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

The bibliometric analysis of extended reality in surgical training: Global and Chinese perspective

Objectives

The prospect of extended reality (XR) being integrated with surgical training curriculum has attracted scholars. However, there is a lack of bibliometric analysis to help them better understand this field. Our aim is to analyze relevant literature focusing on development trajectory and research directions since the 21st century to provide valuable insights.

Methods

Papers were retrieved from the Web of Science Core Collection. Microsoft Excel, VOSviewer, and CiteSpace were used for bibliometric analysis.

Results

Of the 3337 papers published worldwide, China contributed 204, ranking fifth. The world's enthusiasm for this field has been growing since 2000, whereas China has been gradually entering since 2001. Although China had a late start, its growth has accelerated since around 2016 due to the reform of the medical postgraduate education system and the rapid development of Chinese information technology, despite no research explosive period has been yet noted. International institutions, notably the University of Toronto, worked closely with others, while Chinese institutions lacked of international and domestic cooperation. Sixteen stable cooperation clusters of international scholars were formed, while the collaboration between Chinese scholars was not yet stable. XR has been primarily applied in orthopedic surgery, cataract surgery, laparoscopic training and intraoperative use in neurosurgery worldwide.

Conclusions

There is strong enthusiasm and cooperation in the international research on the XR-based surgical training. Chinese scholars are making steady progress and have great potential in this area. There has not been noted an explosive research phase yet in the Chinese pace. The research on several surgical specialties has been summarized at the very first time. AR will gradually to be more involved and take important role of the research.

Benchtop simulation of the retrosigmoid approach: Validation of a surgical simulator and development of a task-specific outcome measure score

Background

Neurosurgical training is changing globally. Reduced working hours and training opportunities, increased patient safety expectations, and the impact of COVID-19 have reduced operative exposure. Benchtop simulators enable trainees to develop surgical skills in a controlled environment. We aim to validate a high-fidelity simulator model (RetrosigmoidBox, UpSurgeOn) for the retrosigmoid approach to the cerebellopontine angle (CPA).

Methods

Novice and expert Neurosurgeons and Ear, Nose, and Throat surgeons performed a surgical task using the model - identification of the trigeminal nerve. Experts completed a post-task questionnaire examining face and content validity. Construct validity was assessed through scoring of operative videos employing Objective Structured Assessment of Technical Skills (OSATS) and a novel Task-Specific Outcome Measure score.

Results

Fifteen novice and five expert participants were recruited. Forty percent of experts agreed or strongly agreed that the brain tissue looked real. Experts unanimously agreed that the RetrosigmoidBox was appropriate for teaching. Statistically significant differences were noted in task performance between novices and experts, demonstrating construct validity. Median total OSATS score was 14/25 (IQR 10-19) for novices and 22/25 (IQR 20-22) for experts (p < 0.05). Median Task-Specific Outcome Measure score was 10/20 (IQR 7-17) for novices compared to 19/20 (IQR 18.5-19.5) for experts (p < 0.05).

Conclusion

The RetrosigmoidBox benchtop simulator has a high degree of content and construct validity and moderate face validity. The changing landscape of neurosurgical training mean that simulators are likely to become increasingly important in the delivery of high-quality education. We demonstrate the validity of a Task-Specific Outcome Measure score for performance assessment of a simulated approach to the CPA.

Telestration with augmented reality improves surgical performance through gaze guidance

BACKGROUND

In minimally invasive surgery (MIS), trainees need to learn how to interpret the operative field displayed on the laparoscopic screen. Experts currently guide trainees mainly verbally during laparoscopic procedures. A newly developed telestration system with augmented reality (iSurgeon) allows the instructor to display hand gestures in real-time on the laparoscopic screen in augmented reality to provide visual expert guidance (telestration). This study analysed the effect of telestration guided instructions on gaze behaviour during MIS training.

