A systematic review of low-cost laparoscopic simulators

BACKGROUND

Opportunities for surgical skills practice using high-fidelity simulation in the workplace are limited due to cost, time and geographical constraints, and accessibility to junior trainees. An alternative is needed to practise laparoscopic skills at home. Our objective was to undertake a systematic review of low-cost laparoscopic simulators.

METHOD

A systematic review was undertaken according to PRISMA guidelines. MEDLINE/EMBASE was searched for articles between 1990 and 2014. We included articles describing portable and low-cost laparoscopic simulators that were ready-made or suitable for assembly; articles not in English, with inadequate descriptions of the simulator, and costs >£1500 were excluded. Validation, equipment needed, cost, and ease of assembly were examined.

RESULTS

Seventy-three unique simulators were identified (60 non-commercial, 13 commercial); 55 % (33) of non-commercial trainers were subject to at least one type of validation compared with 92 % (12) of commercial trainers. Commercial simulators had better face validation compared with non-commercial. The cost ranged from £3 to £216 for non-commercial and £60 to £1007 for commercial simulators. Key components of simulator construction were identified as abdominal cavity and wall, port site, light source, visualisation, and camera monitor. Laptop computers were prerequisite where direct vision was not used. Non-commercial models commonly utilised retail off-the-shelf components, which allowed reduction in costs and greater ease of construction.

CONCLUSION

The models described provide simple and affordable options for self-assembly, although a significant proportion have not been subject to any validation. Portable simulators may be the most equitable solution to allow regular basic skills practice (e.g. suturing, knot-tying) for junior surgical trainees.

Using Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial

BACKGROUND/OBJECTIVE

There is a severe surgical workforce shortage in Rwanda. Innovative educational tools must be introduced to train more residents and increase surgical capacity. Touch Surgery (TS) is a smartphone application that offers trainees the opportunity to practice operations; however, its effect is unknown in low- and middle-income countries. Our objectives were to determine the training effect of TS and its feasibility for use in surgery education in a low-resource setting.

DESIGN

We performed a randomized control trial of University of Rwanda surgical residents. Participants were blocked by postgraduate year and randomized to textbook or TS for learning tendon repair surgical technique. After the learning period, participants performed a tendon repair simulation, evaluated by blinded expert raters. Presimulation and postsimulation questionnaires tested their knowledge of tendon repair.

SETTING

The study was conducted at the simulation center of the University Teaching Hospital of Kigali, a tertiary referral and teaching hospital.

PARTICIPANTS

The study included University of Rwanda surgery residents. A total 27 of 51 surgery residents (52.94%) were enrolled. Participating residents represented the following specialties: general surgery (51.85%), orthopedics (40.74%), and urology (7.41%).

RESULTS

TS users scored 89.7% on tendon repair simulation, compared to textbook users who scored 63.4% (p < 0.001). Postsimulation questionnaires showed a significant improvement in cognitive scores for TS users (38.6%, p < 0.001), as compared to nonsignificant improvement for textbook users (15.9%, p = 0.304). About 92.3% of TS users reported that TS represents a useful training tool, and 61.5% reported that it would be a good or very good required part of the curriculum.

CONCLUSIONS

TS is a useful tool to improve both technical skills and knowledge of tendon repair procedure steps; however, its role may be limited to a supplemental tool as it does not improve the theoretical knowledge. TS has the potential to be implemented in a surgical academic curriculum in low- and middle-income countries.

Construct Validity, Assessment of the Learning Curve, and Experience of Using a Low-Cost Arthroscopic Surgical Simulator

OBJECTIVE

We have developed a low-cost, portable shoulder simulator designed to train basic arthroscopic skills. This study aimed to establish the construct validity of the simulator by determining which parameters discriminated between experience levels and to assess the experience of using the simulator.

DESIGN

Participants were given an introductory presentation and an untimed practice run of a 6-step triangulation task using hooks and rubber bands. A total of 6 consecutive attempts at the task were timed, and the number of times the participant looked at their hands during the task was recorded. Participants then completed a questionnaire on their experience of using the simulator.

SETTING

St George's Hospital, London and the South West London Elective Orthopaedic Centre, Surrey.

