Upscaling telemonitoring in Dutch University Medical Centres: A baseline measurement

INTRODUCTION AND OBJECTIVE

The Dutch university medical centres (UMC's) are on the forefront when it comes to validation, implementation and research of telemonitoring. To aid the UMC's in their effort, the Dutch Government has supported the UMC's by fostering the 'Citrien eHealth program'. This program aims at nationwide implementation and upscaling of telemonitoring via a collaborative network. To quantify the success of this program, this study aims to provide insights into the current adoption of telemonitoring by health care professionals (HCP) within Dutch UMC's.

METHODS

Based on the evaluation framework as adapted from the Normalization Process Theory (NPT) a cross-sectional study was conducted in all Dutch UMC's. Thirty healthcare professionals (HCPs) per UMC were invited to complete the 23-item Normalization MeAsure Development (NoMAD) questionnaire, a tool to assess the degree of normalisation of telemonitoring.

RESULTS

The over-all response rate was 52.4% (124/240). Over 80% of respondents agreed or strongly agreed that they understand how telemonitoring affects the nature of their work, with a mean score of 1.49 (N = 117, SD 0.74). HCPs reported to believe telemonitoring will become a normal part of their work in the near future (N = 124, mean = 8.67, SD = 1.38). Using the Wilcoxon signed-rank test, the difference between current practise and future use of telemonitoring predicts to be statistically significant (Z =  - 7.505, p ≤ 0.001). Mean scores for appropriate training and sufficient resources are relatively low (2.39 and 2.70 respectively), indicating a barrier for collective action.

CONCLUSION

This is the first study to assess the implementation of telemonitoring as standard practise across Dutch UMCs. The HCPs in this study are the frontrunners, believing that telemonitoring will become standard practise in the future despite the fact that it is currently not. Based on the results of this study, both educational and implementation strategies including practical skills training are highly recommended in order to scale up telemonitoring widely.

European Association for Endoscopic Surgery (EAES) consensus on Indocyanine Green (ICG) fluorescence-guided surgery

BACKGROUND

In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.

RESULTS

A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.

CONCLUSIONS

Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

Implementing structured team debriefing using a Black Box in the operating room: surveying team satisfaction

Background

Surgical safety may be improved using a medical data recorder (MDR) for the purpose of postoperative team debriefing. It provides the team in the operating room (OR) with the opportunity to look back upon their joint performance objectively to discuss and learn from suboptimal situations or possible adverse events. The aim of this study was to investigate the satisfaction of the OR team using an MDR, the OR Black Box®, in the OR as a tool providing output for structured team debriefing.

Methods

In this longitudinal survey study, 35 gastro-intestinal laparoscopic operations were recorded using the OR Black Box® and the output was subsequently debriefed with the operating team. Prior to study, a privacy impact assessment was conducted to ensure alignment with applicable legal and regulatory requirements. A structured debrief model and an OR Back Box® performance report was developed. A standardized survey was used to measure participant’s satisfaction with the team debriefing, the debrief model used and the performance report. Factor analysis was performed to assess the questionnaire’s quality and identified contributing satisfaction factors. Multivariable analysis was performed to identify variables associated with participants’ opinions.

Results

In total, 81 team members of various disciplines in the OR participated, comprising 35 laparoscopic procedures. Mean satisfaction with the OR Black Box® performance report and team debriefing was high for all 3 identified independent satisfaction factors. Of all participants, 98% recommend using the OR Black Box® and the outcome report in team debriefing.

Conclusion

The use of an MDR in the OR for the purpose of team debriefing is considered to be both beneficial and important. Team debriefing using the OR Black Box® outcome report is highly recommended by 98% of team members participating.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07526-3) contains supplementary material, which is available to authorized users.

Improving enhanced recovery after surgery (ERAS): ERAS APPtimize study protocol, a randomized controlled trial investigating the effect of a patient-centred mobile application on patient participation in colorectal surgery

BACKGROUND

Perioperative care in colorectal surgery is systematically defined in the Enhanced Recovery After Surgery (ERAS) protocol. The ERAS protocol improves perioperative care in a multimodal way to enhance early and safe release from the hospital. Adequate compliance to the elements of the ERAS protocol is multifactorial. There are still opportunities to improve compliance of the protocol by actively involving the patient. The main objective of this study is to investigate whether compliance of selected items in the ERAS protocol can be improved through actively involving patients in the ERAS care pathway through the use of a patient-centred mobile application.

METHODS

A multicentre randomized controlled trial will be conducted. Patients undergoing elective colorectal surgery, who are 18 years or older and in possession of an eligible smartphone, will be included. Patients assigned to the intervention group will install a patient-centred mobile application to be guided through the ERAS care pathway. Patients in the control group will receive care as usual. Both groups will wear an activity tracker. The primary outcome is overall compliance to selected active elements of the ERAS protocol, as registered by the patient. Secondary outcomes include Patient Reported Outcome Measures (PROMs) such as health-related quality of life, physical activity, and patient satisfaction of received care. Care-related outcomes, such as length of hospital stay, number of complications, re-intervention, and readmission rates, will also be assessed.