METHODS

In a randomized-controlled crossover study, 40 MIS naive medical students performed 8 laparoscopic tasks with telestration or with verbal instructions only. Pupil Core eye-tracking glasses were used to capture the instructor's and trainees' gazes. Gaze behaviour measures for tasks 1-7 were gaze latency, gaze convergence and collaborative gaze convergence. Performance measures included the number of errors in tasks 1-7 and trainee's ratings in structured and standardized performance scores in task 8 (ex vivo porcine laparoscopic cholecystectomy).

RESULTS

There was a significant improvement 1-7 on gaze latency [F(1,39) = 762.5, p < 0.01, ηp2 = 0.95], gaze convergence [F(1,39) = 482.8, p < 0.01, ηp2 = 0.93] and collaborative gaze convergence [F(1,39) = 408.4, p < 0.01, ηp2 = 0.91] upon instruction with iSurgeon. The number of errors was significantly lower in tasks 1-7 (0.18 ± 0.56 vs. 1.94 ± 1.80, p < 0.01) and the score ratings for laparoscopic cholecystectomy were significantly higher with telestration (global OSATS: 29 ± 2.5 vs. 25 ± 5.5, p < 0.01; task-specific OSATS: 60 ± 3 vs. 50 ± 6, p < 0.01).

CONCLUSIONS

Telestration with augmented reality successfully improved surgical performance. The trainee's gaze behaviour was improved by reducing the time from instruction to fixation on targets and leading to a higher convergence of the instructor's and the trainee's gazes. Also, the convergence of trainee's gaze and target areas increased with telestration. This confirms augmented reality-based telestration works by means of gaze guidance in MIS and could be used to improve training outcomes.

Video-based training of situation awareness enhances minimally invasive surgical performance: a randomized controlled trial

BACKGROUND

Many training curricula were introduced to deal with the challenges that minimally invasive surgery (MIS) presents to the surgeon. Situational awareness (SA) is the ability to process information effectively. It depends on general cognitive abilities and can be divided into three steps: perceiving cues, linking cues to knowledge and understanding their relevance, and predicting possible outcomes. Good SA is crucial to predict and avoid complications and respond efficiently. This study aimed to introduce the concept of SA into laparoscopic training.

METHODS

This is a prospective, randomized, controlled study conducted at the MIS Training Center of Heidelberg University Hospital. Video sessions showing the steps of the laparoscopic cholecystectomy (LC) were used for cognitive training. The intervention group trained SA with interposed questions inserted into the video clips. The identical video clips, without questions, were presented to the control group. Performance was assessed with validated scores such as the Objective Structured Assessment of Technical Skills (OSATS) during LC.

RESULTS

72 participants were enrolled of which 61 were included in the statistical analysis. The SA-group performed LC significantly better (OSATS-Score SA: 67.0 ± 11.5 versus control: 59.1 ± 14.0, p value = 0.034) and with less errors (error score SA: 3.5 ± 1.9 versus control: 4.7 ± 2.0, p value = 0.027). No difference in the time taken to complete the procedure was found. The benefit assessment analysis showed no difference between the groups in terms of perceived learning effect, concentration, or expediency. However, most of the control group indicated retrospectively that they believed they would have benefitted from the intervention.

CONCLUSION

This study suggests that video-based SA training for laparoscopic novices has a positive impact on performance and error rate. SA training should thus be included as one aspect besides simulation and real cases in a multimodal curriculum to improve the efficiency of laparoscopic surgical skills training.

Face, Content, and Construct Validity Evaluation of Simulation Models in General Surgery Laparoscopic Training and Education: A Systematic Review

BACKGROUND

Laparoscopic technical surgical skills (LTS) are considered a fundamental competence for General Surgery residents. Several simulation tools (ST) have been explored to develop LTS. Although a plethora of systematic reviews evaluate the translation of LTS developed in simulation to real surgery, there is a lack of evidence that clarifies effectiveness of different validated ST in acquisition of LTS in surgical residents. The aim of this systematic review (SR) is to summarize published evidence on ST validation used for surgery education and training.