PARTICIPANTS

Medical students, trainee doctors and surgeons, and consultant surgeons were approached to use the simulator. Participation was voluntary and nonincentivized. In total, 7 orthopedic consultants, 12 trainee doctors (ranging from foundation year 1 to clinical fellow post-Certificate of Completion of Training), and 9 medical students were recruited.

RESULTS

The average time for medical students to complete the task was 161 seconds, compared to 118 seconds for trainees, and 84 seconds for consultants. The average fastest time for medical students was 105 seconds, 73 seconds for trainees, and 52 seconds for consultants. Students were significantly slower than trainees (p = 0.026) and consultants (p = 0.001). However, times did not differ significantly between trainees and consultants. Consultants looked at their hands 0.7 times on average during the task compared with 2.8 and 3.4 times for trainees and students, respectively. More than 95% of participants found the exercise interesting and agreed or strongly agreed that the simulator was easy to use, easily portable, and well designed and constructed.

DISCUSSION

This study has established construct validity of the simulator by demonstrating the ability to distinguish between surgical experience levels. The learning curve shows improvement in individuals with or without arthroscopic or surgical experience. Simulation is becoming increasingly important in the training of medical students and surgical trainees; this study has established that low-cost portable arthroscopic box trainers may play a significant role.

A Simulation Curriculum for Management of Trauma and Surgical Critical Care Patients

BACKGROUND

Expectations continue to rise for residency programs to provide integrated simulation training to address clinical competence. How to implement such training sustainably remains a challenge. We developed a compact module for first-year surgery residents integrating theory with practice in high-fidelity simulations, to reinforce the preparedness and confidence of junior residents in their ability to manage common emergent patient care scenarios in trauma and critical care surgery.

METHODS

The 3-day module features a combination of simulated patient encounters using standardized patients and electronic manikins, didactic sessions, and hands-on training. Manikin-based scenarios developed in-house were used to teach trauma and critical care management concepts and skills. Separate scenarios in collaboration with the regional organ donation program addressed communication in difficult situations such as brain death. Didactic material based on contemporary evidence, as well as skills stations, was developed to complement the scenarios. Residents were surveyed before and after training on their confidence in meeting the 14 learning objectives of the curriculum on a 5-point Likert scale.

RESULTS

Data from 15 residents who underwent this training show an overall improvement in confidence across all learning objectives defined for the module, with confidence scores before to after training improving significantly from 2.8 (σ = 0.85, median = 3) to 3.9 (σ = 0.87, median = 4) of 5, p < 0.001. Although female residents reported higher posttraining confidence scores compared with male residents (average 4.2 female vs 3.8 male, p = 0.002), there were no other significant differences in confidence scores or changes to scores owing to resident sex or program status (categorical or preliminary).

CONCLUSION

We successfully implemented a multimodal simulation-based curriculum that provides skills training integrated with the clinical context of managing trauma and critical care patients, simultaneously addressing a range of clinical competencies. Results to date show consistent improvement in residents' confidence in meeting learning objectives. Development of the curriculum continues for sustainability, as well as measures to embed objective evaluations of resident competence.

Health Care Simulation in Developing Countries and Low-Resource Situations

INTRODUCTION

Health care simulation, as a complement to traditional learning, has spread widely and seems to benefit both students and patients. The teaching methods involved in health care simulation require substantial human, logistical, and financial investments that might preclude their spread in developing countries. The aim of this study was to analyze the health care simulation experiences in developing countries.

METHODS

A comprehensive literature search was performed from January 2000 to December 2016. Articles reporting studies on educational health care simulation in developing countries were included.

RESULTS

In total, 1161 publications were retrieved, of which 156 were considered eligible based on title and abstract screening. Thirty articles satisfied our predefined selection criteria. Most of the studies were case series; 76.7% (23/30) were prospective and comparative, and five were randomized trials. The development of dedicated task trainers and telesimulation were the primary techniques assessed. The retrieved studies showed encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly tested on the training tool itself. Two of the tools have been proven to be construct valid with clinical impact.

CONCLUSION

Health care simulation in developing countries seems feasible with encouraging results. Higher-quality studies are required to assess the educational value and promote the development of health care simulation programs.

Effectiveness of a Low-Cost Drilling Module in Orthopaedic Surgical Simulation

INTRODUCTION

Financial pressures and resident work hour regulations have led to adjunct means of resident education such as surgical simulation. The purpose of this study is to determine the effectiveness of a hands-on training session in orthopaedic drilling technique educational model during a surgical simulation on reducing drill plunging depth and to determine the effectiveness of senior residents teaching a hands-on training session in orthopaedic drilling technique.

