YouTube as a Potential Training Resource for Laparoscopic Fundoplication

OBJECTIVE

To analyze the surgical proficiency and educational quality of YouTube videos demonstrating laparoscopic fundoplication (LF).

DESIGN

In this cross-sectional study, a search was performed on YouTube for videos demonstrating the LF procedure. The surgical and educational proficiency was evaluated using the objective component rating scale, the educational quality rating score, and total video quality score. Statistical significance was determined by analysis of variance, receiver operating characteristic curve, and odds ratio analysis.

RESULTS

A total of 71 videos were included in the study; 28 (39.4%) videos were evaluated as good, 23 (32.4%) were moderate, and 20 (28.2%) were poor. Good-rated videos were significantly longer (good, 22.0 ± 5.2min; moderate, 7.8 ± 0.9min; poor, 8.5 ± 1.0min; p = 0.007) and video duration was predictive of good quality (AUC, 0.672 ± 0.067; 95% CI: 0.541-0.802; p = 0.015). For good quality, the cut-off video duration was 7:42 minute. This cut-off value had a sensitivity of 67.9%, a specificity of 60.5%, and an odds ratio of 3.23 (95% CI: 1.19-8.79; p = 0.022) in predicting good quality. Videos uploaded from industrial sources and with a higher views/days online ratio had a higher objective component rating scale and total video quality score. In contrast, the likes/dislikes ratio was not predictive of video quality.

CONCLUSIONS

Many videos showing the LF procedure have been uploaded to YouTube with varying degrees of quality. A process for filtering LF videos with high surgical and educational quality is feasible by evaluating the video duration, uploading source, and the views/days online ratio. However, alternative videos platforms aimed at professionals should also be considered for educational purposes.

A new innovative laparoscopic fundoplication training simulator with a surgical skill validation system

PURPOSE

We developed and validated a specific laparoscopic fundoplication simulator for use with the objective endoscopic surgical skills evaluation system. The aim of this study was to verify the quality of skills of surgeons.

MATERIALS AND METHODS

We developed a 1-year-old infant body model based on computed tomography data and reproduced pneumoperitoneum model based on the clinical situation. The examinees were divided into three groups: fifteen pediatric surgery experts (PSE), twenty-four pediatric surgery trainees (PSN), and ten general surgeons (GS). They each had to perform three sutures ligatures for construction of Nissen wrap. Evaluate points are time for task, the symmetry of the placement of the sutures, and the uniformity of the interval of suture ligatures in making wrap. And the total path length and velocity of forceps were measured to assess bi-hand coordination.

RESULTS

PSE were significantly superior to PSN regarding total time spent (p < 0.01) and total path length (p < 0.01). GS used both forceps faster than the other groups, and PSN used the right forceps faster than the left forceps (p < 0.05). PSE were shorter with regard to the total path length than GS (p < 0.01). PSE showed most excellent results in the symmetry of the wrap among three groups.

CONCLUSION

Our new model was used useful to validate the characteristics between GS and pediatric surgeon. Both PSE and GS have excellent bi-hand coordination and can manipulate both forceps equally and had superior skills compared to PSN. In addition, PSE performed most compact and accurate skills in the conflicted operative space.

Effectiveness of short-term endoscopic surgical skill training for young pediatric surgeons: a validation study using the laparoscopic fundoplication simulator

PURPOSE

Pediatric surgeons require highly advanced skills when performing endoscopic surgery; however, their experience is often limited in comparison to general surgeons. The aim of this study was to evaluate the effectiveness of endoscopic surgery training for less-experienced pediatric surgeons and then compare their skills before and after training.

METHODS

Young pediatric surgeons (n = 7) who participated in this study underwent a 2-day endoscopic skill training program, consisting of lectures, box training and live tissue training. The trainees performed the Nissen construction tasks before and after training using our objective evaluation system. A statistical analysis was conducted using the two-tailed paired Student's t tests.

