Surgical resident evaluations of portable laparoscopic box trainers incorporated into a simulation-based minimally invasive surgery curriculum

The Challenges of Dyad Practice in Simulation Training of Basic Open Surgical Skills-A Mixed-Method Study

INTRODUCTION

Simulation training at home improves access to training, but motivation can be difficult to maintain. Dyad training could keep trainees motivated. This study aimed to examine the effect of self-regulated training of basic surgical skills in pairs versus individually.

METHODS

One hundred one medical doctors were included in this prospective, mixed-method, simulation-based study. Participants were randomized to train individually or in pairs during a 6-week course in open surgical skills, consisting of didactic instructions and self-directed training at home. Trainees kept a training log and filled in a questionnaire. Skills were tested before and after the course. Tests were rated by an expert using the Objective Structured Assessment of Technical Skills Global Rating Scale.

RESULTS

Ninety-seven doctors completed the study. We found no differences in test score between dyad and individual trainees. Dyad trainees compared with individual trainees improved by 7.23 points (intercept estimate) versus 6.94 points, respectively (P = 0.881). Dyad trainees trained less frequently [7.3 times (intercept estimate) vs. 12.1 times, P < 0.001, but for longer intervals compared with individual trainees (68 minutes vs. 38 minutes)]. Dyad trainees reported benefits such as having a sparring partner, receiving feedback, corrections, increased motivation, having fun, and more structured training sessions. However, the coordination of training sessions was difficult.

CONCLUSIONS

No differences were found between dyad trainees and individual trainees in improvement of surgical skills. Off-site dyad training led to fewer, but longer training sessions, which may have negatively impacted the effectiveness of training. Dyad trainees perceived dyad training beneficial.

Remote training in laparoscopy: a randomized trial comparing home-based self-regulated training to centralized instructor-regulated training

Background

Simulation-based surgical training (SBST) is key to securing future surgical expertise. Proficiency-based training (PBT) in laparoscopy has shown promising results on skills transfer. However, time constraints and limited possibilities for distributed training constitute barriers to effective PBT. Home-based training may provide a solution to these barriers and may be a feasible alternative to centralized training in times of assembly constraints.

Methods

We randomly assigned first-year trainees in abdominal surgery, gynecology, and urology to either centralized instructor-regulated training (CIRT) or home-based self-regulated training (HSRT) in laparoscopy. All participants trained on portable box trainers providing feedback on metrics and possibility for video reviewing. Training in both groups was structured as PBT with graded proficiency exercises adopted from the Fundamentals of Laparoscopic Surgery (FLS). The HSRT group trained at home guided by online learning materials, while the CIRT group attended two training sessions in the simulation center with feedback from experienced instructors. Performance tests consisted of hand–eye and bimanual coordination, suture and knot-tying, and FLS exercises. We analyzed passing rates, training time and distribution, and test performances.

Results

Passing rates were 87% and 96% in the CIRT and HSRT group, respectively. HSRT facilitated distributed training and resulted in greater variation in training times. Task times for hand–eye and bimanual coordination were significantly reduced between pretest and posttest in both groups. Trainees maintained their posttest performances at the 6-month retention test. Our analyses revealed no significant inter-group differences in performances at pretest, posttest, or retention test. Performance improvements in the two groups followed similar patterns.

Conclusion

CIRT and HSRT in laparoscopy result in comparable performance improvements. HSRT in laparoscopy is a feasible and effective alternative to CIRT when offered inside a supportive instructional design. Further research is needed to clarify trainees’ preferences and explore facilitators and barriers to HSRT.

Assessment of training and selected factors on speed and quality of performing different tasks on the endoscopic simulator

Introduction

One of the most significant challenges nowadays is to educate and predict the predispositions of young surgeons taking into consideration that every ability has its own learning curve.

Aim

To determine the influence of selected factors and examine the shape and the length of the learning curve in performing simple tasks on an endoscopic simulator.

Material and methods

Twenty students took part in 4 training sessions with a one-week break between sessions. They were training 12 min and performed three tasks at every session on the endoscopic simulator. To identify whether selected factors influence the time of completing tasks, the participants were asked to fill in questionnaires. All participants also completed the Minnesota Manual Dexterity Test (MMDT) to assess hand-eye coordination.

Results

Our research reveals that regardless of activities performed in free time, the shape of the learning curve was logarithmic. Improvement after the fourth session ranged from 50% to 75%. Performing specific activities in the free time did not influence the results achieved on the simulator. No statistically significant correlation between MMDT results and the time to accomplish each task was found.

Conclusions

This study has shown that the length of the learning curve of performing simple tasks is quite short and the shape is logarithmic. It suggests that more complex exercises should be included in the training programme.