METHODS

A total of 13 participants (5 orthopaedic interns and 8 medical students) drilled until they penetrated the far cortex of a synthetic bone model and the plunging depth (PD) was measured. They were then randomized and underwent an education session with an attending orthopaedic surgeon or a senior resident. Next, the subjects drilled again with the PD being calculated. The preeducational and posteducational session were compared to determine if there was any improvement in PD and if there was a difference between educators. The cost of the model was also determined.

RESULTS

The mean maximum PD and mean PD before the education session was 1.58 (1.40-2.10) and 1.50cm (1.36-1.76), respectively. Following the educational session, the mean maximum PD and mean PD were 0.53 (0.42-0.75) and 0.50cm (0.40-0.72), respectively. These were both significantly lower than before the education session (p <0.05). After the educational session taught by the attending versus the session taught by the resident, the mean maximum PD was 0.59 (0.42-0.75) and 0.49cm. (0.45-0.75), respectively (p = 0.44). After the educational session taught by the attending versus the session taught by the resident, the mean PD was 0.54 (0.40-0.72) and 0.47cm. (0.40-0.65), respectively (p = 0.44). The cost of the station per participant was $5.44.

CONCLUSION

This study demonstrated a significant reduction in drilling PD with use of a low-cost training model and a formal didactic and skills session on proper drilling technique that can effectively be led by senior residents.

A cost-effectiveness analysis of self-debriefing versus instructor debriefing for simulated crises in perioperative medicine in Canada

PURPOSE

High-fidelity simulation training is effective for learning crisis resource management (CRM) skills, but cost is a major barrier to implementing high-fidelity simulation training into the curriculum. The aim of this study was to examine the cost-effectiveness of self-debriefing and traditional instructor debriefing in CRM training programs and to calculate the minimum willingness-to-pay (WTP) value when one debriefing type becomes more cost-effective than the other.

METHODS

This study used previous data from a randomized controlled trial involving 50 anesthesiology residents in Canada. Each participant managed a pretest crisis scenario. Participants who were randomized to self-debrief used the video of their pretest scenario with no instructor present during their debriefing. Participants from the control group were debriefed by a trained instructor using the video of their pretest scenario. Participants individually managed a post-test simulated crisis scenario. We compared the cost and effectiveness of self-debriefing versus instructor debriefing using net benefit regression. The cost-effectiveness estimate was reported as the incremental net benefit and the uncertainty was presented using a cost-effectiveness acceptability curve.

RESULTS

Self-debriefing costs less than instructor debriefing. As the WTP increased, the probability that self-debriefing would be cost-effective decreased. With a WTP ≤Can$200, the self-debriefing program was cost-effective. However, when effectiveness was priced higher than cost-savings and with a WTP >Can$300, instructor debriefing was the preferred alternative.

CONCLUSION

With a lower WTP (≤Can$200), self-debriefing was cost-effective in CRM simulation training when compared to instructor debriefing. This study provides evidence regarding cost-effectiveness that will inform decision-makers and clinical educators in their decision-making process, and may help to optimize resource allocation in education.

Training on an inexpensive tablet-based device is equally effective as on a standard laparoscopic box trainer: A randomized controlled trial

BACKGROUND

The aim of the study was to assess whether an inexpensive tablet-based box trainer (TBT) is at least equally effective compared with a standard box trainer (SBT) to learn basic laparoscopic skills (BLS). BLS training outside the operating room has been shown to be beneficial for surgical residency. However, simulation trainers are expensive and are not consistently available in all training centers. Therefore, TBT and other homemade box trainers were developed.

METHODS

Medical students were randomized to either a TBT or an SBT and trained 4 fundamentals of laparoscopic surgery (FLS) tasks for 1 hour twice a week for 4 weeks. A baseline test before the training period and a posttraining test were performed. All students then completed a questionnaire to assess their assigned box trainer. The primary outcome measure was the improvement in total test scores. Improvement in the scores for the 4 individual FLS tasks was chosen as a secondary outcome measure.