RESULTS

The enrolment of patients will start in the second quarter of 2019. Data collection had not begun by the time this protocol was submitted.

CONCLUSION

We hypothesize that by providing patients with a patient-centred mobile application, compliance to the active elements of ERAS protocol can be improved, resulting in an increased health-related quality of life, physical activity, and patient satisfaction.

TRIAL REGISTRATION

Netherlands Trial Register, NTR7314 , prospectively registered on the 9th of November 2017 ( http://www.trialregister.nl ).

Legal perspectives on black box recording devices in the operating environment

Background

A video and medical data recorder in the operating theatre is possible, but concerns over privacy, data use and litigation have limited widespread implementation. The literature on legal considerations and challenges to overcome, and guidelines related to use of data recording in the surgical environment, are presented in this narrative review.

Methods

A review of PubMed and Embase databases and Cochrane Library was undertaken. International jurisprudence on the topic was searched. Practice recommendations and legal perspectives were acquired based on experience with implementation and use of a video and medical data recorder in the operating theatre.

Results

After removing duplicates, 116 citations were retrieved and abstracts screened; 31 articles were assessed for eligibility and 20 papers were finally included. According to the European General Data Protection Regulation and US Health Insurance Portability and Accountability Act, researchers are required to make sure that personal data collected from patients and healthcare professionals are used fairly and lawfully, for limited and specifically stated purposes, in an adequate and relevant manner, kept safe and secure, and stored for no longer than is absolutely necessary. Data collected for the sole purpose of healthcare quality improvement are not required to be added to the patient's medical record.

Conclusion

Transparency on the use and purpose of recorded data should be ensured to both staff and patients. The recorded video data do not need to be used as evidence in court if patient medical records are well maintained. Clear legislation on data responsibility is needed to use the medical recorder optimally for quality improvement initiatives.

First real-world experience with mobile health telemonitoring in adult patients with congenital heart disease

BACKGROUND

Arrhythmias and heart failure are common and invalidating sequelae in adult patients with congenital heart disease (CHD). Mobile health (m-Health) enables daily monitoring and a timely response that might prevent deterioration. We present an observational prospective registry to evaluate feasibility of an m‑Health telemonitoring program for managing arrhythmia, heart failure and blood pressure in symptomatic adults with CHD.

METHODS

Symptomatic adult patients with CHD are enrolled in an m‑Health telemonitoring program, which evaluates single-lead ECG, blood pressure and weight measurements. In case of symptoms extra measurements could be performed. Data are collected by mobile apps, matched with individualised thresholds. Patients are contacted if thresholds were exceeded or if arrhythmias were found, for treatment adjustments or reassurance. Data on emergency care utilisation, hospitalisation and patient-reported outcome measures are used to assess quality of life and self-management.

RESULTS

129 symptomatic CHD patients were invited to participate, 55 participated. Reasons for refusing consent included too time consuming to participate in research (30) and to monitor vital signs (14). At baseline 22 patients were in New York Heart Association class ≥ II heart failure, 43 patients had palpitations or documented arrhythmias, and 8 had hypertension. Mean follow-up was 3.0 months, one patient dropped out, and adherence was 97%.

CONCLUSION

The first results indicate that this program is feasible with high adherence.

[Video recording and data collection in the operating room: the way to a 'just culture' in the OR]

The Academic Medical Center, Amsterdam, has started a trial to evaluate the usefulness to team debriefings of performance reports generated by a medical data recorder (MDR) in the operating room (OR). Outcome performance reports in structured debriefings in a secure, non-punitive environment are likely to heighten the level of situational awareness of OR teams. This may prevent future error. In addition, the use of video and - even more likely - use of an MDR may contribute to establishing a 'just culture' in the OR. MDRs offer a wealth of data, but only if these data are processed well do the resulting outcome reports reveal insights useful for structured debriefings. The implementation of video recordings or MDRs must be preceded by carefully addressing privacy and litigation issues relating to both OR staff and patients. In this article, we address viewpoints and discuss implementation strategy and the legal considerations involved in enabling the use of video and data registration in the OR.

Efficacy of pneumodilation in achalasia after failed Heller myotomy

BACKGROUND

Heller myotomy is an effective treatment for the majority of achalasia patients. However, a small proportion of patients suffer from persistent or recurrent symptoms after surgery and they are usually subsequently treated with pneumodilation (PD). Data on the efficacy of PD as secondary treatment for achalasia are scarce. Therefore, this study aimed to investigate the efficacy of PD as treatment for achalasia patients suffering from persistent or recurrent symptoms after Heller myotomy.

METHODS

Patients with recurrent or persistent symptoms (Eckardt score >3) after Heller myotomy were selected. Patients were treated with PD, using a graded distension protocol with balloon sizes ranging from 30 to 40 mm. After each dilation symptoms were assessed to evaluate whether a subsequent dilation with a larger balloon size was required. Patients with recurrent or persistent symptoms (Eckardt score >3) after treatment with a 40-mm balloon were identified as failures.