Development of a Laparoscopic Box Trainer Based on Open Source Hardware and Artificial Intelligence for Objective Assessment of Surgical Psychomotor Skills

Background. A trainer for online laparoscopic surgical skills assessment based on the performance of experts and nonexperts is presented. The system uses computer vision, augmented reality, and artificial intelligence algorithms, implemented into a Raspberry Pi board with Python programming language. Methods. Two training tasks were evaluated by the laparoscopic system: transferring and pattern cutting. Computer vision libraries were used to obtain the number of transferred points and simulated pattern cutting trace by means of tracking of the laparoscopic instrument. An artificial neural network (ANN) was trained to learn from experts and nonexperts’ behavior for pattern cutting task, whereas the assessment of transferring task was performed using a preestablished threshold. Four expert surgeons in laparoscopic surgery, from hospital “Raymundo Abarca Alarcón,” constituted the experienced class for the ANN. Sixteen trainees (10 medical students and 6 residents) without laparoscopic surgical skills and limited experience in minimal invasive techniques from School of Medicine at Universidad Autónoma de Guerrero constituted the nonexperienced class. Data from participants performing 5 daily repetitions for each task during 5 days were used to build the ANN. Results. The participants tend to improve their learning curve and dexterity with this laparoscopic training system. The classifier shows mean accuracy and receiver operating characteristic curve of 90.98% and 0.93, respectively. Moreover, the ANN was able to evaluate the psychomotor skills of users into 2 classes: experienced or nonexperienced. Conclusion. We constructed and evaluated an affordable laparoscopic trainer system using computer vision, augmented reality, and an artificial intelligence algorithm. The proposed trainer has the potential to increase the self-confidence of trainees and to be applied to programs with limited resources.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers

BACKGROUND

Lack of time and access to equipment are recognised barriers to simulation training.

AIM

To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees.

METHOD

Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy).

RESULTS

Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation.

CONCLUSION

A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

"Take-home" box trainers are an effective alternative to virtual reality simulators

BACKGROUND

Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS.

METHODS

After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared.

RESULTS

The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups.

CONCLUSIONS

This study suggests that a basic "take-home" BT is a suitable alternative to VRS.

Validation Study of a Portable Home Trainer Using a Pad for Laparoscopic Practice

The aim of this study was to describe and validate a homemade laparoscopic trainer. The abdominal cavity is simulated within a 3-mm-thick stainless steel model. Thirty-four participants were evaluated in a pilot study to validate our model. Participants were divided into experts (n = 19) and novices (n = 15) to perform basic and complex laparoscopic skills. The comparison between the homemade trainer (HT) and the standard laparoscopic trainer showed no significant differences for the 2 tasks performed for each group ( P > .05). The experts' performance of the 2 tasks was statistically different from the novices ( P < .05) on both trainers. Both experts (84%) and novices (87%) approved the HT as an effective home trainer. Our HT seems to fulfill the conditions of performing the basic and complex laparoscopic psychomotor skills at a low cost and similar efficiency.

Incentivising practice with take-home laparoscopic simulators in two UK Core Surgical Training programmes

Introduction

Practice using simulators has been validated as a mean for surgical trainees to improve basic laparoscopic skills and free their attention for higher cognitive functions. However, mere provision of equipment does not result in frequent practice. This study assesses one approach to incentivising practice within core surgical training programmes and leads to further recommendations.

Methods

30 core surgical trainees (CST) starting laparoscopic-based specialties were recruited from East and West of Scotland CST programmes and given take-home laparoscopic simulators, with six training modules. Attainment of target metric scores generated an eCertificate, to be rewarded by progression in the live theatre. Questionnaires assessed confounding variables and explored CSTs’ anxieties about laparoscopy.

Results

27 trainees (90%) agreed to participate (mean age 28 years, range 24–25; 17 males). 13 CSTs (48%) were in the first year of surgical training. 11 (41%) had no previous simulation experience and 7 (32%) CSTs played video games >3 hours/week. 12 of 27 trainees (44%) completed ≥1 task and 7 completed all (26%).

Performances improved in some participants, but overall engagement with the programme was poor. Reasons given included poor internet connectivity, busy rotations and examinations. CSTs who engaged in the study significantly reduced their anxiety (mean 4.96 vs 3.56, p<0.05).

Conclusions

The provision of take-home laparoscopic simulators with accompanying targets did not successfully incentivise CSTs to practise. However, the subgroup who did engage with the project reported performance improvements and significantly reduced anxiety. Proposals to overcome barriers to practising in simulation, including obligatory simulation-based assessments, are discussed.

Take-home training in a simulation-based laparoscopy course

BACKGROUND

Simulation training can prepare trainees for clinical practice in laparoscopic surgery. Training on box trainers allows for simulation training at home, which studies have shown to be a feasible method of training. However, little research has been conducted into how to make it a more efficient method of training. Our aim was to investigate how box trainers are used in take-home training to help guide the design of take-home training courses.

METHODS

This study was designed using a mixed methods approach. Junior doctors participating in a laparoscopy curriculum, which included practising at home on box trainers, were invited. Quantitative data on training patterns was collected from logbooks. Qualitative data on the use of box trainers was retrieved from focus groups and individual interviews.

RESULTS

From logbooks, we found that 14 out of 18 junior doctors mixed their training modalities, and four practised first on box trainers then on virtual reality simulators. Twelve practised only at home, while five practised at both places and one practised solely at the simulation centre. After a delayed start, most practised for some time, then had a period without training and then started training again towards the end of the course. We found that the themes of the interviews were: training method, training pattern, feedback and self-regulation. Participants identified the lack of feedback as challenging but described how self-rating provided direction during unsupervised training. Mandatory training elements affected when and how much participants practised.

CONCLUSIONS

When participants practised at home, they took an individualised approach to training. They mixed their training at home with training at the simulation centre. Participants practised at the beginning and towards the end of the course. Self-rating helped to guide unsupervised training where feedback was not accessible. Curricular requirements and testing determined when and how much participants practised.