RESULTS

Thirty-two medical students were recruited. Baseline test scores did not differ significantly between the groups. BLS improved significantly in both groups for the total score and for all 4 tasks separately. Participants in the TBT group showed a greater improvement of total scores than those in the SBT group, although this did not reach statistical significance; noninferiority of the TBT compared with the SBT concerning the improvement of total scores could be demonstrated. Regarding the individual FLS tasks, noninferiority of the TBT could be shown for the pattern cutting and the suturing with intracorporeal knot-tying task. The acceptance of the TBT by the trainees was very good.

CONCLUSION

Learning BLS on a homemade TBT is at least equally effective as on an SBT, with the advantage of being very cost saving. Therefore, this readily available box trainer may be used as an effective, flexible training device outside the operating room to improve accessibility to simulation training.

A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation

INTRODUCTION

With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU.

METHODS

The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1-10 Likert scale, with 10 "completely confident"). Pre-post responses were compared by two-tailed paired t test.

RESULTS

We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05).

CONCLUSIONS

We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.

Air Medical Simulation Training: A Retrospective Review of Cost and Effectiveness

OBJECTIVE

Simulation training is an integral part of the training of medical personnel. However, there are limited data on the use of simulation in the training of helicopter emergency medical services (HEMS).

METHODS

In this study, we retrospectively compared the number of orientation flights needed to be released to a full crewmember and the cost of training in an air medical flight academy before and after implementation of a high-fidelity air medical simulator. A total of 13 participants in the air medical services flight academy were analyzed. Four of these participants went through the standard academy. Nine participants went through the standard academy but had additional training using the simulator.

RESULTS

There was no statistical difference in the number of orientation flights before release from training (P = .35). Also, although there was a trend that the simulator decreased the overall cost of training, there was no significant difference between the groups (P = .16).

CONCLUSION

This study found that the use of a high-fidelity simulator when training HEMS personnel does not significantly reduce the number of orientation flights needed to become a full crewmember. There was a trend toward a significant reduction in the total cost of training.

Optimizing training cost-effectiveness of simulation-based laparoscopic inguinal hernia repairs

BACKGROUND

Motor learning theory suggests that highly complex tasks are probably best trained under conditions of part task (PT), as opposed to whole-task (WT) training. Within PT, random practice of tasks has been shown to lead to improved skill retention and transfer.

METHODS

General surgery residents were equally randomized to PT vs WT, mastery learning type, and simulation-based training of laparoscopic inguinal hernia repair. Training time and resources used to reach mastery (skill acquisition), performance at 1-month testing (skill retention), and intraoperative time and performance scores (skill transfer) were compared.

RESULTS

Forty-four general surgery trainees were randomized. All residents achieved mastery benchmarks. Trainees in the PT group achieved mastery on average 17 minutes faster (60.2 ± 23.8 vs 77.1 ± 24.8 minutes, P = .02, saving 6.2 instructor hours), used fewer material resources (curricular cost savings of $2,380 or $121 per learner), and were more likely to retain mastery level performance at 1-month retention testing (59% vs 22.7% P = .03). No differences in intraoperative performance were encountered.

CONCLUSIONS

For laparoscopic inguinal hernia repair, random PT simulation-based training seems to be more cost-effective, compared with WT training.

Low-Cost Training Simulator for Open Dismembered Pyeloplasty: Development and Face Validation

PURPOSE

Surgical simulation has benefited from a surge in interest over the last decade because of the increasing need for a change in the traditional apprenticeship model of teaching surgery. Open surgery for ureteropelvic junction (UPJ) poses unique training challenges owing to smaller workspaces, and finer sutures used that require increased surgical dexterity when compared with adult analogues. We describe the development and face validation of a low-cost training simulator for open dismembered pyeloplasty.

MATERIALS AND METHODS

The simulator is built with A4 Kraft envelopes, catheter tip syringe filled with 30mL of air, tape, 260 modeling balloon, and 11-in party balloon. Evaluation of the device is based on an evaluation form including 11 items on a 5-point Likert-type scale. Thirty-one departments of pediatric surgery in France were contacted and received a pack containing 4 to 10 devices, already set up and ready for use, a tutorial and an evaluation form. Candidates were stratified according to their level of expertise.

RESULTS

A total of 180 devices were sent. Procedures on the device were performed 118 times (65%) by expert surgeons (n = 44), fellows (n = 25), and residents (n = 49). Statistically significant difference was noted for 4 items (anatomy, model exposition, UPJ resection, and difficulty) for the 3 levels of expertise. The global score evaluation for realistic items, face validity, and usability was 4.2 (range: 1-5).