METHODS

A protocol was published in PROSPERO. A SR was carried out following PRISMA guidelines. Complete published articles in English or Spanish that validate either content or construct, plus another form of validation of ST to acquire LTS in general surgery were included. Articles that used only one validation or did not validate an ST were excluded.

RESULTS

1052 publications were initially identified across all searched databases. Title review identified 204 studies eligible for full text screening. 10 studies were included for final review. Two studies assessed both face and content, 4 face and construct, and 4 face, content and construct validity. None of the studies presented comparable outcomes due to metrics variation and scores used for the validation strategies.

CONCLUSIONS

This study assessed validated laparoscopic simulation models, particularly in content and construct validity. Articles reported an increased use of simulation models in laparoscopic training with positive feedback from trainees, but few studies reported validation of training model. Validation strategies are not standardized, limiting comparability between them.

Video-based learning of coping strategies for common errors improves laparoscopy training-a randomized study

AIMS

The aim of this study was to investigate whether shifting the focus to solution orientation and developing coping strategies for common errors could increase the efficiency of laparoscopic training and influence learning motivation. The concept of coping has been particularly defined by the psychologist Richard Lazarus [Lazarus and Folkman in Stress, appraisal, and coping, Springer publishing company, New York, 1984]. Based on this model, we examined the use of observational learning with a coping model for its effectiveness as a basic teaching model in laparoscopic training.

METHODS

55 laparoscopically naive medical students learned a standardized laparoscopic knot tying technique with video-based instructions. The control group was only offered a mastery video that showed the ideal technique and was free from mistakes. The intervention group was instructed on active error analysis and watched freely selectable videos of common errors including solution strategies (coping model) in addition to the mastery videos.

RESULTS

There was no statistically significant difference between the intervention and control groups for number of knot tying attempts until proficiency was reached (18.8 ± 5.5 vs. 21.3 ± 6.5, p = 0.142). However, there was a significantly higher fraction of knots achieving technical proficiency in the intervention group after first use of the coping model (0.7 ± 0.1 vs. 0.6 ± 0.2, p = 0.026). Additionally, the proportion of blinded attempts that met the criteria for technical proficiency was significantly higher for the intervention group at 60.9% vs. 38.0% in control group (p = 0.021). The motivational subscore "interest" of the validated score on current motivation (QCM) was significantly higher for the intervention group (p = 0.032), as well as subjective learning benefit (p = 0.002) and error awareness (p < 0.001).

CONCLUSION

Using video-based learning of coping strategies for common errors improves learning motivation and understanding of the technique with a significant difference in its qualitative implementation in laparoscopy training. The ability to think in a solution-oriented, independent way is necessary in surgery in order to recognize and adequately deal with technical difficulties and complications.

Virtual Reality as an Affirmative Spin-Off to Laparoscopic Training: An Updated Review

Latest advancements in science lead to drastic improvements in patient health care. Techniques and technology evolved in surgery over the years have resulted in the improvement of patient outcomes by leaps and bounds. Open surgeries previously done for procedures like appendectomy and cholecystectomy evolved into laparoscopic minimally invasive procedures. Such procedures pose few challenges to the surgeons, like lack of tissue feedback and fulcrum effect of the abdominal wall. But training surgeons for such an advanced skill is still following conventional methods. These procedures can be effectively trained using Virtual Reality (VR), which can simulate operations outside the operating room (OR). To maximize the outcomes of VR training, knowledge on various strategies affecting the skills acquisition and retention in VR training is essential. This review collected information from PubMed, EMBASE, Cochrane Library (CENTRAL) databases. Data from the previous ten years are included in the review. This included documents, clinical trials, meta-analysis, randomized controlled trials, reviews, systematic reviews, letters to editors, and grey literature. After an advanced Medical Subject Headings (MeSH) search, we got 59,532 results, and after the application of filters, 189 results showed up. Out of these, studies that were not exclusively relevant to the use of VR in laparoscopic surgery were manually excluded, and a total of 35 articles were included in the study. VR is found to be an excellent training modality with promising outcomes. It helps the surgeons perform the surgery accurately at a faster pace and improves confidence and multitasking ability in OR. Instructor feedback from mentors and deliberate practice of trainees, and early introduction of haptics in VR resulted in the most effective outcomes of the VR training. Box trainers are also compared with VR trainers as they are the cheaper modalities of training. However, this area needs more research to conclude if box trainers can act as a cheaper alternative to VR training providing similar outcomes.

