Surgical simulation: a current review

Evaluating the educational environment of an international animal model-based wet lab course for undergraduate students

BACKGROUND

Essential Skills in the management of Surgical Cases - ESMSC is an International Combined Applied Surgical Science and Wet Lab course aimed at the undergraduate level. ESMSC combines interactive basic science workshops and case-based learning, with basic surgical training modules (BST) on Ex Vivo and In Vivo swine model. In Vivo Dissections include more advanced modules i.e. Abdominal Anatomy Dissections and Cardiac Transplant.

AIM

To evaluate the educational environment of a novel course, as well as to compare Medical students' perceptions across various groups.

MATERIALS AND METHODS

83 Delegates from King's College London (KCL) and several Hellenic Medical Schools attended the ESMSC course. The DREEM inventory was distributed upon completion of the modules.

RESULTS

The mean overall score for DREEM inventory was 148.05/200(99-196, SD = 17.90). Cronbach's Alpha value was 0.818, indicating good internal consistency of the data. Year 3/4 Students have a significantly positive "Perception of Learning", when compared to Year 5/6 (36.43 vs. 33.75, p = 0.017). KCL Students have a more positive view of the course compared to their Greek counterparts (155.19 vs. 145.62/200, p = 0.034). No statistical significant difference was noted when comparing male vs. female students (p > 0.05).

CONCLUSIONS

Students seem to positively rate the ESMSC educational environment. Junior as well as KCL students appear to be more enthusiastic. Further research should focus on the optimal strategy for early involvement and motivation of various students' groups in BST.

Laparoscopic ovariectomy in dogs: comparison between laparoendoscopic single-site and three-portal access

This study was conducted to evaluate the feasibility and therapeutic safety of laparoendoscopic single-site ovariectomy (LESS-OVE) and 3-portal laparoscopic ovariectomy (Lap-OVE) in dogs. Ten female mixed breed dogs were included in the study. Dogs were divided into group 1 (LESS-OVE; n = 5) and group 2 (Lap-OVE; n = 5). All procedures were performed by laparoscopic-skilled surgeons, and the anesthetic protocol was the same for all patients. In both groups, the ovarian vascular pedicle and ligaments were transected using a bipolar vessel sealer/divider device. The mean total surgical time was slightly longer in LESS-OVE (36.6 ± 3.5 min) than Lap-OVE (32.0 ± 3.0 min); however, the differences were not significant. Perioperative complications were not reported in any group. Both laparoscopic techniques were shown to be equally feasible and safe for patients. However, surgeons found LESS-OVE to require more skill than Lap-OVE. Therefore, additional studies should be conducted to evaluate this novel approach in clinical veterinary practice, and a proper laparoscopic training program for veterinary surgeons should be developed.

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.

3D printing to simulate laparoscopic choledochal surgery

AIMS OF THE STUDY

Laparoscopic simulation has transformed skills acquisition for many procedures. However, realistic nonbiological simulators for complex reconstructive surgery are rare. Life-like tactile feedback is particularly difficult to reproduce. Technological innovations may contribute novel solutions to these shortages. We describe a hybrid model, harnessing 3D technology to simulate laparoscopic choledochal surgery for the first time.

METHODS

Digital hepatic anatomy images and standard laparoscopic trainer dimensions were employed to create an entry level laparoscopic choledochal surgery model. The information was fed into a 3D systems project 660pro with visijet pxl core powder to create a free standing liver mold. This included a cuboid portal in which to slot disposable hybrid components representing hepatic and pancreatic ducts and choledochal cyst. The mold was used to create soft silicone replicas with T28 resin and T5 fast catalyst. The model was assessed at a national pediatric surgery training day.

RESULTS

The 10 delegates that trialed the simulation felt that the tactile likeness was good (5.6/10±1.71, 10=like the real thing), was not too complex (6.2/10±1.35; where 1=too simple, 10=too complicated), and generally very useful (7.36/10±1.57, 10=invaluable). 100% stated that they felt they could reproduce this in their own centers, and 100% would recommend this simulation to colleagues.

CONCLUSION

Though this first phase choledochal cyst excision simulation requires further development, 3D printing provides a useful means of creating specific and detailed simulations for rare and complex operations with huge potential for development.

Construction and validation of a low-cost surgical trainer based on iPhone technology for training laparoscopic skills

In this article, we describe the construction and validation of a laparoscopic trainer using an iPhone 5 and a plastic document holder case. The abdominal cavity was simulated with a clear plastic document holder case. On 1 side of the case, 2 holes for entry of laparoscopic instruments were drilled. We added a window to place the camera of the iPhone, which works as our camera of the trainer. Twenty residents carried out 4 tasks using the iPhone Trainer and a physical laparoscopic trainer. The time of all tasks were analyzed with a simple paired t test. The construction of the trainer took 1 hour, with a cost of <US$90. Results showed no significant differences in time for the 4 tasks performed in both the trainers. iPhone Trainer is a reusable and fully functional device that allows surgeons to practice their skills anywhere and at their own pace.