CONCLUSION

This low-cost model is evaluated as an efficient tool for UPJ teaching and training. It shows promise as an educational tool.

Validation of a Low-Cost Do-It-Yourself Model for Neonatal Thoracoscopic Congenital Diaphragmatic Hernia Repair

OBJECTIVE

We aimed to develop and validate a low cost, do-it-yourself model for neonatal thoracoscopic congenital diaphragmatic hernia (CDH).

DESIGN

Volunteers with varying skills in neonatal minimally invasive surgery tested and evaluated the model simulating a neonatal thoracoscopic CDH repair. The model was built from ordinary materials purchased in a dime store: a small food container, a neoprene band simulating a diaphragm, an inflated balloon simulating a spleen, a tissue chord simulating intestine, and a body wash sponge simulating a collapsed lung. The evaluation comprised 3 sets of 5-point grading scale concerning appearance, necessary maneuvers, and ability to generate skills. Bowel reduction and suture efficacy was verified for each test.

SETTING

Minimally invasive surgery simulation room at Pediatric Surgery Department of Hospital Universitario de Vall d'Hebron, Barcelona, Spain.

PARTICIPANTS

Volunteer residents and specialists of pediatric surgery.

RESULTS

Bowel reduction was possible in every test, with 1 spleen rupture, 1 bowel entrapment, and 2 inappropriate sutures due to tension. Most volunteers considered the general endoscopic vision (63.2%), external and internal dimensions (both 89.5%) to be highly similar; bowel reduction (68.4%) and diaphragm's manipulation and suture (57.9%) to be highly or very highly similar. Regarding its ability to generate skills, most considered it to be very or extremely useful concerning: camera handling (52.6%), working in small spaces and suture (both 100%), and tissue handling (63.2%). The least liked features were the colors and the diaphragm's tension. The size, portability, and the reproducibility were the most liked features.

CONCLUSIONS

We consider this low cost and easily reproducible model to be realistic enough for CDH repair training, having the potential to be adapted for other simulations.

Paediatric cardiopulmonary resuscitation training program in Latin-America: the RIBEPCI experience

BACKGROUND

To describe the design and to present the results of a paediatric and neonatal cardiopulmonary resuscitation (CPR) training program adapted to Latin-America.

METHODS

A paediatric CPR coordinated training project was set up in several Latin-American countries with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The program was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching. Instructors from each country participated in the development of the next group in the following country. Paediatric Basic Life Support (BLS), Paediatric Intermediate (ILS) and Paediatric Advanced (ALS) courses were organized in each country adapted to local characteristics.

RESULTS

Five Paediatric Resuscitation groups were created sequentially in Honduras (2), Guatemala, Dominican Republican and Mexico. During 5 years, 6 instructors courses (94 students), 64 Paediatric BLS Courses (1409 students), 29 Paediatrics ILS courses (626 students) and 89 Paediatric ALS courses (1804 students) were given. At the end of the program all five groups are autonomous and organize their own instructor courses.

CONCLUSIONS

Training of autonomous Paediatric CPR groups with the collaboration and scientific assessment of an expert group is a good model program to develop Paediatric CPR training in low- and middle income countries. Participation of groups of different countries in the educational activities is an important method to establish a cooperation network.

Simulation-Based Arthroscopic Skills Using a Spaced Retraining Schedule Reduces Short-Term Task Completion Time and Camera Path Length

PURPOSE

To investigate whether acquiring basic knee arthroscopic skills via a spaced retraining schedule could prevent skills deterioration and achieve further skills improvement.

METHODS

In the learning phase, 16 residents with no previous hands-on experience in practicing arthroscopic skills were asked to perform basic arthroscopic tasks on a simulator until they attained perfect scores in each task. Immediately after completing the learning phase, a pretest was performed to assess their performance. Next, they were randomly assigned into 2 groups. The spaced retraining group, which undertook a spaced repetitive training phase with a fixed-time interval, returned on days 2, 4 and 6 to repeat the same tasks for 20 minutes per day, whereas the control group did nothing. On day 7, all participants performed a posttest. A 2 × 2 mixed analysis of variance model was used for statistical analysis.

