A quantitative study about simulation training of basic laparoscopic surgical skills

Introduction : Patient safety is the important priority in surgical education. The new training models and curriculum are needed for maintaining safety and quality of surgical performance. An established laparoscopic surgical skill(LSS) grade 1 level 1 programme running for surgical residents is being already taken up in various european countries under the support of European Association of Endoscopic Surgeons. Aim : The aim of the paper is to evaluate the perception of surgery residents on LSS Grade 1 Level 1 course in South India. Material and methods : A total of 5 accredited LSS Grade I Level 1 courses were held in GSL SMART LAB between April 2013 and December 2016. The demographic data and pre-course surgical experience in laparoscopic surgery of the participants were recorded. After completion of 12 hrs practice on endotrainer and lap mentor combined, the participants attended two days of basic laparoscopic surgical skill programme with different modes of assessment/examination related to basic laparoscopic skills. The participants filled the course evaluation form to evaluate course progress, course materials, assessment, staff, course location and overall impression of the course on a 1-10 scale to evaluate feedback information. Results : 34 surgery residents were enrolled in an LSS Grade I Level 1 programme. The mean age of the participants was 28.294 years (SD = 3.51), the male/female ratio was 31/3 and previous experience with laparoscopic surgery was limited. Overall impression of the course was rated with 8.8 points (SD = 0.78). The applicability of the course content in practice and the balance between theory and hands-on training were also rated very well – mean 8.8 (SD = 1.01) and 8.1 points (SD = 0.80) respectively. Conclusions : The result of this study shows that the course is a well balanced training programme, meeting the expectations of individual surgery residents. Hence, the overall interest in the programme suggests that it might become the future Indian standard of surgical education in laparoscopic surgery. Success of the course may be drawn after the completion of clinical assessment of enrolled participants.

AimsAccording to literature,newly qualified doctors are at risk of being unable to perform practical procedures safely. This has been exacerbated by the disruptions to training and education which the covid-19 pandemic has caused. This intensive course has been developed to improve basic surgical skills and improve confidence in simple wound closure, to mitigate these disruptions.MethodsCandidates attended a three-part course in small groups, where they learned hand ties, basic laparoscopic skills and wound closure on animal models. Self assessment data were collected pre and post workshop on a Likert scale. All data was assessed using basic descriptive analysis.ResultsData was collected from 13 participants (M:F, 5:8) at the level of foundation year 1(61.5%,n=8) and foundation year 2(38.5%,n=5). Only 38.5% (n = 5) had previous basic surgical skills training. Our delegates reported an improvement in the following surgical skills: suturing (n = 11, 84.6%), hand tying (n = 10, 76.9%), laparoscopic skills (n = 10, 76.9%). Overall 61.5% (n = 8) of our delegates reported an improvement in all three domains.ConclusionsParticipants reported limited exposure prior to this course despite successfully completing an undergraduate curriculum. Overall, participants' self-scores improved in all three taught surgical skills. We believe ourcourse is a practical and reproducible solution to help bridge training gaps, which can be safely conducted with social distancing measures.

Computer-based surgical training simulators are instrumental in skill-based training and performance measurement. However, to date, the educational employment of these tools lacks empirically founded insights and effective practical guidelines. This study examined surgical residents during computer-based simulator training of basic laparoscopic surgical skills. The quantitative analysis of residents’ performance averages from training onset to completion produced mixed results, revealing skill improvements as well as decreases, depending on the parameter. The results obtained from the simulator parameters and questionnaires showed that residents with either prior laparoscopic experience or gaming experience significantly outperformed their colleagues. Based on feedback and video-recorded performance analysis, the study concluded that autonomous training with the simulator is not sufficient for developing a minimum standard of performance. Residents need an adequate level of content-based feedback and supervisor support during training. We advise a more detailed and pedagogically informative measurement and feedback system, including specialist-instructor guidance, be developed.

