Evidence to support the early introduction of laparoscopic suturing skills into the surgical training curriculum

Experts in Minimally Invasive Surgery are Outperformed by Trained Novices on Suturing Skills

INTRODUCTION

Learning minimally invasive suturing can be challenging, creating a barrier to further implementation, especially with the development of easier methods. Nevertheless, mastering intracorporeal knot tying is crucial when alternative techniques prove inadequate. Therefore, the minimally invasive surgery (MIS) suturing skills of MIS experts are compared with a group of novices during their learning curve on a simulator.

METHODS

The novice participants repeatedly performed the intracorporeal suturing task on the EoSim MIS simulator (up to a maximum of 20 repetitions). The experts (>50 MIS procedures and advanced MIS experience) completed the same task once. The first and last exercises of the novices and the expert tasks were all blindly recorded and assessed by two independent assessors using the Laparoscopic Suturing Competency Assessment Tool (LS-CAT). Additionally, objective assessment parameters, "time" and "distance", using instrument tracking, were collected. The scores of the experts were then compared with the novices.

RESULTS

At the end of the training, novices significantly outperformed the experts on both the expert assessment (LS-CAT: 16.8 versus 26.8, P = 0.001) and objective parameters (median time: 190 s versus 161 s, P < 0.001; median distance: 6.1 m versus 3.6 m, P < 0.001). Although the experts showed slightly better performance than the novices during their first task, the difference was not significant on the expert assessment (LS-CAT experts 16.8, novices 20.5, P = 0.057).

CONCLUSIONS

Our findings underscore the significance of continued MIS suturing training for both residents and surgeons. In this study, trained novices demonstrated a significant outperformance of experts on both quantitative and qualitative outcome parameters within a simulated setting.

Intracorporeal vs. extracorporeal open and closed knot tying techniques in laparoscopy: A randomized, controlled study

Objective

Tying knots during suturing is one of the most challenging tasks in laparoscopic surgery. Therefore, measures aimed at ensuring both the ease and speed of knot tying not only benefit the surgeon but can also reduce operating time significantly. This study compared extracorporeal and intracorporeal knot tying techniques using a Szabo pelvic trainer model from the Gynaecological Endoscopic Surgical Education and Assessment program.

Design

The students tied intra- and extracorporeal knots using closed- and open-jaw knot pushers. Using an artificial tissue suturing pad in a certified Szabo pelvic trainer, students tied three knots using each technique according to block randomization. Task completion time, knot strength, knot-spread ability, and number of errors were recorded. The Wilcoxon test and mixed-effects models were used to analyze the results. After completing the exercises, participants answered a questionnaire concerning knot-tying techniques and their performance.

Setting

University Hospital Basel, which provides tertiary-level clinical care.

Participants

Fifty-seven medical students with no experience in laparoscopy voluntarily signed up for this study.

Results

Open and closed extracorporeal knot tying was significantly faster (p < 0.001, p < 0.001, respectively), more precise (p = 0.007, p = 0.003), and associated with reduced knot-spread ability (p < 0.001, p < 0.001) compared to intracorporeal knot tying. Open- and closed-jaw knot pushers were shown to be equal in terms of speed (p = 0.563), knot-spread ability (p = 0.49), and precision (p = 0.831). The study participants rated open (30 %) and closed (49 %) extracorporeal knot tying as more intuitive than intracorporeal (21 %) knot tying. Improved concentration was significantly correlated with tighter knots (p = 0.011).

Conclusions

Students achieved significantly better results using extracorporeal knot-tying techniques than intracorporeal ones, including greater speed, tighter knots, and optimized precision. These results suggest that beginners in the field of laparoscopy should be encouraged to practice extracorporeal knot-tying techniques.

The impact of preclinical clerkship in general surgery on medical students' attitude to a surgical career

PURPOSE

With the advent of a new program for postgraduate medical students in 2004, the number of applicants choosing surgical careers in Japan has been declining. We conducted this study to evaluate the impact of preclinical clerkship and how it affects students' attitudes toward a surgical career.

METHODS

The subjects of our study were fifth-year medical students who participated in a clinical clerkship in general surgery in our department between April 2021 and March 2022. We conducted pre- and post-preclinical clerkship surveys to assess the perceived image of surgeons and the impact of clerkship on surgical career interest.

RESULTS

Among 132 medical students (77 men and 55 women) who rotated through preclinical clerkship in our department, 125 participated in the survey and 66% expressed interest in a surgical career. In the post-clerkship survey, an increased interest in a surgical career was expressed by 79% of the students; notably, including those who initially expressed interest. Approximately 77% of students were satisfied with the practical skill training they received.

CONCLUSION

Engaging medical students early in surgical experience through a preclinical clerkship for general surgery appears to promote their interest in a surgical career.

Development and validation of a composed canine simulator for advanced veterinary laparoscopic training

The development of innovative simulation models for veterinary laparoscopic surgery training is a priority today. This study aimed to describe a didactic simulation tool for the training of total laparoscopic gastropexy (TLG) with intracorporeal sutures in dogs. CALMA Veterinary Lap-trainer composite simulator (CLVTS) was developed from a plaster cast of 2 Great Dane canines mimicking the space and the correct position to carry out a TLG. After video instruction, 16 veterinarians with different degrees of experience in minimally invasive surgery (Experts, n = 6 and intermediates, n = 10) evaluated four sequential simulating TLG with intracorporeal suturing in the CLVTS. Subsequently, they completed an anonymous questionnaire analyzing the realism, usefulness, and educational quality of the simulator. The CLVTS showed a good preliminary acceptance (4.7/5) in terms of the usefulness and adequacy of the exercises that, in the participants' opinion, are appropriate and are related to the difficulty of the TLG. In addition, both experienced and intermediate surgeons gave high marks (4.5/5) to the feeling of realism, design, and practicality. There were no significant differences between the responses of the two groups. The results suggest that the CVLTS has both face and content validity. Where it can be practiced in a structured environment for the development of a total laparoscopic gastropexy with intracorporeal suture and without compromising patient safety, but still has some limitations of the scope of the study. Further studies are needed to establish the ability to assess or measure technical skills, including the degree of transferability to the actual surgical environment.