RESULTS

Significant differences between the 2 groups were found in task completion time (P = .003) and camera path length (P = .043) but not cartilage injury (P = .186). Residents in the spaced retraining group decreased their task completion time (163.2 ± 23.9 seconds) whereas the task time in the control group increased (351.3 ± 25.5 seconds). The same pattern was found with the camera path length.

CONCLUSIONS

Implementing a spaced retraining schedule in 1 week resulted in a reduced task completion time and camera path length but no significant reduction in cartilage injury. It appears that introducing a spaced retraining schedule to retain arthroscopic skills acquired through massed learning may be advantageous.

CLINICAL RELEVANCE

In consideration of the training time available to residents and the trend toward massed learning, this spaced retraining schedule may offer a cost-effective and convenient way for residents to maintain and improve their basic arthroscopic skills with no significant increase in time invested.

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda

BACKGROUND

The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty.

METHODS

Five training models were created for use in a low-middle income country setting and implemented during on-site courses with Rwandan general surgery residents. A website <http://thoracicsurgeryeducation.com> was created as a supplement to the on-site teaching. All participants completed a course knowledge assessment before and after the simulation and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants' responses.

RESULTS

Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence, defined as moderate to complete on a Likert scale, for all simulated thoracic procedures (p < 0.05). The overall mean knowledge assessment score improved from 42.5% presimulation to 78.6% postsimulation, (p < 0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement, except for ruptured diaphragm repair (p = 0.45).

CONCLUSIONS

General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.

A Simple and Low-cost Drilling Simulator for Training Plunging Distance Among Orthopedic Surgery Residents

OBJECTIVE

Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth.

DESIGN, SETTING, PARTICIPANTS

This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58), and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 "senior residents" (3+ years) and the 7 "junior residents" during a training session. Measurements were taken again 2 weeks following the training session.

RESULTS

Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs. 5.28 mm, respectively, p < 0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents.

CONCLUSIONS

This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

A comparison of a homemade central line simulator to commercial models

BACKGROUND

Simulation is quickly becoming vital to resident education, but commercially available central line models are costly and little information exists to evaluate their realism. This study compared an inexpensive homemade simulator to three commercially available simulators and rated model characteristics.

MATERIALS AND METHODS

Seventeen physicians, all having placed >50 lines in their lifetime, completed blinded central line insertions on three commercial and one homemade model (made of silicone, tubing, and a pressurized pump system). Participants rated each model on the realism of its ultrasound image, cannulation feel, manometry, and overall. They then ranked the models based on the same variables. Rankings were assessed with Friedman's and post hoc Conover's tests, using alphas 0.05 and 0.008 (Bonferroni corrected), respectively.

RESULTS

The models significantly differed (P < 0.0004) in rankings across all dimensions. The homemade model was ranked best on ultrasound image, manometry measurement, cannulation feel, and overall quality by 71%, 67%, 53%, and 77% of raters, respectively. It was found to be statistically superior to the second rated model in all (P < 0.003) except cannulation feel (P = 0.134). Ultrasound image and manometry measurement received the lowest ratings across all models, indicating less realistic simulation. The cost of the homemade model was $400 compared to $1000-$8000 for commercial models.

CONCLUSIONS

Our data suggest that an inexpensive, homemade central line model is as good or better than commercially available models. Areas for potential improvement within models include the ultrasound image and ability to appropriately measure manometry of accessed vessels.

Process of medical simulator development: An approach based on personal experience

With increasing demand for simulators from the healthcare community and increasingly sophisticated technology being used in the manufacture of medical simulators, the manufacture of healthcare simulators has become a multifaceted undertaking. Based on our experience in the field and our diverse backgrounds, we explore the processes and issues related to the development of these simulators and suggest ways for the developing teams to collaborate and coordinate with each other to achieve a successful outcome.

Cost Comparison of Fundamentals of Laparoscopic Surgery Training Completed With Standard Fundamentals of Laparoscopic Surgery Equipment versus Low-Cost Equipment

OBJECTIVE

Training for the Fundamentals of Laparoscopic Surgery (FLS) skills test can be expensive. Previous work demonstrated that training on an ergonomically different, low-cost platform does not affect FLS skills test outcomes. This study compares the average training cost with standard FLS equipment and medical-grade consumables versus training on a lower cost platform with non-medical-grade consumables.