Simulation training is a validated method for acquiring laparoscopic skills. Training sessions may be sporadic or lack continuity in oversight by instructors since traditional programs mandate in-person teaching and evaluation. This study presents the development, implementation, and results of a novel smartphone application that enables remote teacher-student interaction. This interface is used to complete a validated program that provides learner-specific feedback. Outcomes of training via Lapp were compared to outcomes of traditional in-person training. A web-based and mobile iOS and Android application (Lapp) was developed to enable a remote student-teacher interaction. Instructors use Lapp to assess video recorded training sessions of students at distant locations and guide them through the laparoscopic skill course with specific and personalized feedback. Surgical trainees at two remote training centers were taught using Lapp. A control group was assessed during traditional simulation training at the training facility, with in-person feedback. Pre- and post-training performances were video recorded for each trainee and blindly evaluated by two experts using a global rating scale (GRS) and a specific rating scale (SRS). A total of 30 trainees were trained via Lapp and compared with 25 locally taught. Performance in the Lapp group improved significantly after the course in both GRS and SRS scores, from 15 [6-17] to 23 [20-25], and from 12 [11-15] to 18 [15-20], respectively. The results between both groups were comparable. Laparoscopic simulation training using a mobile app is as effective as in-person instruction in teaching advanced laparoscopic surgical skills. Lapp provides an effective method of teaching through simulation remotely and may allow expansion of robust simulation training curriculums.

Evaluation of the laparoscopic surgical skills of surgical residents is usually a subjective process carried out in the operating room by senior surgeons. The two hypotheses of the current study were: (1) haptic information and tool/tissue interactions (types and transitions) performed in laparoscopic surgery are skill-dependent, and (2) statistical models (Hidden Markov Models--HMMs) incorporating these data are capable of objectively evaluating laparoscopic surgical skills. Eight subjects (six residents--two first-year (R1), two third-year (R3), and two fifth-year (R5)--and two expert laparoscopic surgeons) performed laparoscopic cholecystectomy on pigs using an instrumented grasper equipped with force/torque (F/T) sensors at the hand/tool interface, and F/T data was synchronized with video of the operative maneuvers. Fourteen types of tool/tissue (T/T) interactions, each associated with unique F/T signatures, were defined from frame-by-frame video analysis. HMMs for each subject and step of the operation were compared to evaluate the statistical distance between expert surgeons and residents with different skill levels. The statistical distances between HMMs representing expert surgeons and residents were significantly different (alpha < 0.05). Major differences occurred in: (1) F/T magnitudes; (2) type of T/T interactions and transitions between them; and (3) time intervals for each T/T interaction and overall completion time. The greatest difference in performance was between R1 (junior trainee) and R3 (midlevel trainee). Smaller changes were seen as expertise increased beyond the R3 level. HMMs incorporating haptic and visual information provide an objective tool for evaluating surgical skills. Objective evidence for a "learning curve" suggests that surgical residents acquire a major portion of their laparoscopic skill between year 1 and year 3 of training.

Objective To explore the value of primary and Advanced levels of laparoscopic simulating training in different seniority of gynecologic residents. Methods 77 residents in their first to forth training-year were divided into two groups: 1-2 year resident and 3-4 year resident, trained with different levels of simulating training plans respectively and then assessed in the Department of Obstetrics and Gynecology in Peking University Third Hospital. Results The qualified rate of primary and advanced simulation training was 85.7% and 57.1% respectively. The qualified rate of primary training (80.4% vs. 100.0%, P=0.028) and advanced training (12.5% vs. 57.14%, P=0.000) were significantly different between 1-2 year residents and 3-4 year residents. The operative skills improved significantly in all the residents. In the 1-2 year residents, the scores of the primary training increased more obviously, while in the 3-4 year residents, the scores of the advanced training increased significantly. Conclusion It might be more effective for residents with different seniority to receive different levels of simulating training accordingly, so as to improve their laparoscopic operative skills more effectively. Key words: Laparoscopy; Simulation training; Resident; Department of gynecology

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. 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. 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. 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.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery as a Rescue for Total Vaginal Hysterectomy

Introduction of a comprehensive training curriculum in laparoscopic surgery for medical students: A randomized trial

This study aimed to obtain insight in the effect of expert feedback during a basic laparoscopic skills training course for residents. A questionnaire was held among participants regarding provided feedback and the self-perceived laparoscopic skills improvement. The participants (n = 24) who completed the questionnaire were in their first to fifth postgraduate year. Most feedback was directed at intracorporeal knot tying (47% reported extensive feedback), while camera navigation and body positioning received the least feedback (40% and 43%, respectively, responded to have received no feedback at all). After the course, the self-perceived competence in intracorporeal knot tying and cutting had improved significantly, while camera navigation, body positioning, pointing, and grasping tasks did not improve. In conclusion, most benefit from expert feedback can be obtained at the start of the learning curve. Therefore, the basic laparoscopic skills course should be attended early in residency. Additionally, it is crucial that training objectives are clear prior to a course for both the expert and the trainee, in order to focus the feedback on all training objectives.