KEY RESULTS

Twenty-four patients were included in total; 15 patients with achalasia type I, seven with achalasia type II and two with achalasia type III. Median relapse time was 2.5 years after Heller myotomy (IQR: 9 years and 3 months). Three patients were not suitable for PD; one patient was morbidly obese and not fit for any form of sedation and two had a siphon-shaped esophagus leaving 21 patients to treat. Eight patients were successfully treated with a single 30-mm balloon dilation (median follow-up time: 6.5 years; IQR: 7.5 years). Four patients required dilations with 30- and 35-mm balloons (median follow-up time: 11 years; IQR: 3 years). Nine patients failed on the 35-mm balloon dilation and underwent a subsequent dilation with a 40-mm balloon, and all failed on this balloon as well. Thus, PD was successful in 12 of the 21 treatable patients, resulting in a success rate of 57% for treatable patients or 50% for all patients. Baseline Eckardt scores were also higher in those that failed (median: 8; IQR: 2) than those that were treated successfully (median: 5.5; IQR: 2) treated (p = 0.009). Furthermore, baseline barium column height at 5 min was higher in patients with failed (median: 6 cm; IQR: 6 cm) treatment than in patients with successful (median: 2.6 cm; IQR: 4.7 cm) treatment (p = 0.016). Baseline lower esophageal sphincter pressure was not different between patients who were treated successfully (median: 11 mmHg; IQR: 5 mmHg) and those that failed on PD (median: 17.5 mmHg; IQR: 10.8 mmHg) treatment (p > 0.05). Baseline symptom pattern was also not a predictor of successful treatment. No adverse events were recorded during or after PD.

CONCLUSIONS & INFERENCES

Pneumodilation for recurrent symptoms after previous Heller myotomy is safe and has a modest success rate of 57%, using 30- and 35-mm balloons. Patients with recurrent symptoms after PD with 35-mm balloon are likely to also fail after subsequent dilation with a 40-mm balloon.

Mobile health in adults with congenital heart disease: current use and future needs

Objective

Many adults with congenital heart disease (CHD) are affected lifelong by cardiac events, particularly arrhythmias and heart failure. Despite the care provided, the cardiac event rate remains high. Mobile health (mHealth) brings opportunities to enhance daily monitoring and hence timely response in an attempt to improve outcome. However, it is not known if adults with CHD are currently using mHealth and what type of mHealth they may need in the near future.

Methods

Consecutive adult patients with CHD who visited the outpatient clinic at the Academic Medical Center in Amsterdam were asked to fill out questionnaires. Exclusion criteria for this study were mental impairment or inability to read and write Dutch.

Results

All 118 patients participated (median age 40 (range 18–78) years, 40 % male, 49 % symptomatic) and 92 % owned a smartphone. Whereas only a small minority (14 %) of patients used mHealth, the large majority (75 %) were willing to start. Most patients wanted to use mHealth in order to receive more information on physical health, and advice on progression of symptoms or signs of deterioration. Analyses on age, gender and complexity of defect showed significantly less current smartphone usage at older age, but no difference in interest or preferences in type of mHealth application for the near future.

Conclusion

The relatively young adult CHD population only rarely uses mHealth, but the majority are motivated to start using mHealth. New mHealth initiatives are required in these patients with a chronic condition who need lifelong surveillance in order to reveal if a reduction in morbidity and mortality and improvement in quality of life can be achieved.

Systematic review on the effectiveness of augmented reality applications in medical training

Background

Computer-based applications are increasingly used to support the training of medical professionals. Augmented reality applications (ARAs) render an interactive virtual layer on top of reality. The use of ARAs is of real interest to medical education because they blend digital elements with the physical learning environment. This will result in new educational opportunities. The aim of this systematic review is to investigate to which extent augmented reality applications are currently used to validly support medical professionals training.

Methods

PubMed, Embase, INSPEC and PsychInfo were searched using predefined inclusion criteria for relevant articles up to August 2015. All study types were considered eligible. Articles concerning AR applications used to train or educate medical professionals were evaluated.

Results

Twenty-seven studies were found relevant, describing a total of seven augmented reality applications. Applications were assigned to three different categories. The first category is directed toward laparoscopic surgical training, the second category toward mixed reality training of neurosurgical procedures and the third category toward training echocardiography. Statistical pooling of data could not be performed due to heterogeneity of study designs. Face-, construct- and concurrent validity was proven for two applications directed at laparoscopic training, face- and construct validity for neurosurgical procedures and face-, content- and construct validity in echocardiography training. In the literature, none of the ARAs completed a full validation process for the purpose of use.

Conclusion

Augmented reality applications that support blended learning in medical training have gained public and scientific interest. In order to be of value, applications must be able to transfer information to the user. Although promising, the literature to date is lacking to support such evidence.

Education in wrist arthroscopy: past, present and future

PURPOSE

Arthroscopy has assumed an important place in wrist surgery. It requires specific operative skills that are now mainly acquired in the operating room. In other fields of endoscopic surgery, e-learning and virtual reality (VR) have introduced new perspectives in teaching skills. This leads to the following research question: Could the current way of teaching wrist arthroscopy skills be supported using new educational media, such as e-learning and simulator training?