Virtual reality simulation in robot-assisted surgery: meta-analysis of skill transfer and predictability of skill

BACKGROUND

The value of virtual reality (VR) simulators for robot-assisted surgery (RAS) for skill assessment and training of surgeons has not been established. This systematic review and meta-analysis aimed to identify evidence on transferability of surgical skills acquired on robotic VR simulators to the operating room and the predictive value of robotic VR simulator performance for intraoperative performance.

METHODS

MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science were searched systematically. Risk of bias was assessed using the Medical Education Research Study Quality Instrument and the Newcastle-Ottawa Scale for Education. Correlation coefficients were chosen as effect measure and pooled using the inverse-variance weighting approach. A random-effects model was applied to estimate the summary effect.

RESULTS

A total of 14 131 potential articles were identified; there were eight studies eligible for qualitative and three for quantitative analysis. Three of four studies demonstrated transfer of surgical skills from robotic VR simulators to the operating room measured by time and technical surgical performance. Two of three studies found significant positive correlations between robotic VR simulator performance and intraoperative technical surgical performance; quantitative analysis revealed a positive combined correlation (r = 0.67, 95 per cent c.i. 0.22 to 0.88).

CONCLUSION

Technical surgical skills acquired through robotic VR simulator training can be transferred to the operating room, and operating room performance seems to be predictable by robotic VR simulator performance. VR training can therefore be justified before operating on patients.

Robotic-assisted cholecystectomy is superior to laparoscopic cholecystectomy in the initial training for surgical novices in an ex vivo porcine model: a randomized crossover study

Background

Robotic-assisted surgery (RAS) potentially reduces workload and shortens the surgical learning curve compared to conventional laparoscopy (CL). The present study aimed to compare robotic-assisted cholecystectomy (RAC) to laparoscopic cholecystectomy (LC) in the initial learning phase for novices.

Methods

In a randomized crossover study, medical students (n = 40) in their clinical years performed both LC and RAC on a cadaveric porcine model. After standardized instructions and basic skill training, group 1 started with RAC and then performed LC, while group 2 started with LC and then performed RAC. The primary endpoint was surgical performance measured with Objective Structured Assessment of Technical Skills (OSATS) score, secondary endpoints included operating time, complications (liver damage, gallbladder perforations, vessel damage), force applied to tissue, and subjective workload assessment.

Results

Surgical performance was better for RAC than for LC for total OSATS (RAC = 77.4 ± 7.9 vs. LC = 73.8 ± 9.4; p = 0.025, global OSATS (RAC = 27.2 ± 1.0 vs. LC = 26.5 ± 1.6; p = 0.012, and task specific OSATS score (RAC = 50.5 ± 7.5 vs. LC = 47.1 ± 8.5; p = 0.037). There were less complications with RAC than with LC (10 (25.6%) vs. 26 (65.0%), p = 0.006) but no difference in operating times (RAC = 77.0 ± 15.3 vs. LC = 75.5 ± 15.3 min; p = 0.517). Force applied to tissue was similar. Students found RAC less physical demanding and less frustrating than LC.