Objective To evaluate the learning curve of three–port extraperitoneal laparoscopic radical prostatectomy(ELRP) and to minimize operative time and blood loss about this procedure. Methods From August 2013 to October 2014, the data from 95 consecutive patients, who had undergone three–port ELRP for prostate cancer, were retrospectively analyzed. The mean age was 65.9±7.7 years, mean total PSA level was 15.4±12.7 μg/L, and mean body mass index(BMI) was 24.8±3.2 kg/m2. According to the number of procedures performed by the surgeon, all patients were classified into three chronologic groups, including group A(No.1–32), group B(No.33–64) and group C(No.65–95). There were no significant differences including age, BMI, tPSA, estimated prostate volume, clinical stages, history of neoadjuvant endocrine therapy, history of transurethral resection of the prostate(TURP) among group A, B and C (P>0.05). The operative outcomes analyzed were operative time, estimated blood loss, hospital stay, drainage tube indwelling days, pathological Gleason scores, pathological stages, positive surgical margin rates, biochemical recurrence rates and urinary incontinence rates. Among these 95 patients, the results of the first 32 cases were compared with those of the remaining 63 cases, the first 64 with the remaining 31. Results The average operative time in 95 patients was 81.0±18.6 min. The sloping learning curve for this surgeon showed that the operative time for all 95 cases was strongly correlated with additional experience(|rs|=0.612, P 0.05). Group A had longer operative time than that of Group B plus C(96.4±11.3 min vs 73.2±16.7 min, P 0.05). There were no significant correlation between the accumulation of experience and positive surgical margin rates, biochemical recurrence rates and urinary incontinence rates. Conclusion Our experience of three–port ELRP cases appears to be favorable with decreasing tendency in operative time, estimated blood loss with experience accumulation. Exposure to 32 surgeries, operative time and estimated blood loss reduced significantly, and after 64 cases operative time and estimated blood loss further reduced. Key words: Prostate cancer; Radical prostatectomy; Extraperitoneal approach; Laparoscopy; Learning curving

To present the University of Genoa Advanced Simulation Center (SimAv) and the project of a trainer (eLap4D) that would achieve the equivalent goals of the fundamentals of laparoscopic surgery trainer at an economical cost. The validation process is going to be shown too. METHODS. The laparoscopic trainer is a physical low-cost laparoscopic training platform that reproduces the tactile feedback (eLaparo4d) integrated with a software for virtual anatomical realistic scenarios (Unity3D V 4.1). A sample of 20 students was selected, divided into 2 homogeneous groups with respect to the level of confidence with the use of video games, consoles, smartphones (this has been possible thanks to the use of a questionnaire, administered before the practical phase of training). The groups participated in a training program based on 5 basic laparoscopic skills (laparoscopic focusing and navigation, hand – eye – coordination and grasp coordination). So, a second and a third study sample was chosen, consisting of 20 post graduate students (intermediate group) and 20 experienced surgeons; for these groups a training program was provided, identical to the previous group as well as their subdivision into 2 group. The face validity was used for an ergonomic analysis of the simulator, the construct to test the system's ability to differentiate potential expert users (experienced surgeons) from non-experts (student without experience in laparoscopic surgery). The authors analyzed the results of the three samples obtained by comparing variables such as score, % of fulfillment, panality and time. At the same time, the students' improvements have been monitored, developing a customized learning curve for each user. To evaluate the structural characteristics of the simulator a specific questionnaire has been used. The results were encouraging. The simulator is ergonomically satisfactory and its structural features are adapted to the training. The system was able to differentiate the level of experience and also has therefore met the requirements of “construct validity”. laparoscopic simulators can be constructed at an economical cost.