RESULTS

The time for task was 984 ± 220 s before training and 645 ± 92.8 s after training (p < 0.05). The total path length of both forceps was 37855 ± 10586 mm before training and 22582 ± 3045 mm after training (p < 0.05). The average velocity of both forceps was 26.1 ± 3.68 mm/s before training and 22.9 ± 2.47 mm/sec after training (p < 0.1). The right and left balance of suturing was improved after training (p < 0.05).

CONCLUSION

Pediatric surgery trainees improved their surgical skills after receiving short-term training. We demonstrated the effectiveness of our training program, which utilized a new laparoscopic fundoplication simulator.

Outcomes for trainees vs experienced surgeons undertaking laparoscopic antireflux surgery - is equipoise achieved?

BACKGROUND

There is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication.

METHOD

Patients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared.

RESULTS

One thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants.

CONCLUSION

The learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.

[The pig model for the laparoscopic antireflux surgery training]

The laparoscopic treatment of the Gastroesophageal Reflux Disease (GERD) includes antireflux surgery (AR) procedure which may be performed in an optimal functional manner. To achieve this target adequate training is mandatory for the surgical team. In the "Sf. John" Laparoscopic Training Center (Bucharest, Romania) we have studied the advantages and disadvantages of a pig model for training in laparoscopic antireflux surgery. 16 pigs (20-25 kg) were included in this study. The results of this study included: 1. a complete description of the laparoscopic Nissen fundoplication in pigs and 2. the evaluation of the pig model for laparoscopic AR surgery. The use of pigs with anesthesia as a training model for laparoscopic AR surgery present certain advantages for the trainees: clear and humans similar anatomy, real surgical conditions (OR, equipment, instruments, lived animals).

Laparoscopic Nissen fundoplication

This article will focus on a review of the history and current status of laparoscopic Nissen fundoplication for gastroesophageal reflux disease in infants and children.

METHODS

Review of the available current literature concerning laparoscopic Nissen fundoplication in infants and children. Information regarding the current approach for gastroesophageal reflux disease (GERD) in children will be reviewed in addition to the indications for surgical antireflux operation; application and safety of laparoscopy; and the outcomes of laparoscopic Nissen fundoplication in both normal and neurologically impaired children. Finally, the reported data regarding the learning curve in performing the procedure and short-term and long-term complications of laparoscopic Nissen procedure will be discussed. Compared to open antireflux operations, the laparoscopic Nissen approach in infants and children is safe; durable; provides better cosmetic results; and allows for earlier institution of feedings. The established ''learning curve'' for safe and competent performance of laparoscopic Nissen fundoplication is from 25-50 cases. Neurologically impaired patients may indeed benefit from a minimally invasive approach to GERD and enteral access related to improvement of quality of life. Better nutrition and decreased complications related to malnutrition and a decreased incidence of aspiration pneumonia may be realized for these patients. The laparoscopic Nissen approach to GERD is well accepted and widely utilized in infants and children. Prospective randomized multi-institutional studies will be necessary to accurately determine whether this therapeutic approach to GERD in both neurologically impaired and neurologically normal children is the superior option compared to continued medical therapy or gastrojejunal feeding tube approaches to GERD.

The extended learning curve for laparoscopic fundoplication: a cohort analysis of 400 consecutive cases

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients.

Web-Based Live Telesurgery for Minimally Invasive Procedures in Children as an Educational Tool

Three surgeries--a laparoscopic Nissen fundoplication, a thoracoscopic left lower lobectomy, and a laparoscopically assisted pull-through for imperforate anus--were broadcast live over the internet. Pediatric surgeons and appropriate societies were notified of the broadcasts by e-mail. Viewers registered on-line at no cost. The procedures could be viewed from any computer connected to the internet. There was a surgeon and on-site moderator for each procedure and viewers could ask questions in real time via e-mail. The three surgeries were archived on the web for later viewing. The broadcasts were transmitted without problem. There were over 8500 preliminary hits at the web site, from 49 countries. By report, many sites had multiple viewers. As of April 2006 there have been over 19,000 hits and 5600 viewers have registered to watch the archived video. Web-based broadcasts appear to be an efficient way for sharing surgical experience and may be a way to expand surgeon education in select cases, especially in an era of dispersal of index cases, work hour restrictions, and evolving technologies. A network of pediatric programs linked via the web might provide an important educational tool.