METHOD

The literature was searched for available methods of teaching endoscopic skills. Articles were assessed on the evidence of validity. In addition, a survey was sent to all members of the European Wrist Arthroscopy Society (EWAS) to find out whether hand surgeons express a need to embrace modern educational tools such as e-learning or simulators for training of wrist arthroscopy skills.

RESULTS

This study shows that the current way of teaching wrist arthroscopy skills can be supported using new educational media, such as e-learning and simulator training. Literature indicates that e-learning can be a valuable tool for teaching basic knowledge of arthroscopy and supports the hypothesis that the use of virtual reality and simulators in training enhances operative skills in surgical trainees. This survey indicates that 55 out of 65 respondents feel that an e-learning program would be a valuable asset and 62 out of the 65 respondents are positive on the additional value of wrist arthroscopy simulator in training.

CONCLUSION

Study results support the need and relevance to strengthen current training of wrist arthroscopy using e-learning and simulator training.

LEVEL OF EVIDENCE

V.

Training situational awareness to reduce surgical errors in the operating room

Background

Surgical errors result from faulty decision-making, misperceptions and the application of suboptimal problem-solving strategies, just as often as they result from technical failure. To date, surgical training curricula have focused mainly on the acquisition of technical skills. The aim of this review was to assess the validity of methods for improving situational awareness in the surgical theatre.

Methods

A search was conducted in PubMed, Embase, the Cochrane Library and PsycINFO® using predefined inclusion criteria, up to June 2014. All study types were considered eligible. The primary endpoint was validity for improving situational awareness in the surgical theatre at individual or team level.

Results

Nine articles were considered eligible. These evaluated surgical team crisis training in simulated environments for minimally invasive surgery (4) and open surgery (3), and training courses focused at training non-technical skills (2). Two studies showed that simulation-based surgical team crisis training has construct validity for assessing situational awareness in surgical trainees in minimally invasive surgery. None of the studies showed effectiveness of surgical crisis training on situational awareness in open surgery, whereas one showed face validity of a 2-day non-technical skills training course.

Conclusion

To improve safety in the operating theatre, more attention to situational awareness is needed in surgical training. Few structured curricula have been developed and validation research remains limited. Strategies to improve situational awareness can be adopted from other industries.

Systematic review of serious games for medical education and surgical skills training

Background

The application of digital games for training medical professionals is on the rise. So-called ‘serious’ games form training tools that provide a challenging simulated environment, ideal for future surgical training. Ultimately, serious games are directed at reducing medical error and subsequent healthcare costs. The aim was to review current serious games for training medical professionals and to evaluate the validity testing of such games.

Methods

PubMed, Embase, the Cochrane Database of Systematic Reviews, PsychInfo and CINAHL were searched using predefined inclusion criteria for available studies up to April 2012. The primary endpoint was validation according to current criteria.

Results

A total of 25 articles were identified, describing a total of 30 serious games. The games were divided into two categories: those developed for specific educational purposes (17) and commercial games also useful for developing skills relevant to medical personnel (13). Pooling of data was not performed owing to the heterogeneity of study designs and serious games. Six serious games were identified that had a process of validation. Of these six, three games were developed for team training in critical care and triage, and three were commercially available games applied to train laparoscopic psychomotor skills. None of the serious games had completed a full validation process for the purpose of use.

Conclusion

Blended and interactive learning by means of serious games may be applied to train both technical and non-technical skills relevant to the surgical field. Games developed or used for this purpose need validation before integration into surgical teaching curricula.

Training and learning robotic surgery, time for a more structured approach: a systematic review

BACKGROUND

Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons.

OBJECTIVES

To review the literature on training and learning strategies for robotic assisted laparoscopic surgery.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed.

SELECTION CRITERIA

We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism.

DATA COLLECTION AND ANALYSIS

Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation.

MAIN RESULTS

We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme.

AUTHORS' CONCLUSIONS

Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes.

Laparoscopic skills training using inexpensive box trainers: which exercises to choose when constructing a validated training course

OBJECTIVE

To obtain face and construct validity for a new training course to be used in any type of box/video trainer and to give a comprehensive overview of validated exercises for box/video training.

DESIGN

Cross-sectional study.

SETTING

University Medical Centre.

POPULATION

Students, residents and consultants.

METHODS

Participants (n = 42) were divided into three groups according to their laparoscopic experience: 'Novices' (n = 18), 'Intermediates' (n = 14) and 'Experts' (n = 10). A laparoscopic training course consisting of six exercises was constructed. To emphasise precision, a penalty score was added. Every participant performed two repetitions of the exercises; total score per exercise was calculated. To determine face validity, participants filled in a questionnaire after completion of the exercises. An evidence-based literature search for validated box/video trainer exercises was performed.

MAIN OUTCOME MEASURES

Face and construct validity.