Assessment of Laparoscopic Skills in Veterinarians Using a Canine Laparoscopic Simulator

The aim of the present study was to assess the content and construct validity of the Canine Laparoscopic Simulator (CLS). Forty-two veterinarians were assigned to experienced (n=12), control (n=15), and training (n=15) groups, which were assessed while performing four laparoscopic tasks on the CLS. The initial and final assessments of all tasks were performed blindly by two experienced surgeons using the Global Operative Assessment of Laparoscopic Skills (GOALS) and a task-specific checklist. At the end of the study, the subjects completed an anonymous survey. The experienced group performed all of the tasks faster, with higher GOALS and checklist scores than the training and control groups (p≤.001). In the second assessment, the training group reduced the time needed to complete all of the tasks and obtained significantly higher GOALS and checklist scores than the control group. The participants perceived the CLS and its training program to be positive or very positive. The CLS and its training program demonstrated content and construct validity, supporting the suitability of the simulator for training and teaching and its ability to distinguish the degree of experience in laparoscopic surgery among veterinarians. In addition, face validity showed that the veterinarians fully accepted the CLS's usefulness for learning basic laparoscopic skills.

Effects of Field of View and Visual Complexity on Virtual Reality Training Effectiveness for a Visual Scanning Task

Virtual reality training systems are commonly used in a variety of domains, and it is important to understand how the realism of a training simulation influences training effectiveness. We conducted a controlled experiment to test the effects of display and scenario properties on training effectiveness for a visual scanning task in a simulated urban environment. The experiment varied the levels of field of view and visual complexity during a training phase and then evaluated scanning performance with the simulator's highest levels of fidelity and scene complexity. To assess scanning performance, we measured target detection and adherence to a prescribed strategy. The results show that both field of view and visual complexity significantly affected target detection during training; higher field of view led to better performance and higher visual complexity worsened performance. Additionally, adherence to the prescribed visual scanning strategy during assessment was best when the level of visual complexity during training matched that of the assessment conditions, providing evidence that similar visual complexity was important for learning the technique. The results also demonstrate that task performance during training was not always a sufficient measure of mastery of an instructed technique. That is, if learning a prescribed strategy or skill is the goal of a training exercise, performance in a simulation may not be an appropriate indicator of effectiveness outside of training-evaluation in a more realistic setting may be necessary.

Unanticipated teaching demands rise with simulation training: strategies for managing faculty workload

INTRODUCTION

Using simulation to teach and assess learners represents a powerful approach to training, but one that comes with hidden costs in terms of faculty time, even if programs adopt existing curricula. Some simulators are built to be used independently by learners, but much of the surgical simulation curricula developed for cognitive and psychomotor tasks requires active faculty involvement and low learner-to-faculty teaching ratios to ensure sufficient practice with feedback. The authors hypothesize that the added teaching demands related to simulation have resulted in a significant financial burden to surgery training programs. To date, the effect of simulation-based training on faculty workload has not been estimated objectively and reported in the literature.

METHODS

To test their hypothesis, the authors analyzed data from 2 sources: (1) changes over time (2006-2014) in formal teaching hours and estimated faculty costs at the University of Minnesota, General Surgery Department and (2) a 2014 online survey of general surgery program directors on their use of simulation for teaching and assessment and their perceptions of workload effects.

RESULTS

At the University of Minnesota, the total number of hours spent by department faculty in resident and student simulation events increased from 81 in annual year 2006 to 365 in annual year 2013. Estimated full-time equivalent faculty costs rose by 350% during the same period. Program directors (n = 48) of Association of Program Directors in Surgery reported either a slight (60%) or a significant (33%) increase in faculty workload with the advent of simulation, and moderate difficulty in finding enough instructors to meet this increase. Calling upon leadership for support, using diverse instructor types, and relying on "the dedicated few" represent the most common strategies.

CONCLUSION

To avoid faculty burnout and successfully sustain faculty investment in simulation-based training over time, programs need to be creative in building, sustaining, and managing the instructor workforce.

Education in wrist arthroscopy: past, present and future

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

V.

A review of training research and virtual reality simulators for the da Vinci surgical system

PHENOMENON: Virtual reality simulators are the subject of several recent studies of skills training for robot-assisted surgery. Yet no consensus exists regarding what a core skill set comprises or how to measure skill performance. Defining a core skill set and relevant metrics would help surgical educators evaluate different simulators.

APPROACH

This review draws from published research to propose a core technical skill set for using the da Vinci surgeon console. Publications on three commercial simulators were used to evaluate the simulators' content addressing these skills and associated metrics.

FINDINGS

An analysis of published research suggests that a core technical skill set for operating the surgeon console includes bimanual wristed manipulation, camera control, master clutching to manage hand position, use of third instrument arm, activating energy sources, appropriate depth perception, and awareness of forces applied by instruments. Validity studies of three commercial virtual reality simulators for robot-assisted surgery suggest that all three have comparable content and metrics. However, none have comprehensive content and metrics for all core skills. INSIGHTS: Virtual reality simulation remains a promising tool to support skill training for robot-assisted surgery, yet existing commercial simulator content is inadequate for performing and assessing a comprehensive basic skill set. The results of this evaluation help identify opportunities and challenges that exist for future developments in virtual reality simulation for robot-assisted surgery. Specifically, the inclusion of educational experts in the development cycle alongside clinical and technological experts is recommended.