Simulator training for laparoscopic suturing using performance goals translates to the operating room

BACKGROUND

The purpose of this study was to develop a performance-based laparoscopic suturing curriculum using simulators and to test the effectiveness (transferability) of the curriculum.

STUDY DESIGN

Surgical residents (PGY1 to PGY5, n = 17) proficient in basic skills, but with minimal laparoscopic suturing experience, were enrolled in an IRB-approved, randomized controlled protocol. Subjects viewed an instructional video and were pretested on a live porcine laparoscopic Nissen fundoplication model by placing three gastrogastric sutures tied in an intracorporeal fashion. A blinded rater objectively scored each knot based on a previously published formula (600 minus completion time [sec] minus penalties for accuracy and knot integrity errors). Subjects were stratified according to pretest scores and randomized. The trained group practiced on a videotrainer suturing model until an expert-derived proficiency score (512) was achieved on 12 attempts. The control group received no training. Both the trained and control groups were posttested on the porcine Nissen model.

RESULTS

For the training group, mean time to demonstrate simulator proficiency was 151 minutes (range 107 to 224 minutes) and mean number of attempts was 37 (range 24 to 51 attempts). Both the trained and control groups demonstrated significant improvement in overall score from baseline. But the trained group performed significantly better than the control group at posttesting (389 +/- 70 versus 217 +/- 140, p < 0.001), confirming curriculum effectiveness.

CONCLUSIONS

These data suggest that training to a predetermined expert level on a videotrainer suture model provides trainees with skills that translate into improved operative performance. Such curricula should be further developed and implemented as a means of ensuring proficiency.

An inexpensive ex-vivo porcine laparoscopic Nissen fundoplication training model

BACKGROUND

We recently implemented the use of an ex-vivo porcine model to teach residents the fundamentals of performing a laparoscopic Nissen fundoplication.

METHODS

Residents were trained using intact porcine esophagus, stomach, and spleen placed in a standard video-trainer. They were later asked to complete a survey containing a course evaluation.

RESULTS

Sixteen residents (R1-R4) completed the survey. They agreed that (1) the exercise was a valuable use of their limited time, (2) repeating the exercise will be of additional benefit, (3) it will improve their ability to perform or assist in an actual case in the OR, and (4) the surgical principles learned using the model will transfer to other laparoscopic cases. Significant subjective improvements were reported in resident comfort level in assisting in or performing a laparoscopic Nissen fundoplication.

CONCLUSIONS

The use of an inexpensive ex-vivo porcine training model increases resident comfort level in performing a Nissen fundoplication in the operating room.

Animate advanced laparoscopic courses improve resident operative performance

BACKGROUND

The use of animate training laboratories have been touted as an important part of a surgical resident's training. This study determines if there was any benefit in resident performance and whether that benefit persisted.

METHODS

Twelve senior surgical residents attended a course in advanced laparoscopy with didactic and laboratory components. The residents' skills were tested by having them perform a laparoscopic fundoplication before, immediately after, and 6 months after the course. The procedure was videotaped, and divided into stages that were timed and scored by a single, masked observer.

RESULTS

Overall performance score was 35.7 +/- 2.5 for the pretest, improving to 16.5 +/- 1.2 (P <0.05) immediately after the course, and 23.7 +/- 5.1 (P <0.05) at 6 months. Significant improvements were seen with trocar insertion, crural closure, division of short gastric arteries, and fundoplication.