DESIGN

Subjects were prospectively randomized to either the standard FLS training platform (n = 19) with medical-grade consumables (S-FLS), or the low-cost platform (n = 20) with training-grade products (LC-FLS). Both groups trained to proficiency using previously established mastery learning standards on the 5 FLS tasks. The fixed and consumable cost differences were compared.

SETTING

Training occurred in a surgical simulation center.

PARTICIPANTS

Laparoscopic novice medical student and resident physician health care professionals who had not completed the national FLS proficiency curriculum and who had performed less than 10 laparoscopic cases.

RESULTS

The fixed cost of the platform was considerably higher in the S-FLS group (S-FLS, $3360; LC-FLS, $879), and the average consumable training cost was significantly higher for the S-FLS group (S-FLS, $1384.52; LC-FLS, $153.79; p < 0.001). The LC-FLS group had a statistically discernable cost reduction for each consumable (Gauze $9.24 vs. $0.39, p = 0.002; EndoLoop $540.00 vs. $40.60, p < 0.001; extracorporeal suture $216.45 vs. $25.20, p < 0.001; intracorporeal suture $618.83 vs. $87.60, p < 0.001). The annual fixed and consumable cost to train 5 residents is $10,282.60 in the S-FLS group versus $1647.95 in the LC-FLS group.

CONCLUSIONS

This study shows that the average cost to train a single trainee to proficiency using a lower fixed-cost platform and non-medical-grade equipment results in significant financial savings. A 5-resident program will save approximately $8500 annually. Residency programs should consider adopting this strategy to reduce the cost of FLS training.

Reusable Low-Cost 3D Training Model for Aneurysm Clipping

BACKGROUND

Aneurysm clipping requires the proficiency of several skills, yet the traditional way of practicing them has been recently challenged, especially by the growth of endovascular techniques. The use of simulators could be an alternative educational tool, but some of them are cumbersome, expensive to implement, or lacking in realism. The aim of this study is to evaluate a reusable low-cost 3-dimensional printed training model we developed for aneurysm clipping.

METHODS

The simulator was designed to replicate the bone structure, arteries, and targeted aneurysms. Thirty-two neurosurgery residents performed a craniotomy and aneurysm clipping using the model and then filled out a survey. They were divided into Junior and Senior groups. Descriptive, exploratory, and confirmatory factor analysis was performed using IBM SPSS statistical software.

RESULTS

The overall residents' response was positive, with high scores to face validity and content validity questions. There was no significant statistical difference between the Junior and Senior groups. The confirmatory factor and internal consistency analysis confirmed that the evaluation was highly reliable. Globally, 97% of the residents found the model was useful and would repeat the simulator experience. The financial cost is $2500 USD for implementation and only $180 USD if further training sessions are required.

CONCLUSIONS

The main strengths of our training model are its highlighted realism, adaptability to trainees of different levels of expertise, sustainability, and low cost. Our data support the concept that it can be incorporated as a new training opportunity during professional specialty meetings and/or within residency academic programs.

"I got it on Ebay!": cost-effective approach to surgical skills laboratories

BACKGROUND

Surgical education is witnessing a surge in the use of simulation. However, implementation of simulation is often cost-prohibitive. Online shopping offers a low budget alternative. The aim of this study was to implement cost-effective skills laboratories and analyze online versus manufacturers' prices to evaluate for savings.

MATERIALS AND METHODS

Four skills laboratories were designed for the surgery clerkship from July 2014 to June 2015. Skills laboratories were implemented using hand-built simulation and instruments purchased online. Trademarked simulation was priced online and instruments priced from a manufacturer. Costs were compiled, and a descriptive cost analysis of online and manufacturers' prices was performed. Learners rated their level of satisfaction for all educational activities, and levels of satisfaction were compared.

RESULTS

A total of 119 third-year medical students participated. Supply lists and costs were compiled for each laboratory. A descriptive cost analysis of online and manufacturers' prices showed online prices were substantially lower than manufacturers, with a per laboratory savings of: $1779.26 (suturing), $1752.52 (chest tube), $2448.52 (anastomosis), and $1891.64 (laparoscopic), resulting in a year 1 savings of $47,285. Mean student satisfaction scores for the skills laboratories were 4.32, with statistical significance compared to live lectures at 2.96 (P < 0.05) and small group activities at 3.67 (P < 0.05).