Assessment of competence in pediatric gastrointestinal endoscopy

Gastrointestinal endoscopy is an invaluable tool for the diagnosis and treatment of upper and lower gastrointestinal diseases in children. Pediatric and adult endoscopy differ in several respects including differences in procedural indications, sedation practices, pre-procedure preparation, equipment, and the importance of routine tissue sampling and terminal ileum intubation. In the same way that performance of endoscopy in children requires pediatric-specific training, assessment of pediatric endoscopists requires an approach that is tailored to pediatric practice and the use of assessment methods and measures that have been developed and validated specifically within the pediatric context.

Haptics - touchfeedback technology widening the horizon of medicine

Haptics, or touchsense haptic technology is a major breakthrough in medical and dental interventions. Haptic perception is the process of recognizing objects through touch. Haptic sensations are created by actuators or motors which generate vibrations to the users and are controlled by embedded software which is integrated into the device. It takes the advantage of a combination of somatosensory pattern of skin and proprioception of hand position. Anatomical and diagnostic knowledge, when it is combined with this touch sense technology, has revolutionized medical education. This amalgamation of the worlds of diagnosis and surgical intervention adds precise robotic touch to the skill of the surgeon. A systematic literature review was done by using MEDLINE, GOOGLE SEARCH AND PubMed. The aim of this article was to introduce the fundamentals of haptic technology, its current applications in medical training and robotic surgeries, limitations of haptics and future aspects of haptics in medicine.

History of simulation in medicine: from Resusci Annie to the Ann Myers Medical Center

Medical and surgical graduate medical education has historically used a halstedian approach of "see one, do one, teach one." Increased public demand for safety, quality, and accountability in the setting of regulated resident work hours and limited resources is driving the development of innovative educational tools. The use of simulation in nonmedical, medical, and neurosurgical disciplines is reviewed in this article. Simulation has been validated as an educational tool in nonmedical fields such as aviation and the military. Across most medical and surgical subspecialties, simulation is recognized as a valuable tool that will shape the next era of medical education, postgraduate training, and maintenance of certification.

Virtual reality simulators for gastrointestinal endoscopy training

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees' learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-the-art simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.

Face, content, and construct validity of a novel portable ergonomic simulator for basic laparoscopic skills

OBJECTIVE

Laparoscopic skills can be improved effectively through laparoscopic simulation. The purpose of this study was to verify the face and content validity of a new portable Ergonomic Laparoscopic Skills simulator (Ergo-Lap simulator) and assess the construct validity of the Ergo-Lap simulator in 4 basic skills tasks.

DESIGN

Four tasks were evaluated: 2 different translocation exercises (a basic bimanual exercise and a challenging single-handed exercise), an exercise involving tissue manipulation under tension, and a needle-handling exercise. Task performance was analyzed according to speed and accuracy. The participants rated the usability and didactic value of each task and the Ergo-Lap simulator along a 5-point Likert scale.

SETTING

Institutional academic medical center with its affiliated general surgery residency.

PARTICIPANTS

Forty-six participants were allotted into 2 groups: a Novice group (n = 26, <10 clinical laparoscopic procedures) and an Experienced group (n = 20, >50 clinical laparoscopic procedures).

RESULTS

The Experienced group completed all tasks in less time than the Novice group did (p < 0.001, Mann-Whitney U test). The Experienced group also completed tasks 1, 2, and 4 with fewer errors than the Novice group did (p < 0.05). Of the Novice participants, 96% considered that the present Ergo-Lap simulator could encourage more frequent practice of laparoscopic skills. In addition, 92% would like to purchase this simulator. All of the experienced participants confirmed that the Ergo-Lap simulator was easy to use and useful for practicing basic laparoscopic skills in an ergonomic manner. Most (95%) of these respondents would recommend this simulator to other surgical trainees.

CONCLUSIONS

This Ergo-Lap simulator with multiple tasks was rated as a useful training tool that can distinguish between various levels of laparoscopic expertise. The Ergo-Lap simulator is also an inexpensive alternative, which surgical trainees could use to update their skills in the skills laboratory, at home, or in the office.

Development and evaluation of a canine laparoscopic simulator for veterinary clinical training

Human laparoscopic simulators have been used in medical education for minimally invasive surgery (MIS) in the past years. Simulator-based laparoscopic training has attracted much interest because unique skills have to be learned not only by surgeons in training but also by surgeons in practice. MIS forces the surgeon to adapt to monocular vision and decreased tactile sensation and entails training and improving hand-eye and hand-hand coordination. Those skills require a learning curve that could be overcome gradually with use of simulators. The Canine Laparoscopic Simulator (CLS) for laparoscopic training was developed based on the working and optical space obtained from computed tomography (CT) scan images of three Beagle dogs. Thirty veterinarians (expert group, n=7; novice group, n=23) performed basic laparoscopic exercises in one training session on the CLS. During the performance of the exercises, an experienced laparoscopic veterinarian assessed all the tasks. Afterwards, participants were asked to complete an anonymous survey describing their experience. Most participants expressed positive opinions about the design and usability of the CLS. There were no significant differences between the two groups' opinions. The CLS showed good preliminary acceptance in the basic laparoscopy tasks by veterinarians. They perceived it to be a good training tool, and these results suggest that CLS is an engaging tool for education but still has some limitations inherent in training boxes. Further studies would be needed to establish the validity of training programs performed in the CLS.

Open surgical simulation--a review

BACKGROUND

Surgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation.