The Spaced Learning Concept Significantly Improves Acquisition of Laparoscopic Suturing Skills in Students and Residents: A Randomized Control Trial

INTRODUCTION

 Spaced learning consists of blocks with highly condensed content that interrupted by breaks during which distractor activities, such as physical activity, are performed. The concept has been shown to be superior in complex motor skill acquisition like laparoscopic suturing and knot tying. Preliminary studies have solely been conducted with medical students. Therefore, it remained unanswered if the spaced learning concept would also work for pediatric surgery residents.

MATERIALS AND METHODS

 The study aimed to evaluate the effectiveness of spaced learning, students, and residents were asked to perform four surgeons' square knots on a bowel model within 30 minutes prior and post 3 hours of hands-on training. To examine the long-term skills, the same subjects were asked to perform a comparable, but more complex task 12 months later without receiving training in the meantime. Total time, knot stability, suture accuracy, knot quality, and laparoscopic performance were assessed. Additionally, motivation was accessed by using the questionnaire on current motivation. Differences were calculated using mixed analysis of variance, Mann-Whitney U test, and multivariate analysis of covariance.

RESULTS

 A total of 20 medical students and 14 residents participated in the study. After randomization, 18 were trained using the spaced learning concept and 16 via conventional methods. Both groups had comparable baseline characteristics and improved significantly after training in all assessed measures. The spaced learning concept improved procedure performance as well as knot quality and stability in both students and residents. However, residents that trained via spaced learning showed significantly better long-term results regarding knot quality and speed in comparison to students. Although anxiety was significantly reduced in both training groups over time, residents were significantly more interested regarding knot tying than students.

CONCLUSION

 This study dispels any remaining doubt that the spaced learning concept might only work for medical students. It appears that the spaced learning concept is very suitable for residents in acquiring complex motor skills. It is superior to conventional training, resulting in improved procedural performance as well as knot quality and speed. Hence, tailored training programs should not only be integrated early on in students' curricula but also in surgical training programs.

Surgical simulation of pediatric laparoscopic dismembered pyeloplasty: Reproducible high-fidelity animal-tissue model

PURPOSE

To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of laparoscopic dismembered pyeloplasty in infants and children.

MATERIALS AND METHODS

A previously described animal tissue model using chicken crop was surgically modified and attached to piglet kidney specimens in order to provide organ model realistically resembling infant and children hydronephrosis for simulation of dismembered laparoscopic pyeloplasty. Dismembered pyeloplasty could then be carried out in a standard pelvi-trainer using a standard instrumentation as in a regular case.

RESULTS

The model created could prove to be a high-fidelity, animal tissue model for the surgical simulation of dismembered pyeloplasty. The surgical modification of the used animal tissues of chicken crop and piglet kidney respectively used in this fusion model was able to provide a high grade of resembling a realistic organ situs for infant and pediatric pyeloplasty, respectively. The surgical procedure could be carried out as a simulation of a regular case while providing high-grade realistic anatomy, adequate sizes of a dilated renal pelvis and of the ureter, respectively. Biological as well as haptic conditions of the tissue were able to resemble human tissue in a high grade as well.

DISCUSSION

Despite a live animal model has been described for dismembered pyeloplasty, its time-consuming creation and possible conflict concerning animal welfare cadaver models are more practicable for daily simulation. In literature so far animal-tissue models described range from folded chicken skin to a chicken crop model. While these types of models have its own advantages and disadvantages none of them provide adequate anatomical relations. By dissecting chicken crop and fixating it to a piglet's kidney this limitation could be overcome and furthermore will enable future modifications for a perfused model for laparoscopic dismembered pyeloplasty.

CONCLUSION

The fusion of a previously described tissue model of chicken crop for simulation of pyeloplasty along with also previously used piglet kidneys for surgical simulation can provide a highly realistic model for surgical simulation of pediatric dismembered laparoscopic pyeloplasty. In addition, this model rules out the disadvantage of native animal kidney specimens which the lack of pathology of a dilated renal pelvis. Surgical modification is an established method to provide high-fidelity animal tissue models for surgical simulation and therefore training of complex procedures, respectively. For simulation purposes in pediatric laparoscopic urology, i.e., reconstructive procedures such as dismembered pyeloplasty this model appears to be promising in terms of providing realistic pathology in pediatric dimensions.

Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) - Observational feasibility study

Background

Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India.

Methods

A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated.

Results

Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers.

Conclusion

Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.

Minimising in minimally invasive surgery through the use of a novel and flexible super elastic titanium needle suitable for a 3.5- and 5-mm trocar

The use of smaller ports in surgery is the next step in the evolution of minimally invasive procedures. We present findings, using a novel flexible needle made from a super elastic titanium alloy, which demonstrate that it is possible for a 26- and 30-mm needle to pass through a 3.5- and 5-mm trocar. This new approach results in less trauma and improved cosmetic effect in comparison to the classical 10-mm port. Traditional steps such as handling of the needle holders, loading the needle and placing it at the correct angle and direction, inserting the needle into the tissue and finally safely tying a knot remain the same as with the standard procedure. We propose that this improved type of needle creates a refinement opportunity to replace the classic ones during both laparoscopic and robotic surgeries.