such as those without a research facility, may not be able to adapt the procedures described in this paper.

Abdominal cavity simulator for skill progression in videolaparoscopic sutures in Brazil

PURPOSE

To develop and test a model of teaching by means of an abdominal cavity simulator.

METHODS

This study had two stages: development of a teaching model and an experimental prospective study that aimed to evaluate the residents' competence. The participants were divided into 3 groups: first-year resident, second-year resident, and senior surgeon. The two groups of resident physicians received training in the simulator, under instructor supervision for skill acquisition, according to the model proposed in first stage. The surgeons did not receive this intervention. The correlations and associations were verified through simple and multiple linear regressions. The learning curves were analysed using Cox regression models. The impact of the epidemiological characteristics was tested.

RESULTS

All residents reached the maximum score at the end of 16 steps and were comparable to the experimental (p<0.001).

CONCLUSION

Residents who underwent training using the methodology of the proposed teaching model, which is based on realistic simulation, acquired proficiency in the accomplishment of endosutures in up to 16 hours of training in the laboratory.

Influence of training level on cervical cone size and resection margin status at conization: a retrospective study

Objective

To explore whether a surgeon’s training level influences the rate of incomplete resections or the amount of resected cervical tissue in women treated with large loop excision of the transformation zone (LLETZ).

Methods

The present study is a retrospective analysis of the data of women who had undergone LLETZ for cervical intraepithelial neoplasia (CIN) within the years 2004–2008 at the Medical University of Vienna. Women were grouped according to the level of training of the operating surgeon (i.e, resident or staff gynecologist) and univariate and multivariable analyses were performed to identify independent risk factors for excessive cone volume, depth and incomplete resection (i.e., positive resection margin).

Results

Data of 912 women were analysed. Residents had a significantly larger cone volume [median 2681 (interquartile range 1472–4109) mm³] than staff gynecologists [2094 (1309–3402) mm³] (p = 0.001) in univariate analysis. The depth of resection and the rate of incomplete resection were comparable between both groups. In a binary logistic multivariable analysis, the level of training as well as patient’s age was significantly associated with a cone volume larger than 2500 mm³.

Conclusion

Conization performed by residents as opposed to staff gynecologists does not compromise the procedure’s effectiveness but may expose women to a potential additional risk for adverse obstetrical outcomes due to excessive resection of cervical tissue.

Electronic supplementary material

The online version of this article (10.1007/s00404-018-4761-1) contains supplementary material, which is available to authorized users.