CONCLUSIONS

A cost-effective approach for implementation of skills laboratories showed substantial savings. By using hand-built simulation boxes and online resources to purchase surgical equipment, surgical educators overcome financial obstacles limiting the use of simulation and provide learning opportunities that medical students perceive as beneficial.

Shooting with sound: optimizing an affordable ballistic gelatin recipe in a graded ultrasound phantom education program

OBJECTIVES

The goal of this study was to investigate the durability and longevity of gelatin formulas for the production of staged ultrasound phantoms for education.

METHODS

Gelatin phantoms were prepared from Knox gelatin (Kraft Foods, Northfield, IL) and a standard 10%-by-mass ordinance gelatin solution. Phantoms were durability tested by compressing to a 2-cm depth until cracking was visible. Additionally, 16 containers with varying combinations of phenol, container type, and storage location were tested for longevity against desiccation and molding. Once formulation was determined, 4 stages of phantoms from novice to clinically relevant were poured, and clinicians with ultrasound training ranked them on a 7-point Likert scale based on task difficulty, phantom suitability, and fidelity.

RESULTS

On durability testing, the ballistic gelatin outperformed the Knox gelatin by more than 200 compressions. On longevity testing, gelatin with a 0.5% phenol concentration stored with a lid and refrigeration lasted longest, whereas containers without a lid had desiccation within 1 month, and those without phenol became moldy within 6 weeks. Ballistic gelatin was more expensive when buying in small quantities but was 7.4% less expensive when buying in bulk. The staged phantoms were deemed suitable for training, but clinicians did not consistently rank the phantoms in the intended order of 1 to 4 (44%).

CONCLUSIONS

Refrigerated and sealed ballistic gelatin with phenol was a cost-effective method for creating in-house staged ultrasound phantoms suitable for large-scale ultrasound educational training needs. Clinician ranking of phantoms may be influenced by current training methods that favor biological tissue scanning as easier.

Development and Validation of a Novel and Cost-Effective Animal Tissue Model for Training Transurethral Resection of the Prostate

OBJECTIVES

To develop and validate a new and cost-effective animal tissue training model for practicing resection skills of transurethral resection of the prostate (TURP).

METHODS AND MATERIALS

A porcine kidney was prepared and restructured to simulate the relevant anatomy of the human prostate. The restructured prostate was connected to an artificial urethra and bladder. Face, content, and construct validity of the model was carried out using a 5-point Likert scale questionnaire, and comparison in task performance between participants and experts was made using observational clinical human reliability analysis.

RESULTS

A total of 24 participants and 11 experts who practiced TURP skills on this model from October 2014 to December 2015 were recruited. The mean score on specific feature of the anatomy and color, sensation of texture and feeling of resection, conductibility of current, and efficacy and safety of the model were 4.34 ± 0.37, 4.51 ± 0.63, 4.13 ± 0.53, and 4.35 ± 0.71, respectively, by participants whereas they were 4.22 ± 0.23, 4.30 ± 0.48, 4.11 ± 0.62, and 4.56 ± 0.77, respectively, by the experts on a scale of 1 (unrealistic) to 5 (very realistic). Participants committed more technical errors than the experts (11 vs 7, p < 0.001), produced more movements of the instruments (51 vs 33, p < 0.001), and required longer operating time (11.4 vs 6.2min, p < 0.001).

CONCLUSIONS

A newly developed restructured animal tissue model for training TURP was reported. Validation study on the model demonstrates that this is a very realistic and effective model for skills training of TURP. Trainees committed more technical errors, more unproductive movements, and required longer operating time.

Homemade laparoscopic simulator

PURPOSE

To describe a guide for the construction of a laparoscopic training simulator.

METHODS

Step-by-step description of an inexpensive and easy to assemble homemade laparoscopic training box, capable of simulating the laparoscopic environment in its peculiarities to enable technical skills training.

RESULTS

The total cost of the materials for the construction of the simulator was US$ 75.00 (about R$ 250.00 "reais") and it can be reduced to US$ 60.00 if the builder judges that there is no need for internal lighting. The use of real trocars imposes the same challenges as real surgeries regarding positioning, visibility and limitation of movements.

CONCLUSION

The proposed economical and efficient alternative can contribute to the teaching and practice of laparoscopic surgical technique worldwide, benefiting surgeons and patients.