RESULTS

The mean score of the 'experts' was set as the training target. Total scores appeared to be positively correlated with individual's laparoscopic experience. The overall score and the score for each exercise were significantly higher in the intermediate and expert groups when compared with the novice group (P ≤ 0.001). All participants completed the questionnaire. The overall assessment of the exercises was considered to be good. The course was found to be most appropriate for training residents year 1-3.

CONCLUSION

Face and construct validity for an inexpensive course for box/video training was established. A comprehensive and practical overview of all validated and published exercises for box/video trainers is provided to facilitate an inexpensive, but optimal and tailored selection for training purposes.

The SEP "robot": a valid virtual reality robotic simulator for the Da Vinci Surgical System?

The aim of the study was to determine if the concept of face and construct validity may apply to the SurgicalSim Educational Platform (SEP) "robot" simulator. The SEP robot simulator is a virtual reality (VR) simulator aiming to train users on the Da Vinci Surgical System. To determine the SEP's face validity, two questionnaires were constructed. First, a questionnaire was sent to users of the Da Vinci system (reference group) to determine a focused user-group opinion and their recommendations concerning VR-based training applications for robotic surgery. Next, clinical specialists were requested to complete a pre-tested face validity questionnaire after performing a suturing task on the SEP robot simulator. To determine the SEP's construct validity, outcome parameters of the suturing task were compared, for example, relative to participants' endoscopic experience. Correlations between endoscopic experience and outcome parameters of the performed suturing task were tested for significance. On an ordinal five-point, scale the average score for the quality of the simulator software was 3.4; for its hardware, 3.0. Over 80% agreed that it is important to train surgeons and surgical trainees to use the Da Vinci. There was a significant but marginal difference in tool tip trajectory (p = 0.050) and a nonsignificant difference in total procedure time (p = 0.138) in favor of the experienced group. In conclusion, the results of this study reflect a uniform positive opinion using VR training in robotic surgery. Concepts of face and construct validity of the SEP robotic simulator are present; however, these are not strong and need to be improved before implementation of the SEP robotic simulator in its present state for a validated training curriculum to be successful .

Transatlantic comparison of the competence of surgeons at the start of their professional career

Background

Although the objective in European Union and North American surgical residency programmes is similar—to train competent surgeons—residents' working hours are different. It was hypothesized that practice-ready surgeons with more working hours would perform significantly better than those being educated within shorter working week curricula.

Methods

At each test site, 21 practice-ready candidate surgeons were recruited. Twenty qualified Canadian and 19 qualified Dutch surgeons served as examiners. At both sites, three validated outcome instruments assessing multiple aspects of surgical competency were used.

Results

No significant differences were found in performance on the integrative and cognitive examination (Comprehensive Integrative Puzzle) or the technical skills test (Objective Structured Assessment of Technical Skill; OSATS). A significant difference in outcome was observed only on the Patient Assessment and Management Examination, which focuses on skills needed to manage patients with complex problems (P < 0·001). A significant interaction was observed between examiner and candidate origins for both task-specific OSATS checklist (P = 0·001) and OSATS global rating scale (P < 0·001) scores.

Conclusion

Canadian residents, serving many more working hours, perform equivalently to Dutch residents when assessed on technical skills and cognitive knowledge, but outperformed Dutch residents in skills for patient management. Secondary analyses suggested that cultural differences influence the assessment process significantly.

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

BACKGROUND

Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation.

METHODS

A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education.

RESULTS

The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence.

CONCLUSIONS

In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.

Improved competence after a palliative care course for internal medicine residents

Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of residents in internal medicine. Before and after the course, we carried out a questionnaire survey and knowledge test in 91 residents. The results show that many residents felt they had limited competence or were incompetent when taking care of patients in the palliative care phase. This was particularly true with respect to communication concerning euthanasia and physician-assisted suicide or hastened death (86% and 85% respectively reported limited competence or incompetence). Participants reported that they received inadequate training in palliative care and believed that specific education would make them feel more competent. The number of times that residents were engaged in palliative care situations and the years of clinical experience had a positive influence on perceived competence. Participating in the course improved perceived competence and knowledge in palliative care. No correlation was found between perceived competence and knowledge of palliative care.

Virtual reality training for endoscopic surgery: voluntary or obligatory?

Introduction

Virtual reality (VR) simulators have been developed to train basic endoscopic surgical skills outside of the operating room. An important issue is how to create optimal conditions for integration of these types of simulators into the surgical training curriculum. The willingness of surgical residents to train these skills on a voluntary basis was surveyed.

Methods

Twenty-one surgical residents were given unrestricted access to a VR simulator for a period of four months. After this period, a competitive element was introduced to enhance individual training time spent on the simulator. The overall end-scores for individual residents were announced periodically to the full surgical department, and the winner was awarded a prize.

Results

In the first four months of study, only two of the 21 residents (10%) trained on the simulator, for a total time span of 163 minutes. After introducing the competitive element the number of trainees increased to seven residents (33%). The amount of training time spent on the simulator increased to 738 minutes.

