Simulation and Training in Laparoscopic Surgery

Training and credentialing in laparoscopic surgery — the need of the day

Advanced training in laparoscopic abdominal surgery: A systematic review

To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.

Laparoscopic simulators : Are they useful!

Current surgical training: simultaneous training in open and laparoscopic surgery

The ACPGBI has been at the forefront in developing guidelines, position statements and national training programs related to both common, and complex, colorectal pathology. These initiatives often serve as a global reference in this challenging field. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) 2007 Colorectal Cancer Management Guidelines have been the basis for continuous evolution in the way these cancers are managed. The current update aims to clarify many recent developments on the multidisciplinary management of colorectal cancer and to provide links to relevant publications. The recommendations made within these guidelines have been graded according to the Oxford Centre for Evidence-based Medicine – levels of evidence (www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/). We hope that these guidelines will offer a framework for clinicians and MDT's to tailor treatments to suit individual patients. We also hope to direct future research and debate in a rapidly evolving field. A substantial part of the workload of colorectal units is to not only exclude diagnosis of cancer but to manage cancer of the colon, rectum and anal canal. Access to information through technology, and particularly the internet, has changed perceptions and expectations of cancer patients, their carers and clinicians. The general public and healthcare providers continue to shift focus towards cancer prevention and early diagnosis. At the other end of the spectrum, patients with locally advanced, recurrent or metastatic cancer are increasingly being considered for tailored multimodal therapy, based on molecular biology and pharmaceutical advances. In the UK, through the NCRI Colorectal Cancer Clinical Trials Group and numerous other research organizations, we are proud of our record of being at the forefront of designing and completing many internationally acclaimed oncological and surgical trials. These have been instrumental in shaping our current clinical practice. We must continue to build on this foundation by developing and recruiting into new trials to further improve treatment. Over the last few decades, multidisciplinary teams (MDTs) have evolved, and consolidated, in individual units to manage colorectal cancer. At the MDT meeting, the clinical nurse specialist, with the attending surgeon, are best positioned to act as the patients’ advocates and ensure crucial decisions are made with a first-hand knowledge of the patient and their wishes. It is pertinent that MDT recommendations are based on the available information and recommendations may, or may not be appropriate, or acceptable to the individual patient. Clinicians should support patients requesting second opinions and guide them with appropriate pathways. Current MDTs should look to extend their role in training junior surgeons, radiologists, histopathologists and oncologists, and mentoring new members of the core team. Personal-audits and regular feedback between core members should be an integral part of the development of the MDT. Ongoing sub-specialization has encouraged development of specialist MDTs in a number of areas including anal cancer, early rectal cancer, ‘beyond’-TME and recurrent pelvic cancers, and cytoreductive surgery. Teams treating colorectal disease need to recognize the spectrum of disease, diversity of treatments and develop care pathways to access specialist MDT's. Public awareness campaigns and the NHS Bowel Cancer Screening Program have impacted positively on the diagnosis of early stage disease, and polyp detection and clearance are likely to reduce colorectal cancer incidence. Introduction of Faecal Immunochemical Test and Bowel Scope Screening will further improve the stage at diagnosis of colon and rectal cancer. Bowel cancer screening has added to the challenge of treating polyp cancers and early rectal cancer; oncological adequacy of minimally invasive interventions (polypectomy and local excisions) vs morbidity and mortality risk of resection surgery. The ongoing SPECC (Significant Polyp Early Colorectal Cancer) Pelican/ACPGBI Program aims to stimulate discussion and training in these areas. Robust risk stratification tools to help MDTs and patients make informed decisions, especially in an older and frailer population, are needed. Clinical trials, such as the recently completed NCRI TREC-1 and the new NCRI STAR-TREC in early rectal cancer will add to this knowledge. The Laparoscopic Colorectal Surgery (LAPCO) program, which was a joint initiative between the ACPGBI and NHS England, delivered high quality accreditation training in laparoscopic surgery to NHS colorectal surgeons. This initiative, together with increasing public awareness of laparoscopic surgery, has resulted in a steady year-on-year increase in the proportion of cases treated by minimal access, whilst achieving good oncological outcomes in addition to the short-term early benefits, particularly in colon cancer but less so in rectal cancer. Introduction of ERAS on the background of minimally invasive surgery has improved short-term outcomes including length of stay. Optimal results have been reported using a combination of ERAS and minimal access techniques. The concepts from colorectal surgical ERAS programs have been adopted by other surgical fields and have benefited a wider group of patients. The Low Rectal Cancer Development (LOREC) program is another joint initiative between the ACPGBI and NHS England, providing training to MDTs on the overall management of cancers arising at, or below, the level of the insertion of the levator muscles, including the appropriate use of extralevator abdominoperineal excision (ELAPE). The longer-term oncological outcomes and the associated morbidity of this initiative are yet to be reported. High quality radiology and detailed histopathology reporting is crucial, as it underpins MDT decision making. This provides quality assurance to patients and clinicians on management decisions. Radiology and pathology provide valuable prognostic indicators in colon and rectal cancer, which helps to determine further management. Advances in imaging and use of biomarkers have initiated individualized treatment strategies to be developed in all stages of disease. We predict that these advances will expand exponentially in the next decade. The use of preoperative radiotherapy, with or without chemotherapy in addition to surgery in ‘operable’ rectal cancer reduces local recurrence rates, but much of the published evidence predates modern imaging, making it difficult to quantify the exact benefits. Together with ongoing improvements in surgical techniques, such as ELAPE for advanced low rectal cancer, and an increasing awareness of immediate and long-term toxicity, the risk-benefit of using radiotherapy in rectal cancer, either to downstage disease or to reduce local recurrence needs careful consideration on an individual basis. There remains significant variation in the use of radiotherapy nationally, but with further refinements in imaging and expansion of knowledge, this will allow more selective utilization. However the role of optimal surgery remains crucial. Further advances in the use of adjuvant chemotherapy, with the addition of new targeted agents have failed to materialize. The focus has shifted to earlier use of systemic therapy in the neoadjuvant setting for colon and rectal cancers, as well as reducing the duration and toxicity of adjuvant therapies. There is increasing worldwide interest in the potential for non-operative management of rectal cancers of all stages. Ongoing trials to improve pathological complete response rates (pCR) and translational studies to develop new predictive markers, together with high-quality observational trials such as the NCRI Deferral of Surgery, may allow for safe deferral and hopefully, complete avoidance of surgery in selected patients who have potentially achieved pCR after preoperative chemoradiotherapy (CRT). The National Bowel Cancer Audit (NBOCA) has evolved from being a voluntary audit when first launched in 2000, to currently being a quality assurance tool for individual surgeons and NHS Trusts. Although it has provided invaluable data to drive up the standards of care delivered nationally, there remain opportunities to further improve the quality of data collected. Through NBOCA, the publication of individual colorectal surgeons’ outcomes has empowered patients, by providing online information about volumes and outcomes of individual surgeons and NHS Trusts. Individual surgeon outcome reporting is contentious and unit data may be more meaningful and is the subject of ongoing discussion. Most importantly, treatment of colorectal cancer should take into account individual preferences, and be delivered with dignity, compassion and respect. Patients need to understand that the management of their cancer is individualized and complex. They should be given an explanation for the perceived delays in commencing treatment, such as the need for further investigations or MDT discussion. Response to treatment is often unpredictable, as are many of the acute and late toxicities. These uncertainties should be openly discussed and patients should be able to make informed choices about their care, in partnership with their healthcare professionals. These decisions should be subject to regular review at appropriate key points during treatment, to accommodate any changes in circumstances and to allow the patient the opportunity for further discussion or reconsideration. Healthcare professionals must not underestimate the psychological and social impact of a diagnosis of colorectal cancer on the individual as well as family, carers and supporters. There is wide variation in their reactions, their ability to cope and their recall of information received, which may be subject to strong emotions and anxiety. Communication and listening skills for such patients need to be exemplary as they form a vital part of the patient journey, from undergoing treatment, to recovery and eventual readjustment to life beyond hospital. These guidelines offer an updated framework for colorectal cancer clinicians and MDTs. They will continue to evolve and require updating in light of ongoing developments and emerging evidence. None of the authors have any conflicts to declare.

