EASIER: A new model for online learning of minimally invasive surgery skills

INTRODUCTION

Technology Enhanced Learning (TEL) can provide the tools to safely master minimally invasive surgery (MIS) skills in patient-free environments and receive immediate objective feedback without the constant presence of an instructor. However, TEL-based systems tend to work isolated from one another, focus on different skills, and fail to provide contents without a sound pedagogical background.

OBJECTIVE

The objective of this descriptive study is to present in detail EASIER, an innovative TEL platform for surgical and interventional training, as well as the results of its validation.

METHODS

EASIER provides a Learning Management System (LMS) for institutions and content creators that can connect and integrate TEL "external assets" (virtual reality simulators, augmented box trainers, augmented videos, etc.) addressing different skills. The platform integrates all skills under an Assessment Module that measures skills' progress in different courses. Finally, it provides content creators with a pedagogical model to scaffold contents while retaining flexibility to approach course design with different training philosophies in mind. Three courses were developed and hosted in the platform to validate it with end-users in terms of usability, performance, learning results in the courses and student self-perception on learning.

RESULTS

In total 111 volunteers completed the validation. The study was limited due to the COVID-19 pandemic, which limited access to external assets (virtual reality simulators). Nevertheless, usability was rated with 73.1 in the System Usability Scale. Most positive aspects on performance were easiness to access the platform, easiness to change the configuration and not requiring additional plug-ins to use the platform. The platform was rated above average in the six scales of the User Experience Questionnaire. Overall, student results improved significantly across the three courses (p < 0.05).

CONCLUSIONS

This study provides, within its limitations, evidence on the usefulness of the EASIER platform for distance learning of MIS skills. Results show the potential impact of the platform and are an encouraging boost for the future, especially in the aftermath of the COVID-19 pandemic.

Three-Dimensionally Printed Hydrogel Cardiac Patch for Infarct Regeneration Based on Natural Polysaccharides

Myocardial infarction is one of the more common cardiovascular diseases, and remains the leading cause of death, globally. Hydrogels (namely, those using natural polymers) provide a reliable tool for regenerative medicine and have become a promising option for cardiac tissue regeneration due to their hydrophilic character and their structural similarity to the extracellular matrix. Herein, a functional ink based on the natural polysaccharides Gellan gum and Konjac glucomannan has, for the first time, been applied in the production of a 3D printed hydrogel with therapeutic potential, with the goal of being locally implanted in the infarcted area of the heart. Overall, results revealed the excellent printability of the bioink for the development of a stable, porous, biocompatible, and bioactive 3D hydrogel, combining the specific advantages of Gellan gum and Konjac glucomannan with proper mechanical properties, which supports the simplification of the implantation process. In addition, the structure have positive effects on endothelial cells' proliferation and migration that can promote the repair of injured cardiac tissue. The results presented will pave the way for simple, low-cost, and efficient cardiac tissue regeneration using a 3D printed hydrogel cardiac patch with potential for clinical application for myocardial infarction treatment in the near future.

CONTENT VALIDATION OF THREE MODULES FOR ONLINE TRAINING OF MINIMALLY INVASIVE SURGERY

Introduction

Training tools should follow a thorough validation process that assure their value before their wider use. In this regard, three online modules for laparoscopic cholecystectomy, lumbar punction and knee arthroscopy have been created for an integrative Learning Management System (LMS) that connects external assets, therefore allowing training of technical and nontechnical skills. This work focuses on the content validation of the modules to determine the appropriateness of the material for learning purposes.

Methods

The contents for the three modules have been developed following a 3D pedagogical model designed for e-learning in minimally invasive surgery. Experts were requested to rate 10 items about the contents and the activities included within the modules. Rating was done on a 5-point Likert scale (5-Strongly agree, 1-Strongly disagree).

Results

Six experts took part in the study. Contents were well rated as unique (4.17), sufficient to cover the learning objectives (4.50), up to date (4.33), realistic and relevant (4.83), professional (4.67), with adequate assessment (4), useful forum (4.33), good quality multimedia contents (4) but not so innovative (3.83). Lastly, external assets provided added value to the courses (4.5).

Conclusions

In general, experts were satisfied with the structure and the quality of the education material and found them to be well prepared according to the best practice of each profession. Therefore, the modules will be incorporated in the LMS for training, which will be further validated to prove its utility as a training tool.

SUBJECTIVE USABILITY VALIDATION OF A LEARNING MANAGEMENT SYSTEM FOR ONLINE TRAINING OF MINIMALLY INVASIVE SURGERY: COMPARISON BETWEEN EXPERTS AND STUDENTS

Introduction

Remote learning has been increasingly required after the COVID-19 pandemic. In this regard, an integrative Learning Management System (LMS) that connects external assets for technical and nontechnical skills training in minimally invasive surgery has been implemented. Before its wider use as a training tool, a comparison of usability perception between experts and students has been performed.