CURRENT STATE OF OPEN SURGICAL SIMULATION

Open surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment.

FUTURE OF OPEN SURGICAL SIMULATION

The skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient's safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools.

The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study

INTRODUCTION

Colonoscopic simulators offer the opportunity for skill acquisition in the preclinical setting. Currently available simulators vary widely with respect to level of fidelity and technological sophistication. Despite the belief that more realistic is better, there is a paucity of evidence regarding the relative effectiveness of simulator fidelity (high vs low) on the acquisition of basic colonoscopic skills. We hypothesized that novice learners can acquire basic colonoscopic skills using simulators, however fidelity of the simulator does not make a difference.

METHODS

We randomly assigned novice third-year and fourth-year medical students to practice on either a low-fidelity or high-fidelity colonoscopy model. The low-fidelity model used is described in the module 16 of the American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for residents, Phase 1: basic or core skills and tasks < http://elearning.facs.org/mod/resource/view.php?1d=450 >. The high-fidelity model was the AccuTouch colonoscopy simulator, Immersion Medical (AccuTouch CS) that has 6 different simulated scenarios for diagnostic colonoscopy (level 1-6). Both groups had 16 students and were given standard instruction by an expert with respect to the procedure and instrument handling on both models. Both groups were pretested and posttested on level 1 of the AccuTouch CS. The high-fidelity group practiced on level 2 and 4 of the AccuTouch CS, whereas the low-fidelity group practiced on the low-fidelity model for 2 sessions of 1 hour each. The computer-based evaluation parameters available on the AccuTouch CS were used to compare performances.

RESULTS

Both groups had similar demographics. There were no significant differences in the baseline performances of either group. Each group demonstrated significant improvement for insertion time and percentage of mucosa visualized. However, there were no significant differences between the groups on posttesting on any of the measured parameters.

CONCLUSIONS

Colonoscopic skill training on a low-fidelity model appears to be as effective as high-fidelity model training for basic endoscopic skill acquisition for novice learners.

Collaboration in simulation: the development and initial validation of a novel thoracoscopic neonatal simulator

PURPOSE

We sought to create and validate a high fidelity, anatomically correct real tissue simulation model for thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair.

METHODS

A scale reproduction of a neonatal rib cage was created. Surgically modified (EA/TEF) fetal bovine tissue completed the simulator. Nine pediatric surgery fellows and two attending pediatric surgeons (n=11) performed the simulated thoracoscopic EA/TEF repair. Participants completed a self-report rating scale, ranging from 1 (Don't know) to 5 (Highly realistic). Construct validity relevant to test content was evaluated by examining the ratings using the many-Facet Rasch model.

RESULTS

Analyses indicated no differences when comparing faculty (Observed Average (OA)=4.5/5.0) to fellow (OA=3.3) ratings, p=.71. In descending order, observed averages of the domains were 4.7 (Relevance), 4.5 (Physical attributes), 4.5 (Realism of materials), 4.4 (Ability to perform task), and 4.2 (Value). The observed Global opinion rating indicated the simulator can be considered for teaching thoracoscopic EA/TEF repair but could be improved slightly.

CONCLUSIONS

Fellow and faculty ratings indicated the simulator was valuable as a learning tool with minor modifications. Comments were consistent with high physical attribute ratings.

Review of influential articles in surgical education: 2002-2012

BACKGROUND

Exploring the trends in surgical education research offers insight into concerns, developments, and questions researchers are exploring that are relevant to teaching and learning in surgical specialties.

OBJECTIVE

We conducted a review of the surgical education literature published between 2002 and 2012. The purpose was 2-fold: to provide an overview of the most frequently cited articles in the field of surgical education during the last decade and to describe the study designs and themes featured in these articles.

METHODS

Articles were identified through Web of Science by using "surgical education" and "English language" as search terms. Using a feature in Web of Science, we tracked the number of citations of any publication. Of the 800 articles produced by the initial search, we initially selected 23 articles with 45 or more citations, and ultimately chose the 20 articles that were most frequently cited for our analysis.

RESULTS

Analysis of the most frequently cited articles published in US journals between the years 2002-2012 identified 7 research themes and presented them in order of frequency with which they appear: use of simulation, issues in student/resident assessment, specialty choice, patient safety, team training, clinical competence assessment, and teaching the clinical sciences, with surgical simulation being the central theme. Researchers primarily used descriptive methods.

CONCLUSIONS

Popular themes in surgical education research illuminate the information needs of surgical educators as well as topics of high interest to the surgical community.

Sensor fusion for laparoscopic surgery skill acquisition

Surgical techniques are becoming more complex and require substantial training to master. The development of automated, objective methods to analyze and evaluate surgical skill is necessary to provide trainees with reliable and accurate feedback during their training programs. We present a system to capture, visualize, and analyze the movements of a laparoscopic surgeon for the purposes of skill evaluation. The system records the upper body movement of the surgeon, the position, and orientation of the instruments, and the force and torque applied to the instruments. An empirical study was conducted using the system to record the performances of a number of surgeons with a wide range of skill. The study validated the usefulness of the system, and demonstrated the accuracy of the measurements.