Training in laparoscopic surgery is important not only to acquire and improve skills but also avoid the loss of acquired abilities. The aim of this single-centre, prospective randomized study was to assess skill acquisition of different laparoscopic techniques and identify the point in time when acquired skills deteriorate and training is needed to maintain these skills. Sixty surgical novices underwent laparoscopic surgery (LS) and single-incision laparoscopic surgery (SILS) baseline training (BT) performing two validated tasks (peg transfer, precision cutting). The novices were randomized into three groups and skills retention testing (RT) followed after 8 (group A), 10 (group B) or 12 (group C) weeks accordingly. Task performance was measured in time with time penalties for insufficient task completion. 92% of the participants completed the BT and managed to complete the task in the required time frame of proficiency. Univariate and multivariate analyses revealed that SILS (P<0.0001) and precision cutting (P<0.0001) were significantly more difficult. Males performed significantly better than females (P<0.005). For LS, a deterioration of skills (comparison of BT vs RT) was not identified; however, for SILS a significant deterioration of skills (adjustment of BT and RT values) was demonstrated for all groups (A-C) (P<0.05). Our data reveal that complex laparoscopic tasks (cutting) and techniques (SILS) are more difficult to learn and acquired skills more difficult to maintain. Acquired LS skills were maintained for the whole observation period of 12weeks but SILS skills had begun to deteriorate at 8weeks. These data show that maintenance of LS and SILS skills is divergent and training curricula need to take these specifics into account.