Methods

The system usability scale (SUS) was used. Users rated the 10-item questionnaire on a 5-point Likert-scale (5-Strongly agree, 1-Strongly disagree), with odd questions referring to positive aspects and even questions to negative ones. Two profiles were considered: experts in surgical training and students and residents. They were requested to use the LMS and complete any of the implemented courses. Comparison between groups was done with a Mann-Whitney U-test.

Results

Seven experts and 110 students participated in the study. Overall, SUS score by experts reached a mean value of 67.14 points [Q1 = 68.05, Q3= 76.81; interquartile range (IQR) = 9.67], while the mean SUS score given by students was 73.09 [Q1 = 65.00, Q3= 84.38; IQR = 19.38]. When comparing both groups, significant differences were not found (p-value=0.639).

Conclusions

Since SUS scores are usually considered to be valid when the average is greater than 68, experts were slightly below, while students surpassed this threshold. Nevertheless, since there were no significant differences, it might be assumed that usability of the LMS is acceptable and it will not hinder the training process, although further studies to prove its pedagogical value are required.

DEVELOPMENT OF A NATURAL POLYMER-BASED HYDROGEL FOR BIOENGINEERED VASCULAR GRAFTS

Introduction

Cardiovascular diseases are a main cause of death globally, and their treatment implies various vascular repairs through different techniques like angioplasty, stent placement in the blocked artery, or bypass surgery. Artificial grafts would significantly reduce the number of non-treated patients, but middle and long-term failures compromise their clinical use.

Methods

Herein, we developed a hydrogel composed of gellan gum, gelatin, and sodium alginate for bioengineered vascular graft production. The vascular grafts were characterized by their swelling, porosity, biodegradability, and cytotoxic profile.

Results

The bioengineered materials were easily assembled due to the thermoresponsive nature of the hydrogel and had a vessel-like structure resembling the native vasculature. These vessels had a very controlled swelling degree, and notably, the hydrogel structure was stable and maintained its morphology. The vascular grafts had a porosity of 82.6 ± 4.3% and exhibited a controlled biodegradation rate with a maximum of 24.2 ± 3.0%. As expected, the natural materials used showed no cytotoxicity toward HUVECs cells since they are natural polymers described as biocompatible.

Conclusions

This developed natural hydrogel showed promising potential to be used to develop bioengineered vascular grafts.

PRELIMINARY RESULTS ON FUNCTIONALIZATION OF POLYPROPYLENE SURGICAL MESHES

Introduction

Due to inflammatory response in patients, many efforts have been devoted to developing advanced (biological or bioactive) surgical meshes. Some of them look for new synthetic materials and others work to improve their biocompatibility through different methods (coating, soaking, plasma). However, it is critical to avoid pore obstruction or lose mechanical properties while its amphiphilic behaviour is increased.

Methods

A deposition method was used to functionalize surgical meshes with a polypropylene derivative block copolymer that improved its amphiphilic behaviour. Therefore, this copolymer was dispersed on several solvents with different polarities and chemical natures. Then, meshes were immersed and a chemical adsorption-based coating was performed. Additionally, a qualitative study was carried out by optical and fluorescence microscopy on two size samples: small (1 cm2 squares) and large (standard T bone shapes).

Results

First, pore obstruction was perfectly avoided in small samples but was partially present in large samples. Second, the deposition was thicker with polar solvent in both sizes. And finally, fluorescence analysis showed a homogeneous and smooth coating with the most polar solvent.

Conclusions

After exposure to UV light, small samples show a better coating while large one's present irregular adherences on their surface. Moreover, the aprotic polar solvent provides a thickness layer and a smooth mesh surface.

TOWARDS AN UNIFIED FRAMEWORK FOR VALIDATING DEEP LEARNING METHODS FOR COLORECTAL POLYPS: FIRST STEPS

INTRODUCTION

Deep learning techniques have significantly contributed to the field of medical imaging analysis. In case of colorectal cancer, they have shown a great utility for increasing the adenoma detection rate at colonoscopy, but a common validation methodology is still missing. In this study, we present preliminary efforts towards the definition of a validation framework.

MATERIAL AND METHODS

Different models based on different backbones and encoder-decoder architectures have been trained with a publicly available dataset that contains white light and NBI colonoscopy videos, with 76 different lesions from colonoscopy procedures in 48 human patients. A computer aided detection (CADe) demonstrator has been implemented to show the performance of the models.