Teaching and assessing procedural skills: a qualitative study

BACKGROUND

Graduating Internal Medicine residents must possess sufficient skills to perform a variety of medical procedures. Little is known about resident experiences of acquiring procedural skills proficiency, of practicing these techniques, or of being assessed on their proficiency. The purpose of this study was to qualitatively investigate resident 1) experiences of the acquisition of procedural skills and 2) perceptions of procedural skills assessment methods available to them.

METHODS

Focus groups were conducted in the weeks following an assessment of procedural skills incorporated into an objective structured clinical examination (OSCE). Using fundamental qualitative description, emergent themes were identified and analyzed.

RESULTS

Residents perceived procedural skills assessment on the OSCE as a useful formative tool for direct observation and immediate feedback. This positive reaction was regularly expressed in conjunction with a frustration with available assessment systems. Participants reported that proficiency was acquired through resident directed learning with no formal mechanism to ensure acquisition or maintenance of skills.

CONCLUSIONS

The acquisition and assessment of procedural skills in Internal Medicine programs should move toward a more structured system of teaching, deliberate practice and objective assessment. We propose that directed, self-guided learning might meet these needs.

The optimal frequency of endoscopic skill labs for training and skill retention on suturing: a randomized controlled trial

OBJECTIVE

To determine, given a fixed amount of training, the optimal distribution of sessions needed to acquire intracorporeal endoscopic suturing skills and to retain said skills for 1 to 6 months.

DESIGN

A randomized controlled trial consisted of 6 study groups who received identical laparoscopic suturing training but at differing frequencies of sessions.

SETTING

The faculty of medicine of the KULEUVEN is the largest medical faculty in Belgium.

PARTICIPANTS

Medical students without experience in laparoscopy (n = 145).

METHODS

After baseline assessments, the students were randomized into 6 groups to receive 6 training sessions of 1.5 hours each. Training Groups were as follows: 3 sessions daily (TD), bidaily sessions, 1 session daily (OD), 1 session on alternative days, 1 session weekly, and 1 session weekly with an optional "deliberate practice" in between sessions (WD). All exercises and feedback given were identical. One and 6 months after the final session, an evaluation was performed where a 5-cm chicken-skin incision had to be closed with 3 laparoscopic knots. The cumulative time to approximate the skin edges adequately was used for qualitative and quantitative analysis.

RESULTS

There were no significant differences amongst the groups at baseline concerning ambidexterity, motivation, or spatial abilities. The group OD outperformed the massed groups (TD and bidaily sessions) and the weekly groups (1 session weekly and WD) significantly (p = 0.003). After 1 month there was still a significant advantage for regular training groups (OD, 1 session on alternative days, and WD) over massed training groups (TD) (p = 0.004). After 6 months only a statistical difference (p = 0.04) between group OD and group TD was observed. Group WD's score remained stable after 6 months.

CONCLUSIONS

Short-term, once daily 1.5-hours session seems most beneficial for learning intracorporeal endoscopic suturing. After 6 months, distributed shorter training still remains better than massed practice but weekly training and daily training are comparable. "Optional Deliberate Practice" between the official training sessions reduces skill decay.

Enhancing Fundamental Robot-Assisted Surgical Proficiency by Using a Portable Virtual Simulator

Background. The development of a virtual reality (VR) training platform provides an affordable interface. The learning effect of VR and the capability of skill transfer from the VR environment to clinical tasks require more investigation. Methods. Here, 14 medical students performed 2 fundamental surgical tasks—bimanual carrying (BC) and peg transfer (PT)—in actual and virtual environments. Participants in the VR group received VR training, whereas participants in the control group played a 3D game. The learning effect was examined by comparing kinematics between pretraining and posttraining in the da Vinci Surgical System. Differences between VR and playing the 3D game were also examined. Results. Those who were trained with the VR simulator had significantly better performance in both actual PT ( P = .002) and BC ( P < .001) tasks. The time to task completion and the total distance traveled were significantly decreased in both surgical tasks in the VR group compared with the 3D game group. However, playing the 3D game showed no significant enhancement of fundamental surgical skills in the actual PT task. The difference between pretraining and posttraining was significantly larger in the VR group than in the 3D game group in both the time to task completion ( P = .002) and the total distance traveled ( P = .027) for the actual PT task. Participants who played the 3D game seemed to perform even worse in posttraining. Conclusions. Training with the portable VR simulator improved robot-assisted surgical skill proficiency in comparison to playing a 3D game.

Program for laparoscopic urologic skills: a newly developed and validated educational program

OBJECTIVE

To develop and evaluate a program for laparoscopic urologic skills (PLUS) to determine the face, content, and construct validation to achieve uniformity and standardization in training residents in urology.

METHODS

The PLUS consists of 5 basic laparoscopic tasks. Three tasks were abstracted from the Fundamentals of Laparoscopic Surgery program, and 2 additional tasks were developed under continuous evaluation by expert urologists. Fifty participants were recruited from different hospitals and performed the final PLUS training. They all completed a questionnaire after performance. Three outcome parameters were measured: performance quality, time, and dropped objects. The relationship between laparoscopic experience and the outcome parameters was investigated.

RESULTS

Of the 50 participants, 13 were students, 20 were residents, and 17 were urologists. Double-log linear regression analysis for all 5 tasks showed a significant effect (effect size range 0.53-0.82; P < .0005) for laparoscopic experience on performance time. Substantial correlations were found between experience and quality ratings (log-linear regression effect size 0.37; P = .012) and the number of dropped objects (Spearman correlation effect size 0.49; P < .01). The usefulness of the PLUS model as a training tool for basic laparoscopic skills was rated 4.55 on a scale from 1 (not useful) to 5 (useful) (standard deviation 0.58; range 3-5).