Conclusions

Free unlimited access to a VR simulator for training basic endoscopic skills, without any form of obligation or assessment, did not motivate surgical residents to use the simulator. Introducing a competitive element for enhancing training time had only a marginal effect. The acquisition of expensive devices to train basic psychomotor skills for endoscopic surgery is probably only effective when it is an integrated and mandatory part of the surgical curriculum.

Face validity study of the ProMIS augmented reality laparoscopic suturing simulator

To prevent unnecessary mistakes and avoidable complications in laparoscopic surgery, there has to be proper training. A safe way to train surgeons for laparoscopy is simulation. This study addresses the face validity of ProMIS, an Augmented Reality laparoscopic simulator, as a tool for training suturing skills in laparoscopic surgery. A two-paged, 12-item structured questionnaire, using a five-point-Likert scale, was presented to 50 surgeons/surgical interns. The participants were allotted to two groups: an "expert" (>50 procedures; N=23) and a referent group (<50 procedures; N=27). Non-parametric statistics were used to determine statistical differences. General consensus existed in both expert and referent groups, delineating ProMIS as a useful tool in teaching suturing skills surgeons/surgical interns (mean + or - st dev, resp, score 4.91 + or - 0.42 and 4.93 + or - 0.38) with regard to realism, tactile feedback, and suturing techniques. Significant differences in opinion regarding the ergonomics and design of ProMIS between the expert and referent groups existed. The ProMIS Augmented Reality laparoscopic simulator is regarded as a useful tool in laparoscopic training in both expert and referent groups. Although significant differences in opinion existed with regards to ergonomics and design of ProMIS, they were present between experts and novices.

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND

Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands.

METHODS

Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire.

RESULTS

A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines.

CONCLUSIONS

A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Construct validity and assessment of the learning curve for the SIMENDO endoscopic simulator

BACKGROUND

The SIMENDO is an affordable virtual reality simulator designed to train basic psychomotor skills for endoscopic surgery. This study aimed first to establish construct validity by determining which parameters can discriminate groups with different experience levels, and second to establish the extent to which training is useful by determining when inexperienced groups reach expert level.

METHODS

The study participants were divided into four groups according to their experience with endoscopic procedures: experienced group (group A, >50 procedures performed, n = 15), intermediate group (group B, 1-50 procedures performed, n = 18), endoscope navigation group (group C, endoscope navigation experience, n = 14), and novice group (group D, no endoscopic experience, n = 14). Each participant performed three repetitions of six consecutive exercises. The parameters studied were task time, path length of the instruments, and number of errors (collisions). Some participants continued training up to 10 repetitions to get insight in the learning curve.

RESULTS

Group A (expert) outperformed all the other groups (B, C, and D) in terms of total median task time (p < 0.05), groups C and D in terms of path length, and group D in terms of collision frequency in the first two repetitions. Group B (intermediate) outperformed group D (novice) in total time and endoscope path length for all repetitions, and group C (camera navigation) outperformed group D (novice) in the first repetition. Less experienced groups D and C did not reach expert level for the task time within 10 repetitions, and group B reached it after the eighth repetition (p < 0.05).

CONCLUSION

The study was able to establish construct validity for the training program with the simulator under study. The learning curve showed that training with this simulator is useful for subjects with or without limited endoscopic experience. Furthermore, previous endoscopic camera navigation already improves motor skills to more than the basic level.

Construct validity of the LapSim: Can the LapSim virtual reality simulator distinguish between novices and experts?

BACKGROUND

Virtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden).

METHODS

Forty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer.

RESULTS

The higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters.

CONCLUSIONS

Our results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.

The Eindhoven laparoscopic cholecystectomy training course--improving operating room performance using virtual reality training: results from the first E.A.E.S. accredited virtual reality trainings curriculum

BACKGROUND

This study was undertaken to investigate operating room performance of surgical residents, after participating in the Eindhoven virtual reality laparoscopic cholecystectomy training course. This course is the first formal surgical resident trainings course, using a variety of complementary virtual reality (VR) skills training simulation in order to prepare surgical residents for their first laparoscopic cholecystectomy. The course was granted EAES certification.

METHODS

The four-day course is based on multimedia and multimodality approach. A variety of increasingly difficult simulation training sessions, next to intimate focus-group "knowledge sessions" are included. Both basic and procedural VR simulation is featured, using MIST-VR and the Xitacts' LapChol simulation software. The operating room performance of twelve surgical residents who participated in the course and twelve case-control counterparts were compared. The case-control group was matched for clinical number laparoscopic cholecystectomy performance (maximum of 4 procedures). Two observers analyzed a randomly mixed videotape, featuring the part of the "clip-and-cut" procedure of the laparoscopic cholecystectomy, and were blinded for participants' group status. Structured questionnaires including multiple observation scales were used to assess performance.

RESULTS

Residents of both the experimental and control group did not differ in demographic parameters, except for number of laparoscopic cholecystectomies in favor of the control group (p-value 0.008). Both observers judge the experimental group to perform significantly better (p-value 0.004 and 0.013). Experimental group residents valued their course highly in terms of their laparoscopic surgical skills improvement and the use of VR simulators in the surgical curriculum.