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 adoption of laparoscopic surgery has significantly transformed surgical practice. However, mastering these techniques requires specialized training. In Saudi Arabia, the level of proficiency in laparoscopic skills among General Surgery (GS) trainees is not well-documented. This study aims to assess GS residents' satisfaction with their laparoscopic training, self-appraise their proficiency, and objectively evaluate their skills using the Fundamentals of Laparoscopic Surgery (FLS) test. This cross-sectional study, approved by the Institutional Review Board and funded by Alfaisal University, took place between October 2021 and May 2023. It involved a two-part approach: an online survey and objective FLS testing. The survey, distributed to GS residents in seven government hospitals in Riyadh, captured self-reported satisfaction and subjective proficiency data. Subsequently, residents who volunteered for FLS testing were objectively assessed using standardized criteria. Of 195 residents, 70 (36%) responded to the survey. Satisfaction with academic teaching and hands-on training in laparoscopic surgery was low (24% and 44%, respectively), while 62% were satisfied with case volume. Self-assessed proficiency was higher for basic skills than for advanced skills like extra-corporeal and intracorporeal knotting. Only a third had been exposed to laparoscopic trainers, and 14.3% had FLS certification prior. Fourteen residents participated in FLS testing, revealing a 36% failure rate in task completion. Prior simulation practice or laparoscopic training certification significantly improved performance (p<0.001), reflected by achieving higher scores and passing FLS proficiency scores. Despite satisfaction with exposure to laparoscopic surgeries, the study highlights a considerable gap in satisfaction and proficiency among GS residents in Saudi Arabia, particularly in advanced laparoscopic skills. The positive impact of simulation-based practice and laparoscopic training certification underscores the need for structured training programs. Addressing these gaps, through integrating comprehensive simulation-based programs and promoting laparoscopic skill certification, is crucial for enhancing surgical education and training outcomes.

Oncologic Outcome and Continence Recovery after Laparoscopic Radical Prostatectomy: 3 Years’ Follow-Up in a “Second Generation Center”

IntroductionIn the last decade, we have seen the advance of laparoscopic surgery in urology. All laparoscopic procedures in our department are performed by staff members and are assisted by a single resident, ensuring resident training in laparoscopic surgery. The aim of this study is to evaluate the results of the Hospital La Paz training program for residents in the field of laparoscopic surgery.Material and methodsWe have done a retrospective review of LRP performed by the residents in our department. We also evaluated different variables. Descriptive statistical analysis was done and the results were compared with the descriptive analysis of the initial series of our department.ResultsWe reviewed 82 patients, with an average age of 61.6 years. Most cases were pT1c at diagnosis. Average surgical time was 288 minutes, with a transfusion rate of 9.7% and a intra and postoperative complication rates of 1.2% and 7.3%. The mean hospital stay was 3.3 days. Histological results of this series are: 76.8% of pT2 and 23.2% of pT3. The biochemical relapse rate is 15.8%. Global surgical margin rate is 20.7%. The global continence rate is 52.4%.ConclusionsThe outcomes of LRP performed by residents are similar to the ones reported in the initial series of our department. The fact that 84.6% of the residents formed in this period actually belong to different laparoscopic units supports the success of La Paz Hospital training model.

Context This study examined the effect of using laparoscopic simulation on the enhancement of psychomotor capabilities linked to performing laparoscopic appendectomy. Participants and methods Thirty surgical trainees carried out a laparoscopic appendectomy in the operating room (OR). The participants were then randomized to have a training course of six sessions (1 h each) on our simple simulator (MED-SIMU) or no training. Subsequently, all participants performed a further laparoscopic appendectomy in the OR. Both operations of each participant were recorded on video tapes, and assessed by two blinded laparoscopic senior surgeons using the predefined objective criteria such as time to complete the operation and the error counting. Results No differences in baseline variables were found between the two groups. Surgeons who received simulator training carried out laparoscopic appendectomy significantly faster than those in the control group (P=0.0006) and showed a greater improvement in error (P=0.0001). Conclusion Surgeons who had simulator training showed a greater enhancement in performance in the OR than those in the control group. Our simple surgical simulator is, therefore, a suitable tool for the training of laparoscopic motor skills and could be included in surgical training programs.

Does intermittent pneumatic compression PREVENT deep vein thrombosis in the ICU?

Peer review report 2 on “Virtual reality training in laparoscopic surgery: A systematic review and meta-analysis”

EDITOR, - There is increasing pressure on the royal colleges to introduce some form of accreditation and assessment of practical skills in minimally invasive surgery. This is partly driven by attention in the media to cases that have had an unfavourable outcome. There has never, however, been a demand for such accreditation in general surgical skills. Theoretically, a doctor who has never performed surgery can obtain a fellowship of the Royal College of Surgeons or membership of the Royal College of Obstetricians and Gynaecologists. Yet there are no calls for assessment of the technical competence of general surgeons or gynaecologists. Perhaps it would be more appropriate if assessment of technical skill in surgical specialties generally, rather than just in innovations such as minimally invasive surgery, was addressed. C M S Royston and colleagues discuss different modes of training in laparoscopic surgery and suggest that the porcine model is useful.1 They do not make clear …