CONCLUSION

The results of the present study indicated the face, content, and construct validity for the PLUS. The training is considered appropriate for use as a primary training tool for an entry test or as part of a step-wise training program in which basic and procedural laparoscopic skills are integrated.

Towards an augmented ultrasound guided spinal needle insertion system

We propose a haptic-based simulator for ultrasound-guided percutaneous spinal interventions. The system is composed of a haptic device to provide force feedback, a camera system to display video and augmented computed tomography (CT) overlay, a finite element model for tissue deformation and US simulation from a CT volume. The proposed system is able to run a large finite element model at the required haptic rate for smooth force feedback, and uses haptic device position measurements for a steady response. The simulated US images from CT closely resemble the vertebrae images captured in vivo. This is the first report of a system that provides a training environment to couple haptic feedback with a tracked mannequin, and a CT volume overlaid on a visual feed of the mannequin.

Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy

BACKGROUND

Traditionally, training in gastrointestinal endoscopy has been based upon an apprenticeship model, with novice endoscopists learning basic skills under the supervision of experienced preceptors in the clinical setting. Over the last two decades, however, the growing awareness of the need for patient safety has brought the issue of simulation-based training to the forefront. While the use of simulation-based training may have important educational and societal advantages, the effectiveness of virtual reality gastrointestinal endoscopy simulators has yet to be clearly demonstrated.

OBJECTIVES

To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience.

SEARCH METHODS

Health professions, educational and computer databases were searched until November 2011 including The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Scopus, Web of Science, Biosis Previews, CINAHL, Allied and Complementary Medicine Database, ERIC, Education Full Text, CBCA Education, Career and Technical Education @ Scholars Portal, Education Abstracts @ Scholars Portal, Expanded Academic ASAP @ Scholars Portal, ACM Digital Library, IEEE Xplore, Abstracts in New Technologies and Engineering and Computer & Information Systems Abstracts. The grey literature until November 2011 was also searched.

SELECTION CRITERIA

Randomised and quasi-randomised clinical trials comparing virtual reality endoscopy (oesophagogastroduodenoscopy, colonoscopy and sigmoidoscopy) simulation training versus any other method of endoscopy training including conventional patient-based training, in-job training, training using another form of endoscopy simulation (e.g. low-fidelity simulator), or no training (however defined by authors) were included.  Trials comparing one method of virtual reality training versus another method of virtual reality training (e.g. comparison of two different virtual reality simulators) were also included. Only trials measuring outcomes on humans in the clinical setting (as opposed to animals or simulators) were included.

DATA COLLECTION AND ANALYSIS

Two authors (CMS, MES) independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. Due to significant clinical and methodological heterogeneity it was not possible to pool study data in order to perform a meta-analysis. Where data were available for each continuous outcome we calculated standardized mean difference with 95% confidence intervals based on intention-to-treat analysis. Where data were available for dichotomous outcomes we calculated relative risk with 95% confidence intervals based on intention-to-treat-analysis.

MAIN RESULTS

Thirteen trials, with 278 participants, met the inclusion criteria. Four trials compared simulation-based training with conventional patient-based endoscopy training (apprenticeship model) whereas nine trials compared simulation-based training with no training. Only three trials were at low risk of bias. Simulation-based training, as compared with no training, generally appears to provide participants with some advantage over their untrained peers as measured by composite score of competency, independent procedure completion, performance time, independent insertion depth, overall rating of performance or competency error rate and mucosal visualization. Alternatively, there was no conclusive evidence that simulation-based training was superior to conventional patient-based training, although data were limited.

AUTHORS' CONCLUSIONS

The results of this systematic review indicate that virtual reality endoscopy training can be used to effectively supplement early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience. However, there remains insufficient evidence to advise for or against the use of virtual reality simulation-based training as a replacement for early conventional endoscopy training (apprenticeship model) for health professions trainees with limited or no prior endoscopic experience. There is a great need for the development of a reliable and valid measure of endoscopic performance prior to the completion of further randomised clinical trials with high methodological quality.

Validation of a new box trainer-related tracking device: the TrEndo

Background

There is an increasing demand for structured objective ex vivo training and assessment of laparoscopic psychomotor skills prior to implementation of these skills in practice. The aim of this study was to establish the internal validity of the TrEndo, a motion-tracking device, for implementation on a laparoscopic box trainer.

Methods

Face validity and content validity were addressed through a structured questionnaire. To assess construct validity, participants were divided into an expert group and a novice group and performed two basic laparoscopic tasks. The TrEndo recorded five motion analysis parameters (MAPs) and time.

Results

Participants demonstrated a high regard for face and content validity. All recorded MAPs differed significantly between experts and novices after performing a square knot. Overall, the TrEndo correctly assigned group membership in 84.7 and 95.7% of cases based on two laparoscopic tasks.

Conclusion

Face, content, and construct validities of the TrEndo were established. The TrEndo holds real potential as a (home) training device.