CONCLUSIONS

The data presented demonstrate significant and persistent improvement in laparoscopic operative skills as a result of focused laboratory skill training.

Does the learning phase influence the late outcome of patients with gastroesophageal reflux disease after laparoscopic fundoplication?

BACKGROUND

Although the degree of surgical experience clearly affects early outcome of laparoscopic antireflux surgery, its influence on long-term results has not been fully evaluated. The aim of this study was to verify whether the initial experience in laparoscopic antireflux surgery could also influence the late clinical outcome.

METHODS

Clinical and endoscopic findings, together with quality of life, of the first 25 patients successfully submitted to laparoscopic fundoplication were compared with those of 25 matched controls operated on later.

RESULTS

At more than 2 years', follow-up, reflux symptoms, endoscopic findings, use of antisecretory drugs, side effects, and quality of life were not significantly different in both groups, despite a high occurrence of major anatomical failures (three vs one) in the first set of patients.

CONCLUSION

The late clinical outcome of patients with gastroesophageal disease operated on during the learning phase or after gaining experience is not different, provided the surgeon is adequately trained in laparoscopic surgery.

When can I be proficient in laparoscopic surgery? A systematic review of the evidence

PURPOSE

The aim of this study was to quantify the learning curve in laparoscopic surgery.

METHODS

A systematic review of the evidence using a defined search strategy (PubMed, Medline, OVID, Embase, ERIC, Cochrane databases) was performed. Studies without statistical evaluation of the learning curve and opinion articles were excluded. The authors analysed 7 common laparoscopic procedures: cholecystectomy, fundoplication, colectomy, herniorrhaphy, splenectomy, appendicectomy, and pyloromyotomy. The "initial" and "late" stages of experience were compared with regards to the following outcome measures: operating time, conversion rate, complication rate, and length of stay in hospital.

RESULTS

A total of 3,641 articles were reviewed, of which, 37 (25,777 patients) fulfilled the entry criteria (5 in children). In all articles, the definition of proficiency was subjective, and the number of operations required to reach it was highly variable. There were improvements in all 4 outcome measures for cholecystectomy, fundoplication, colectomy, herniorrhaphy, and splenectomy between the "initial" and "late" experience. No data were available for the learning curves in appendicectomy or pyloromyotomy.

CONCLUSIONS

The number of procedures required to reach proficiency in laparoscopic surgery has not been defined clearly. These findings are important for training, ethical and medico-legal issues.

Laparoscopic fundoplication: learning curve and patient satisfaction

AIMS

Laparoscopic fundoplication is now accepted as the optimal surgical option for the management of selected cases of gastro-oesophageal reflux disease. The principal aim of this study was to evaluate the learning curve experience of two consultant surgeons in the technique of laparoscopic fundoplication (LF). Additional variables assessed were total number of cases, preoperative investigations, conversion rate, duration of operation, ASA grade, morbidity, mortality, necessity of further procedures, and patient satisfaction rate.

PATIENTS AND METHODS

Retrospective case-note analysis of all adult patients who underwent fundoplication under the care of two consultant general surgeons over a 3-year period from January 1997 to December 1999.

RESULTS

A total of 61 patients were included, 31 males and 30 females, with a median age of 46 years (range, 21-73 years). Of the patients, 90% were either ASA 1 or 2. The mean time for which the 24-h pH < 4 was 20.5% (95% CI, 15.3-25.7). Of the 61 patients, 6 were operated on by open technique, for medical reasons and previous abdominal procedures. Out of the remaining 55 patients, 13 had to be converted (23.6%). Mean operating times were 120 min for LF, 85 min for open operation and 142 min for LF plus conversion. There was a significant decline in conversion rate with time (P < 0.002). Mortality was nil. One patient had a perforation of the cricopharyngeus secondary to insertion of a bougie. The mean length of hospital stay following the laparoscopic technique was 3.4 days compared to 8.7 days following the open technique. Overall, 59 patients (96%) were happy with the result, and the operation failed in 2 patients. Five patients (8%) needed endoscopic dilatation in the first few weeks after the operation.