The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Orthopaedic Surgery (ABOS) recently mandated major changes to curricular requirements for the PGY-1 (intern) year for categorical orthopaedic surgery residents. Since July 1, 2013, PGY-1 residents are required to have 6 months of orthopaedic surgery rotations, 6 months of nonorthopaedic surgery rotations, and complete a mandatory surgical skills curriculum [1, 2]. The ACGME and ABOS executed these changes in an effort to improve the quality and breadth of education for interns, preparing them for more advanced orthopaedic education. These changes were prompted by shifts in general surgery procedures (from open to laparoscopic), which have reduced the operating room experience of suturing and knot tying for interns, as well as by duty hour requirements that further reduce the operating room experience for interns. Together, these shifts in first-year resident experience have resulted in less surgical training for the orthopaedic surgery intern. The new ABOS requirements, which commence on July 1, 2014, seek to offset those losses [1, 2]. This column describes the changes mandated by the ABOS and ACGME for the orthopaedic intern year, discusses some limitations associated with these changes, and offers program strategies for effective implementation.

Implementation of laparoscopy into residency training is difficult. This study was conducted to assess the current state of implementation of laparoscopic surgery into gynecological residency program, to identify factors influencing laparoscopic skills training, and to find solutions toward better training and implementation. In 2003 a questionnaire was sent to all 68 postgraduate year 5 and year 6 residents in obstetrics and gynecology in The Netherlands. The questionnaire addressed demographics, performance of laparoscopy, self-perceived competence, simulator training, and factors influencing laparoscopic training in residency. Of the 68 residents, 60 (88%) responded; 46 (37%) were men and 78 (63%) women. Men showed significant higher mean self-perceived competence in some laparoscopic procedures than women. Of the respondents, 20% had no advanced laparoscopic gynecologist present in their teaching hospital. Residents felt that simulator training is important in relation to their performance in the operating room. Of all gynecological teaching hospitals in the Netherlands, 55% did not have the opportunity of simulator training. Of the respondents who had the possibility of simulator training, 33% did not use the simulator voluntarily. Residents who trained on a simulator felt training was significantly more important (p = 0.02) than residents who never practiced on a simulator. Respondents' laparoscopic skills were subjectively evaluated in the operating room (92%) or were evaluated based on the number of laparoscopic procedures performed as primary surgeon (49%). Of the respondents, 47% were satisfied with their current laparoscopic skills and 27% also felt prepared for the more advanced procedures. Not having been primary surgeon in nonacademic teaching hospitals and even more so in academic teaching hospitals (p < 0.05) was a limiting factor in acquiring laparoscopic skills. Incorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.

Objective: comparative evaluation of perioperative clinicopathologic characteristics and short-term outcomes of robotic and laparoscopic surgeries for colorectal cancer (CRC), depending on the phases of the learning curve. Materials and methods. Patients who underwent robotic or laparoscopic surgeries were compared retrospectively (n = 77 and n = 123 respectively). Cumulative sum (CUSUM) was used to evaluate the learning curve. Results. Robotic operations were comparable with laparoscopic in the average blood loss and conversion rate, but differed in the longer duration (237.5 ± 74.9 min versus 213.5 ± 73.1 min, p = 0.024). The short-term outcomes and pathomorphological characteristics were not significantly different in both procedures. According to CUSUM, the learning curve of robotic surgery was the 46 cases and of laparoscopic surgery was the 54 cases. Comparison between 1st phase and 2nd phase in the robotic group showed significant difference in the total operation time and in docking and surgeon console time. Other perioperative characteristics did not differ significantly between the phases of the learning curve. For the laparoscopic group, there was also a decrease in the operation time after the 1st phase of the learning curve, as well as a statistically significant decrease in intraoperative blood loss (140.9 ± 68.8 ml for 1st phase versus 108.1 ± 67.8 ml for 2nd phase, p = 0.009). All cases of conversion in the laparoscopic group were in the 1st phase of the learning curve (p = 0.047). Comparison between 1st phase and 2nd phase for laparoscopic surgery showed no significant difference for the short-term outcomes. Pathologic outcomes were not significantly different in both procedures and phases. Conclusions. The learning curve for robotic surgery was shorter than for laparoscopic surgery. There were no significant differences in perioperative clinicopathologic characteristics and short-term outcomes in both procedures and phases of the learning curve.