Teaching aseptic technique for central venous access under ultrasound guidance: a randomized trial comparing didactic training alone to didactic plus simulation-based training

BACKGROUND

Our goal was to determine whether simulation combined with didactic training improves sterile technique during ultrasound (US)-guided central venous catheter (CVC) insertion compared with didactic training alone among novices. We hypothesized that novices who receive combined didactic and simulation-based training would perform similarly to experienced residents in aseptic technique, knowledge, and perception of comfort during US-guided CVC insertion on a simulator.

METHODS

Seventy-two subjects were enrolled in a randomized, controlled trial of an educational intervention. Fifty-four novices were randomized into either the didactic group or the simulation combined with didactic group. Both groups received didactic training but the simulation combined with didactic group also received simulation-based CVC insertion training. Both groups were tested by demonstrating US-guided CVC insertion on a simulator. Aseptic technique was scored on 8 steps as "yes/no" and also using a 7-point Likert scale with 7 being "excellent technique" by a rater blinded to subject randomization. After initial testing, the didactic group was offered simulation-based training and retesting. Both groups also took a pre- and posttraining test of knowledge and rated their comfort with US and CVC insertion pre- and posttraining on a 5-point Likert scale. Subsequently, 18 experienced residents also took the test of knowledge, rated their comfort level, and were scored while performing aseptic US-guided CVC insertion using a simulator.

RESULTS

The simulation combined with didactic group achieved a 167% (95% confidence interval [CI] 133%-167%) incremental increase in yes/no scores and 115% (CI 112%-127%) incremental increase in Likert scale ratings on aseptic technique compared with novices in the didactic group. Compared with experienced residents, simulation combined with didactic trained novices achieved an increase in aseptic scores with a 33.3% (CI 16.7%-50%) increase in yes/no ratings and a 20% (CI 13.3%-40%) increase in Likert scaled ratings, and scored 2.5-fold higher on the test of knowledge. There was a 3-fold increase in knowledge and 2-fold increase in comfort level among all novices (P < 0.001) after combined didactic and simulation-based training.

CONCLUSION

Simulation combined with didactic training is superior to didactic training alone for acquisition of clinical skills such as US-guided CVC insertion. After combined didactic and simulation-based training, novices can outperform experienced residents in aseptic technique as well as in measurements of knowledge.

[Preliminary validation of the Simulap(®) physical simulator and its assessment system for laparoscopic surgery]

INTRODUCTION

Our aim is to assess the face and content validities of the physical simulator Simulap(®), as well as the construct validity of its assessment method.

MATERIAL AND METHODS

Five novice surgeons (G1) and five experts (G2) performed seven basic tasks and one suturing exercise on Simulap(®), which were assessed through an exam based on mistakes and performance time. Face and content validations were carried out by novice surgeons and expert surgeons, respectively. Both validations consisted of a questionnaire graded on a five-point scale about the Simulap(®) and its tasks. Construct validity of the assessment system was determined by comparing the scores of both groups.

RESULTS

Surgeons rated the Simulap(®) simulator and its training program positively, obtaining an average score of 4±1.1 for G1 and of 4.9±0.6 for G2. G2 considered training on Simulap(®) very useful for the training of residents and surgeons, obtaining a maximum score of 5. G2 outperformed G1 in all task scores, with statistically significant differences in the eye-hand coordination (G1: 52.2±6.7 vs. G2: 39.6±6.5; P=.027), dissection (G1: 301.8±100.2 vs. G2: 150.8±66.7; P=.028) and suturing exercises (G1: 258.5±87.0 vs. G2: 108.4±20.2; P=.009).

CONCLUSIONS

The assessment method for Simulap(®) is able to distinguish different levels of experience in laparoscopic surgery. Furthermore, this simulator showed a great acceptance by surgeons for the learning of basic skills.

Halting the revolving door of faculty turnover: recruiting and retaining clinician educators in an academic medical simulation center

Simulation-based education is indispensable in preparing healthcare providers for patient care. Simulation centers and programs that serve as a critical platform for promoting patient safety and high-quality training depend on multiple requirements for success: diversified and sustainable financing, technical personnel with a long-term commitment to simulation education, simulation and information technology infrastructure designed to match priority training needs, and resources for curricular development, instruction, faculty development, and research. An additional requirement not widely discussed in the literature is the recruitment and retention of faculty who serve as simulation educators, which is the focus of this report.

Optimizing integration of electrosurgical hand controls within a laparoscopic surgical tool

Abstract In laparoscopic surgery, electrosurgical equipment is operated by means of one or more foot pedals positioned on the floor in front of the surgeon causing poor ergonomic posture and physical discomfort. The focus of this study was to ergonomically explore the integration of electrosurgical hand controls within the previously designed Intuitool™ laparoscopic surgical instrument to optimize functionality. Three different hand control designs (CDs) were implemented within the Intuitool™ and each CD contained the standard cutting and coagulation features, previously operated by foot pedals. This study used 26 right-handed participants, with no previous laparoscopic surgery experience. The participants completed simple tasks using all three CDs within a simulated abdomen. Electromyography (EMG) sensors and force sense resistors (FSRs) were utilized to measure muscle activity and button actuation force, respectively. A questionnaire was also utilized to measure comfort level of each CD. The results indicated that the close proximity of CD 1 generated greater actuation force for all tasks, was rated easier to use (P = 0.003) and was preferred more frequently by the participants (53.8%) compared to CD 2 and 3. As a result, CD 1 was determined to be an optimal ergonomic design for electrosurgical hand controls within the Intuitool™.