Conclusions

Novices performed their first cholecystectomies with better performance and less complications with RAS than with CL, while operating time showed no differences. Students perceived less subjective workload for RAS than for CL. Unlike our expectations, the lack of haptic feedback on the robotic system did not lead to higher force application during RAC than LC and did not increase tissue damage. These results show potential advantages for RAS over CL for surgical novices while performing their first RAC and LC using an ex vivo cadaveric porcine model.

Registration number

researchregistry6029

Graphic abstract

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Applications of Virtual Reality Technology in Medical Groups Teaching

INTRODUCTION

Virtual reality is a new method for training different medical groups. Based on this technology, professionals and students of various medical sciences can determine their level of competence for medical treatment before any performance on the patient. Therefore, the aim of this study was to identify the applications of virtual reality technology for training the medical groups.

METHODS

This is a scoping review study conducted in 2016. Articles were retrieved through the search of related keywords in databases such as Pub Med, Scopus, Web of Sciences, Springer, and Google scholar. Then, after applying the entry criteria, 21 papers were selected from a total of 1343. Data extraction was done by a data collection form. The collected data were summarized and reported using content analysis technique according to the study purpose.

RESULTS

The findings of the study indicated that 11 cases (48%) have used virtual education technology for laparoscopic surgery training. Using virtual reality has improved learning in 17 (74%) studies. A higher accuracy in medical practice by people trained through VR has been reported in 20 (87%) studies.

CONCLUSION

The results indicate that the application of virtual reality capabilities plays an important role in improving the performance of different medical groups. According to the results, it can be suggested that virtual reality capabilities should be used to train different medical groups based on their individual and collective needs.

LapTrain: multi-modality training curriculum for laparoscopic cholecystectomy-results of a randomized controlled trial

BACKGROUND

Multiple training modalities for laparoscopy have different advantages, but little research has been conducted on the benefit of a training program that includes multiple different training methods compared to one method only. This study aimed to evaluate benefits of a combined multi-modality training program for surgical residents.

METHODS

Laparoscopic cholecystectomy (LC) was performed on a porcine liver as the pre-test. Randomization was stratified for experience to the multi-modality Training group (12 h of training on Virtual Reality (VR) and box trainer) or Control group (no training). The post-test consisted of a VR LC and porcine LC. Performance was rated with the Global Operative Assessment of Laparoscopic Skills (GOALS) score by blinded experts.

RESULTS

Training (n = 33) and Control (n = 31) were similar in the pre-test (GOALS: 13.7 ± 3.4 vs. 14.7 ± 2.6; p = 0.198; operation time 57.0 ± 18.1 vs. 63.4 ± 17.5 min; p = 0.191). In the post-test porcine LC, Training had improved GOALS scores (+ 2.84 ± 2.85 points, p < 0.001), while Control did not (+ 0.55 ± 2.34 points, p = 0.154). Operation time in the post-test was shorter for Training vs. Control (40.0 ± 17.0 vs. 55.0 ± 22.2 min; p = 0.012). Junior residents improved GOALS scores to the level of senior residents (pre-test: 13.7 ± 2.7 vs. 18.3 ± 2.9; p = 0.010; post-test: 15.5 ± 3.4 vs. 18.8 ± 3.8; p = 0.120) but senior residents remained faster (50.1 ± 20.6 vs. 25.0 ± 1.9 min; p < 0.001). No differences were found between groups on the post-test VR trainer.

CONCLUSIONS

Structured multi-modality training is beneficial for novices to improve basics and overcome the initial learning curve in laparoscopy as well as to decrease operation time for LCs in different stages of experience. Future studies should evaluate multi-modality training in comparison with single modalities.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00011040.

Does rating the operation videos with a checklist score improve the effect of E-learning for bariatric surgical training? Study protocol for a randomized controlled trial

BACKGROUND

Laparoscopic training has become an important part of surgical education. Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed. Surgeons must be well trained prior to operating on a patient. Multimodality training is vital for bariatric surgery. E-learning with videos is a standard approach for training. The present study investigates whether scoring the operation videos with performance checklists improves learning effects and transfer to a simulated operation.