CONCLUSIONS

The Eindhoven Virtual Reality laparoscopic cholecystectomy training course improves surgical skill in the operating room above the level of residents trained by a variety of other training methods.

Determination of face validity for the Simbionix LAP mentor virtual reality training module

This study determines the expert and referent face validity of LAP Mentor, the first procedural virtual-reality (VR) trainer. After a hands-on introduction to the simulator a questionnaire was administered to 49 participants (21 expert laparoscopists and 28 novices). There was a consensus on LAP Mentor being a valid training model for basic skills training and the procedural training of laparoscopic cholecystectomies. As 88% of respondents saw training on this simulator as effective and 96% experienced this training as fun it will likely be accepted in the surgical curriculum by both experts and trainees. Further validation of the system is required to determine whether its performance concurs with these favourable expectations.

Consensus guidelines for validation of virtual reality surgical simulators

The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed sub-group of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for six different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into two basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. Whilst level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org ).

Minimal-access surgery training in the Netherlands: a survey among residents-in-training for general surgery

BACKGROUND

The purpose of this study was to assess the state of surgical training and its possible shortcomings in minimal-access surgery (MAS) among Dutch surgical residents.

METHODS

A pretested questionnaire was distributed to all residents-in-training for general surgery in The Netherlands.

RESULTS

The questionnaire was sent to 407 surgical residents. The response rate was 65%. Overall, 87.7% of all the responders were highly interested in the autonomous performance of laparoscopic surgery. Residents interested in gastrointestinal (GI) or oncologic surgery (n = 137) are significantly more interested than residents interested in non-GI/oncologic surgery. All the residents (100%) thought it was important to be able to perform the three basic MAS procedures (diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy) autonomously at the end of their surgical training. Other MAS procedures were considered to be advanced procedures. Gastrointestinal/oncologic residents were most interested in performing advanced MAS procedures, although only 17.8% expected to be adequately prepared at the end of their surgical training. Most residents had the opportunity to attend MAS skills education. Irrespective of the format or training method, only 26.9% of residents stated their MAS skills training was objectively evaluated. The residents thought every surgical hospital department in the Netherlands should have a surgeon specialized in laparoscopic surgery (86.9%).

CONCLUSIONS

The current study showed that Dutch residents believe it is very important to perform basic MAS autonomously. Of the GI/oncologic-interested residents, the majority want to be able to perform advanced MAS, but expect to be unable to do so at the end of their training. They attribute this discrepancy to "not having enough chance to be the first operator" and to "lack of volume of procedures in the hospital." Specific and properly implemented, monitored, and evaluated MAS skills training programs in skills laboratory settings could offer a promising environment for overcoming this discrepancy.

The learning curve on the Xitact LS 500 laparoscopy simulator: profiles of performance

BACKGROUND

This study assesses the acquisition of skill and the learning curve associated with the performance of the clip-and-cut task on the Xitact LS 500 virtual reality (VR) simulator in laparoscopic cholecystectomy.

METHODS

A group of 33 residents and interns with no previous laparoscopic experience participated in the study. All participants received a 1-h familiarization tour on the simulator. Thirty participants completed a full course of 30 simulation runs over 3 days (10 runs per day). The outcome parameters were a previously validated sum-score and time to complete performance.

RESULTS

Group demographics were similar. Of the participants who completed the full study, 16.7% appeared to have such a high level of innate psychomotor abilities that they were considered proficient in the task immediately after the initial familiarization tour. Most participants (63.3%) had a moderate level of innate abilities, and their performance improved through repetitive VR training. In our study, 20% of the participants had such a low level of innate abilities that they were unable to achieve an acceptable performance in our minimal-access surgery (MAS) simulation.

CONCLUSIONS

Learning curves cannot be assessed by examining the repetitive training of only one person. There seem to be four different performance profiles, reflecting the fact that some people are more adept than others to be trained by MAS procedural VR simulation. For participants receptive to training--63.3% in this study--proficiency in the task occurs after approximately 25 simulative runs.

Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy

AIMS

The use of axillary lymph node dissection (ALND) in women with breast cancer is associated with considerable morbidity. Sentinel node biopsy (SNB) removes the lymph node in the axillary basin indicative for receiving first lymphatic drainage from the breast. This study compares the nature and severity of physical morbidity among breast cancer patients who underwent primary surgery for breast cancer combined with either ALND or SNB. Also, it assesses influence of subsequent radiotherapy on morbidity.

METHOD

Two hundred and thirteen ALND patients were compared with 180 SNB patients retrospectively. Morbidity was measured using a disease-specific quality-of-life questionnaire.