Prospective randomized controlled trial of simulator-based versus traditional in-surgery laparoscopic camera navigation training

BACKGROUND

Surgical residents often use a laparoscopic camera in minimally invasive surgery for the first time in the operating room (OR) with no previous education or experience. Computer-based simulator training is increasingly used in residency programs. However, no randomized controlled study has compared the effect of simulator-based versus the traditional OR-based training of camera navigation skills.

METHODS

This prospective randomized controlled study included 24 pregraduation medical students without any experience in camera navigation or simulators. After a baseline camera navigation test in the OR, participants were randomized to six structured simulator-based training sessions in the skills lab (SL group) or to the traditional training in the OR navigating the camera during six laparoscopic interventions (OR group). After training, the camera test was repeated. Videos of all tests (including of 14 experts) were rated by five blinded, independent experts according to a structured protocol.

RESULTS

The groups were well randomized and comparable. Both training groups significantly improved their camera navigational skills in regard to time to completion of the camera test (SL P = 0.049; OR P = 0.02) and correct organ visualization (P = 0.04; P = 0.03). Horizon alignment improved without reaching statistical significance (P = 0.20; P = 0.09). Although both groups spent an equal amount of actual time on camera navigation training (217 vs. 272 min, P = 0.20), the SL group spent significantly less overall time in the skill lab than the OR group spent in the operating room (302 vs. 1002 min, P < 0.01).

CONCLUSION

This is the first prospective randomized controlled study indicating that simulator-based training of camera navigation can be transferred to the OR using the traditional hands-on training as controls. In addition, simulator camera navigation training for laparoscopic surgery is as effective but more time efficient than traditional teaching.

Teaching and training in laparoscopic surgery: experience of Catholic Laparoscopy Advanced Surgery School in the basic gynecological surgery

PURPOSE

To evaluate the effectiveness of our training method for basic "hands-on" laparoscopic courses.

METHODS

A prospective observational study between September 2008 and December 2010 at Catholic Laparoscopy Advanced Surgery School of the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Sacred Heart-Rome, was conducted. Each course lasted for 3 days, divided into theoretical and practical parts, ending with a live surgery. Gynecologists who attended our 'hands-on' laparoscopic courses had no or minimum experience with laparoscopic technique. The teachers were expert laparoscopists of our Division, and every single group of participants had the same tutor for the entire course. Trainees completed self-assessment anonymous questionnaire of laparoscopic knowledge, before and immediately after the course.

RESULTS

During the study period, we performed 20 basic courses, enrolling 120 consecutive gynecologists. Among them, 114 (95%) decided to participate. Average age was 41 years (range 35-60 years) and 108 (94.7%) trainees were Italian. The subjective assessment showed an immediate improvement of motor skills.

CONCLUSIONS

Laparoscopic training course can improve both theoretical knowledge and motor skills. Such courses result in a short-term subjective improvement.

Progress in virtual reality simulators for surgical training and certification

There is increasing evidence that educating trainee surgeons by simulation is preferable to traditional operating-room training methods with actual patients. Apart from reducing costs and risks to patients, training by simulation can provide some unique benefits, such as greater control over the training procedure and more easily defined metrics for assessing proficiency. Virtual reality (VR) simulators are now playing an increasing role in surgical training. However, currently available VR simulators lack the fidelity to teach trainees past the novice-to-intermediate skills level. Recent technological developments in other industries using simulation, such as the games and entertainment and aviation industries, suggest that the next generation of VR simulators should be suitable for training, maintenance and certification of advanced surgical skills. To be effective as an advanced surgical training and assessment tool, VR simulation needs to provide adequate and relevant levels of physical realism, case complexity and performance assessment. Proper validation of VR simulators and an increased appreciation of their value by the medical profession are crucial for them to be accepted into surgical training curricula.

Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit

INTRODUCTION

Interventions to reduce preventable complications such as catheter-related bloodstream infections (CRBSI) can also decrease hospital costs. However, little is known about the cost-effectiveness of simulation-based education. The aim of this study was to estimate hospital cost savings related to a reduction in CRBSI after simulation training for residents.

METHODS

This was an intervention evaluation study estimating cost savings related to a simulation-based intervention in central venous catheter (CVC) insertion in the Medical Intensive Care Unit (MICU) at an urban teaching hospital. After residents completed a simulation-based mastery learning program in CVC insertion, CRBSI rates declined sharply. Case-control and regression analysis methods were used to estimate savings by comparing CRBSI rates in the year before and after the intervention. Annual savings from reduced CRBSIs were compared with the annual cost of simulation training.

RESULTS

Approximately 9.95 CRBSIs were prevented among MICU patients with CVCs in the year after the intervention. Incremental costs attributed to each CRBSI were approximately $82,000 in 2008 dollars and 14 additional hospital days (including 12 MICU days). The annual cost of the simulation-based education was approximately $112,000. Net annual savings were thus greater than $700,000, a 7 to 1 rate of return on the simulation training intervention.

CONCLUSIONS

A simulation-based educational intervention in CVC insertion was highly cost-effective. These results suggest that investment in simulation training can produce significant medical care cost savings.