METHODS/DESIGN

This is a monocentric, two-arm, randomized controlled trial. The trainees are medical students from the University of Heidelberg in their clinical years with no prior laparoscopic experience. After a laparoscopic basic virtual reality (VR) training, 80 students are randomized into one of two arms in a 1:1 ratio to the checklist group (group A) and control group without a checklist (group B). After all students are given an introduction of the training center, VR trainer and laparoscopic instruments, they start with E-learning while watching explanations and videos of RYGB. Only group A will perform ratings with a modified Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale checklist for all videos watched. Group B watches the same videos without rating. Both groups will then perform an RYGB in the VR trainer as a primary endpoint and small bowel suturing as an additional test in the box trainer for evaluation.

DISCUSSION

This study aims to assess if E-learning and rating bariatric surgical videos with a modified BOSATS checklist will improve the learning curve for medical students in an RYGB VR performance. This study may help in future laparoscopic and bariatric training courses.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00010493 . Registered on 20 May 2016.

Validation of the mobile serious game application Touch Surgery™ for cognitive training and assessment of laparoscopic cholecystectomy

BACKGROUND

Touch Surgery^™ (TS) is a serious gaming application for cognitive task simulation and rehearsal of key steps in surgical procedures. The aim was to establish face, content, and construct validity of TS for laparoscopic cholecystectomy (LC). Furthermore, learning curves with TS and a virtual reality (VR) trainer were compared in a randomized trial.

METHODS

The performance of medical students and general surgeons was compared for all three modules of LC in TS to establish construct validity. Questionnaires assessed face and content validity. For analysis of learning curves, students were randomized to train on VR or TS first, and then switched to the other training modality. Performance data were recorded.

RESULTS

54 Surgeons and 51 medical students completed the validation study. Surgeons outperformed students with TS: patient preparation (students = 45.0 ± 19.1%; surgeons = 57.3 ± 15.2%; p < 0.001), access and laparoscopy (students = 70.2 ± 10.9%; surgeons = 75.9 ± 9.7%; p = 0.008) and LC (students = 69.8 ± 12.4%; surgeons = 77.7 ± 9.6%; p < 0.001). Both groups agreed that TS was a highly useful and realistic application. 46 students were randomized for learning curve analysis. It took them 2-4 attempts to reach a 100% score with TS. Training with TS first did not improve students' performance on the VR trainer; however, students who trained with VR first scored significantly higher in module 3 of TS.

CONCLUSION

TS is an accepted serious gaming application for learning cognitive aspects of LC with established construct, face, and content validity. There appeared to be a synergy between TS and the VR trainer. Therefore, the two training modalities should accompany one another in a multimodal training approach to laparoscopy.

Learning from the surgeon's real perspective - First-person view versus laparoscopic view in e-learning for training of surgical skills? Study protocol for a randomized controlled trial

Background

Surgical proficiency is highly dependent on continuous and efficient training. However, efficacy of training hinges on questions such as accessibility and how intuitively the training can be translated into reality. Minimally invasive surgery (MIS) in particular relies on adequate training modalities in order to compensate for its additional psychomotor and visuospatial challenges. The increasing demand for MIS procedures longs for further enhancement of training and steep learning curves. We are investigating a nouveau training concept that continuously utilizes the first person view as addendum to laparoscopic view. We hypothesize this approach to be more intuitive thus faster and more naturally to apprehend than a laparoscopic view only and aim to establish a new standard to implement into training curricula.

Methods and analysis

The present study is conducted as a monocentric, two-arm randomized trial. Participants undergo a training curriculum in laparoscopic suturing and knot tying, using e-learning video material with either the first-person perspective of the surgeon or the laparoscopic view only. Primary endpoint is the total training time needed to reach a predefined proficiency level. Participants are evaluated by blinded raters using validated checklists. Number of attempts, procedure and knot quality subscore difference as well as metric parameter analysis from the first and last knots analyzed as secondary endpoints. Furthermore, trainees are assessed with regard to surgical background, basic skills level and spatial awareness. A total sample size of 80 participants for the analysis of the primary endpoint was determined, which will be performed as a two-sided t-test.