RESULTS

Patients' demographic characteristics were alike. The axillary procedure is the strongest and most consistent factor in explaining differences in a variety of self-reported complaints. Patients having had SNB have a 3.2-fold lower risk of experiencing pain, a 5-fold lower risk of lymph oedema, a 7.7-fold lower risk of numbness, a 3.7-fold lower risk of tingling sensations, a 7.1-fold lower risk of loss of strength in arm/hand, a 3.6-fold lower risk of loss of active motion range of the arm and a 2.9-fold lower risk of impaired use of the arm. Axillary radiation therapy adds to complaints next to the axillary surgical procedure by increasing the risk of lymph oedema 2.4-fold and enhancing the risk of impaired use of the arm by 2.6-fold. Axillary radiation therapy does not explain lymph oedema by itself.

CONCLUSION

SNB is associated with less morbidity compared to ALND in patients with primary breast cancer.

Influence of maternal position during epidural labor analgesia

The influence of maternal position on the spread of local anesthetics in low concentration has not been well examined during epidural analgesia for labor. This study was designed to investigate the differences in sensory block, pain relief and incidence of supine hypotensive syndrome between parturients in the left lateral position and in a modified supine position. Sixty-seven parturients were randomly assigned to lie either in the left lateral position (n = 34) or in a modified supine position (n = 33), and received 0.125% bupivacaine 10 mL with epinephrine 1:800000 and sufentanil 7.5 microg. At 20 min parturients in the modified supine position turned to the left lateral position and a second investigator, unaware of the initial position, measured the extent of the sensory block at 20 and 30 min and just before a second epidural injection was requested. More dermatomes were blocked on the dependent side when the dose was injected in the left lateral position (at 20 and 30 min: P < 0.05; before the second epidural injection: P < 0.0005). In the modified supine position the incidence of bilaterally blocked dermatomes T10-L1 was greater at 20 and 30 min (P < 0.05) and the pain on a visual analogue scale was better at 30 min (P < 0.05). Three parturients in the modified supine position had signs and symptoms of supine hypotensive syndrome. We conclude that injecting in the modified supine position results in a more equal spread of local anesthetic and better pain relief.

The Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) objectifying subjective psychomotor test performance

BACKGROUND

This study was undertaken to establish the value of the Advanced Dundee Psychomotor Tester (ADEPT) as an objective real-time scoring system, correcting for subjective assessor opinion on endoscopic task performance. The main research questions were as follows: Are surgeons good estimators of their own performance on ADEPT? Do surgeons perceive ADEPT to be a valid instrument for measuring laparoscopic skills? Does performance on ADEPT reflect innate psychomotor ability?

METHODS

Each of 45 surgeons completed two runs on ADEPT. The runs comprised five standardized tasks. A posttest visual analog scaled (VAS) questionnaire measuring attitude toward skills testing in general, validation, and performance on ADEPT was used. Subjective responses were compared with objective scores generated through performance on ADEPT.

RESULTS

Surgeons emphasize the importance of using a variety of training methods for surgical residents during their residency, including laparoscopic virtual reality simulators. Monitoring of residents' endoscopic progress seemed to be a key issue. Surgeons themselves underestimate their individual performance on ADEPT (mean subjective score of 6.1 vs mean objective score of 6.6). Self-reported performance on ADEPT is unreliable because confidence intervals between the VAS score and the ADEPT score overlap. Surgeons disagree on the validity of ADEPT. The mean score for validity was 5.8, ranging from 0 to 10 with almost equal distribution over the scale. Innate ability is established as surgeons' scores express high concordance between test run and true run, with 72.7% of the participants' true run score within one distance from the test run.

CONCLUSIONS

Surgeons cannot correctly predict their standardized individual test result on ADEPT. Performance on ADEPT reflects innate psychomotor ability along with improvement over runs. Surgeons are ambivalent in assessing the validity of ADEPT, irrespective of personal performance.

Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer

AIMS

In the treatment of patients with locally advanced primary or locally recurrent rectal cancer much attention is given to the oncological aspects. In long-term survivors, urogenital morbidity can have a large effect on the quality of life. This study evaluates the functional outcome after multimodality treatment in these patient groups.

PATIENTS AND METHODS

Between 1994 and August 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with multimodality treatment: i.e. high-dose preoperative external beam radiation therapy, followed by extended surgery and intraoperative radiotherapy. The medical records of the 121 patients were reviewed. To assess long-term urogenital morbidity, all patients still alive, with a minimum follow-up of 4 months, were asked to fill out a questionnaire about their voiding and sexual function. Seventy-six of the 79 currently living patients (96%) returned the questionnaire (median FU 14 months, range 4-60).

RESULTS

The questionnaire revealed identifiable voiding dysfunction as a new problem in 31% of the male and 58% of the female patients. In 42% of patients after locally advanced primary and 48% after locally recurrent rectal cancer treatment bladder dysfunction occurred. The preoperative ability to have an orgasm had disappeared in 50% of the male and 50% of the female patients, and in 45% of patients after locally advanced primary and in 57% after locally recurrent rectal cancer treatment.

CONCLUSION

Multimodality treatment for locally advanced primary and recurrent rectal cancer results in acceptable urogenital dysfunction if weighed by the risk of uncontrolled tumour progression. Long-term voiding and sexual function is decreased in half of the patients. Preoperative counselling of these patients on treatment-related urogenital morbidity is important.