RESULTS

This CADe demonstrator shows the areas detected as polyp by overlapping the predicted mask on the endoscopic image. It allows selecting the video to be used, among those from the test set. Although it only present basic features such as play, pause and moving to the next video, it easily loads the model and allows for visualization of results. The demonstrator is accompanied by a set of metrics to be used depending on the aimed task: polyp detection, localization and segmentation.

CONCLUSIONS

The use of this CADe demonstrator, together with a publicly available dataset and predefined metrics will allow for an easier and more fair comparison of methods. Further work is still required to validate the proposed framework.

Approaches towards training in human risk management of surgical technology

A safe application of modern surgical technology and computer-assisted surgery devices is based on an operation by adequately trained surgeons who are familiar with the benefits and limitations of the devices. We analyzed the in-depth interviews with seven Spanish and 10 German surgeons. Together with other studies, this analysis highlights the need for specific training in technological competence for surgeons. One way to train technological competence is to help surgeons understanding the basic principles of medical devices as well as explaining the basic concepts of risk analysis and risk management. Based on this premise, a stage model for risk assessment was developed and adapted for the training of surgeons. This was developed further into a train the trainer (TTT) concept, which was then evaluated for two example cases. During TTT-training, the trainers (expert surgeons) performed a risk analysis for several medical devices. Afterwards, the trainers organized a surgical workshop for surgical trainees (resident surgeons), in which high-fidelity simulators and the original medical devices were used. The results showed that the surgeons performed the risk analysis correctly with the stage model and afterwards were able to successfully apply the results in the workshop context.

[New technologies in minimally invasive surgery training: what do surgeons demand?]

BACKGROUND

Minimally invasive surgery might greatly benefit from the Information and Communications Technologies. The objective of this work is to determine the better approach to include those technologies, in particular an e-Learning platform, into an in-person training course.

METHODS

An online survey was sent to all participants in any of the laparoscopic training courses at Jesús Usón Minimally Invasive Surgery Centre. This survey included questions regarding new technologies used for training. Once all data were gathered, a descriptive analysis was performed.

RESULTS

382 questionnaires were sent of which 102 were correctly received back. This means a response rate equal to 30%. Current theoretical training means are watching surgical videos (85-83.3%) and assisting to in-person training courses (77-75.5%). Participants rated as useful the use of new technologies for training (4.1 ± 0.9) and they would mainly use it both before and after assisting to an in-person training course (80-78.4%).

CONCLUSIONS

It is proposed a methodology that provides participants with didactic resources based on surgical videos, both before and after assisting to an in-person training course. Through the application of this methodology, an improvement and reduction of the time that surgeons expend in training is aimed.

E-Learning and Multimedia Contents for Minimally Invasive Surgery Learning

Background: Minimally Invasive Surgery has revolutionized the surgical practice for the last years but it presents specific training processes. At the same time, e-Learning platforms and multimedia contents are now having great success within teaching processes in different fields. Purpose: to determine perception of surgeons towards e-MIS: e-Learning and multimedia contents for minimally invasive surgery. Methods: A 19-item online survey was sent. Statistical and descriptive analyses were performed. Results: 307 surgeons responded to the survey. 99% of participants agree to include new technologies in surgical learning and 99.3% consider surgical videos as a good training tool. Conclusion: The widespread use and capabilities of e-Learning together with the use of surgical videos within the surgical learning process makes possible creating new technological systems and tools that address current problems in surgical training derived from time constraints and patient safety concerns.

Construct and face validity of SINERGIA laparoscopic virtual reality simulator

PURPOSE

Laparoscopic techniques have nowadays become a gold standard in many surgical procedures, but they imply a more difficult learning skills process. Simulators have a fundamental role in the formative stage of new surgeons. This paper presents the construct and face validity of SINERGIA laparoscopic virtual reality simulator in order to decide whether it can be considered as an assessment tool.

METHODS

Twenty people participated in this study, 14 were novices and 6 were experts. Five tasks of SINERGIA were included in the study: coordination, navigation, navigation and touch, precise grasping and coordinate traction. For each one of these tasks, a certain number of metrics are automatically recorded. All subjects accomplished each task only once and filled in two questionnaires. A statistical analysis was made and results from both groups were compared with the Mann-Whitney U-test, considering significant differences when P < or = 0.05. Internal consistency of the system has been analyzed with the Cronbach's alpha test.

RESULTS

Novices and experts positively rated SINERGIA characteristics. At least one of the evaluated metrics of each exercise presented significant differences between both groups. Nevertheless, all metrics under study gave a better punctuation to the executions accomplished by experts (lower time, higher efficiency, fewer errors. . .) than to those made by novices.

CONCLUSION

SINERGIA laparoscopic virtual reality simulator is able to discriminate subjects according to their level of experience in laparoscopic surgery; therefore, it can be used within a training program as an assessment tool.