Ethics and dissemination

Ethical approval was obtained from the Ethics Committee of the Medical Faculty at Heidelberg University (Code S-334/2011). This trial was registered with the German Clinical Trials Register (DRKS) in Freiburg, Germany, on May 6th (DRKS00009997). The results will be published and presented at appropriate conferences.

[Risk awareness and training for prevention of complications in minimally invasive surgery]

BACKGROUND

Minimally invasive surgery (MIC) requires surgeons to have a different set of skills and capabilities from that of open surgery. The indirect camera view, lack of a three-dimensional view, restricted haptic feedback with lack of tissue feeling and difficult instrument coordination with fulcrum and pivoting effects result in an additional learning curve compared to open surgery. The prolonged learning curve leads to a higher risk of complications and special awareness of these risks is therefore mandatory. Training of special laparoscopic skills outside the operating room is needed to optimize patient outcome and to minimize the ocurrence of complications related to the learning curve.

RESULTS AND DISCUSSION

Training modalities for laparoscopic surgery include simple box trainers, computer simulation with virtual reality, the use of artificial and cadaver organs, as well as live animal models and cadaver training. These training modalities have been proven in studies to have a beneficial effect on the learning curve for acquisition of laparoscopic skills and for improving operative performance as well as avoidance of complications. Laparoscopic training is currently gaining a more and more important role for official education and accreditation purposes. In some countries the participation in laparoscopic training courses has become mandatory prior to participation in laparoscopic operations. Future research will include the optimization of multimodal training curricula, the development of individualized training approaches that allow both trainee and patient-specific preparation, as well as the use of novel devices to facilitate the collection and transfer of expertise between the generations and schools of surgeons.

Face validity of the pulsatile organ perfusion trainer for laparoscopic cholecystectomy

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Direct Observation versus Endoscopic Video Recording-Based Rating with the Objective Structured Assessment of Technical Skills for Training of Laparoscopic Cholecystectomy

Purpose: The validated Objective Structured Assessment of Technical Skills (OSATS) score is used for evaluating laparoscopic surgical performance. It consists of two subscores, a Global Rating Scale (GRS) and a Specific Technical Skills (STS) scale. The OSATS has accepted construct validity for direct observation ratings by experts to discriminate between trainees' levels of experience. Expert time is scarce. Endoscopic video recordings would facilitate assessment with the OSATS. We aimed to compare video OSATS with direct OSATS. Methods: We included 79 participants with different levels of experience [58 medical students, 15 junior residents (novices), and 6 experts]. Performance of a cadaveric porcine laparoscopic cholecystectomy (LC) was evaluated with OSATS by blinded expert raters by direct observation and then as an endoscopic video recording. Operative time was recorded. Results: Direct OSATS rating and video OSATS rating correlated significantly (ρ = 0.33, p = 0.005). Significant construct validity was found for direct OSATS in distinguishing between students or novices and experts. Students and novices were not different in direct OSATS or video OSATS. Mean operative times varied for students (73.4 ± 9.0 min), novices (65.2 ± 22.3 min), and experts (46.8 ± 19.9 min). Internal consistency was high between the GRS and STS subscores for both direct and video OSATS with Cronbach's α of 0.76 and 0.86, respectively. Video OSATS and operative time in combination was a better predictor of direct OSATS than each single parameter. Conclusion: Direct OSATS rating was better than endoscopic video rating for differentiating between students or novices and experts for LC and should remain the standard approach for the discrimination of experience levels. However, in the absence of experts for direct rating, video OSATS supplemented with operative time should be used instead of single parameters for predicting direct OSATS scores.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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