CONCLUSIONS

The results show that LF is a safe procedure, takes longer than open procedure, and has an acceptable morbidity. Experience with the technique reduces the need for conversion. The mean length of hospital stay is significantly less and there is a high level of patient satisfaction.

The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992-1997

BACKGROUND

The population level frequency of adverse events after antireflux procedures and its relationship to surgical experience has not been well studied.

STUDY DESIGN

Two parallel retrospective, population-based cohort studies were conducted using the Washington State discharge database and the United States Health Care Utilization Project (HCUP) database. All adult patients assigned ICD-9 procedure codes for antireflux surgery from 1992 to 1997 were included. The frequency of case fatality, splenectomy, and esophageal injury was measured. In Washington State, the relationship of adverse outcomes to the cumulative number of procedures performed by a given surgeon (case-order) was determined.

RESULTS

Nationwide, an estimated 86,411 patients underwent antireflux surgery between 1992 and 1997. Splenectomy was performed in 2.3%, suture of esophageal laceration in 1.1%, and in-hospital death occurred in 0.8%. Adverse events were significantly more likely when procedures at case-order less than or equal to 15 (median) were compared with those at case-order greater than 15. As case-order increased by 1, the risk of death decreased by 1.7% (p = 0.001), and the risk of splenectomy and injury repair decreased by 1.6% (p = 0.001). If performed at case-order less than 15, the odds ofsplenectomy were 2.7 times, esophageal laceration repair 2.3 times, and death 5.6 times greater than the odds of adverse outcomes for procedures performed at later case-orders.

CONCLUSIONS

On a national level, morbidity and mortality associated with antireflux surgery performed in the 1 990s was quite low, but was somewhat higher than suggested by case series. Surgical experience with the procedure was linked to better outcomes.

[Follow-up results and learning curve in laparoscopic gastrofundoplications]

AIM OF THE STUDY

To analyze the postoperative results and the learning curve of laparoscopic gastrofundoplications by postoperative clinical monitoring of consequences and self-evaluation of complaints 12 months after surgery.

METHODS

One hundred patients (58 female and 42 male) were operated at the Department of Surgery, Hospital of Kaunas University of Medicine, from April 1998 to January 2001 because of hiatal hernias, complicated with gastroesophageal reflux (in 59 cases sliding axial non-fixed, in 38 cases sliding axial fixed, and in 3 cases paraesophageal hernias were found). 89 Nissen and 11 Toupet fundoplications were performed. Patients were distributed into five groups (20 patients in each). Operation time, number of postoperative complications, postoperative hospital stay were analyzed.

RESULTS

The mean operation time was 198 min in the 1 st group, 105 min in the 2 nd group, 110 min in the 3 rd group, 124 min in the 4 th group and 120 min in the 5 th group. Conversion to laparotomy was necessary in two cases (the 1 st and the 2 nd groups). The number of postoperative complications decreased from 5 in the 1 st group to 2 in the 2 nd group, and to 1 in the 3 rd and 4 th groups; no complications were noted in the 5 th group. According patient's opinion, successful results were received in 87 %.

CONCLUSIONS

Laparoscopy is a good approach for surgical management of hiatal hernias complicated with gastroesophageal reflux, but laparoscopic gastrofundoplication needs advanced skills to be performed safely. The learning curve in terms of operation time covered initial 20 procedures and remained stable afterwards, the number of postoperative complications decreased after initial 20 operations, but dangerous complications occurred until the 60 th procedure. Other conventional elective surgical procedures of medium extent can be successfully performed simultaneously with laparoscopic fundoplication without affecting the outcome. The true learning curve of laparoscopic fundoplication can be drawn by careful follow-up and analysis of long-term postoperative results; this enables to improve operative techniques.