Resident perceptions of advanced laparoscopic skills training

Confronting new challenges: Faculty perceptions of gaps in current laparoscopic curricula in a changing training landscape

Background

Opportunities for residents to develop laparoscopic skills have decreased with the rise in robotic operations and the development of complex, subspecialized laparoscopic operations. Given the changing training landscape, this study aimed to identify laparoscopic surgeons' perceptions of gaps in current laparoscopic skills in general surgery, obstetrics-gynecology, and urology residency programs.

Methods

Laparoscopic surgeons who operate with residents participated in semi-structured interviews. Questions addressed expectations for resident proficiency, deficits in laparoscopic surgical skills, and barriers to learning and teaching. Two authors independently coded de-identified transcripts followed by a conventional content analysis.

Results

Fourteen faculty members from thirteen subspecialties participated. Faculty identified three main areas to improve laparoscopic training across specialties: foundational knowledge, technical skills, and cognitive skills. They also recognized an overarching opportunity to address faculty development.

Conclusions

This qualitative study highlighted key deficiencies in laparoscopic training that have emerged in the current, changing era of minimally invasive surgery.

Key message

This qualitative study identified laparoscopic educators' perceptions of deficiencies in laparoscopic training. Findings emphasized the importance of incorporating high quality educational practices to optimize training in the current changing landscape of laparoscopic surgery.

Assessment of Minimally Invasive Suturing Skills: Is Instrument Tracking an Accurate Prediction?

Introduction: Minimally invasive surgery (MIS) suturing demands advanced surgical skills. Therefore, it is important these skills are adequately trained and assessed. Assessment and feedback can consist of judgments and scores of expert observers or objective parameters using instrument tracking. The aim of this study was to determine to what extent objective parameters correspond to expert assessment. Methods: Participants performed an intracorporeal suturing task on the EoSim simulator repeatedly (maximum 20 repetitions) during training. The best discriminating parameters, which previously shown construct validation, were combined into a composite score, using regression analysis. All videos were blinded and assessed by 2 independent reviewers using the validated laparoscopic suturing competency assessment tool (LS-CAT). These scores were compared with the composite score. Results: A 100 videos of 16 trainees, during separate points on their learning curve, and 8 experts were used. The parameters "time" and "distance" were statistically significantly correlated with all LS-CAT domains. The composite score (calculated from "time" and "distance") showed improvement between the first and the last knot (57% versus 94%, P < .001). Also the LS-CAT score improved (28 versus 17, P < .001). However, the correlation of the composite score with the LS-CAT score was weak (R: 0.351), with an accuracy of 55/100 when pooling the outcomes based on inadequate, adequate, or good performance. Conclusion: Instrument tracking parameters (using Surgtrac) could give an indication of the skill level, however, it missed important elements, essential for reliable assessment. Therefore, expert assessment remains superior to determine the skill level in MIS suturing skills.

An Ex Situ Cadaver Liver Training Model Continuously Pressurized to Simulate Specific Skills Involved in Laparoscopic Liver Resection: the Lap-Liver Trainer

BACKGROUND

Laparoscopic liver resection (LLR) requires delicate skills. The aim of the study was to develop a training model mimicking as much as possible intraoperative bleeding and bile leakage during LLR. We also assessed the educational value of the training model.

METHODS

The Lap-liver trainer (LLT) combined a continuously pressurized ex situ cadaver liver and a customized mannequin. The customized mannequin was designed by computer-aided design and manufactured by 3D printing. The left lateral sectionectomy (LLS) was chosen to assess the feasibility of a LLR with the LLT. Eighteen volunteers were recruited to perform LLS and to assess the educational value of the LLT using a Likert scale.

RESULTS

The customized mannequin consisted of a close laparoscopic training device based on a simplified reconstruction of the abdominal cavity in laparoscopic conditions. Ex situ cadaver livers were pressurized to simulate blood and bile supplies. Each expert surgeon (n = 3) performed two LLS. They were highly satisfied of simulation conditions (4.80 ± 0.45) and strongly recommended that the LLT should be incorporated into a teaching program (5.00 ± 0.0). Eight novice and 4 intermediate surgeons completed a teaching program and performed a LLS. Overall, the level of satisfaction was high (4.92 ± 0.29), and performing such a procedure under simulation conditions benefited their learning and clinical practice (4.92 ± 0.29).

CONCLUSIONS

The LLT could provide better opportunities for trainees to acquire and practice LLR skills in a more realistic environment and to improve their ability to deal with specific events related to LLR.

Cadaver Training for Minimally Invasive Pediatric Surgery: A Preliminary Report

Aim: To report the value of adult cadavers for training in minimally invasive surgical (MIS) techniques for pediatric surgery (PS). Materials and Methods: Three teams, each consisting of a board-certified consultant pediatric surgeon (CS), a senior trainee (ST), and a junior trainee (JT), attended a cadaver surgical training (CST) course involving five procedures: thoracoscopic esophagoesophagostomy (TEE), thoracoscopic right lower lobectomy (TRL), laparoscopic fundoplication (LFN), laparoscopic hepaticoduodenostomy (LHD), and laparoscopic ureteroureterostomy (LUU). The same teams also performed LFN on live pigs. Attendees (3 CSs, 3 STs, and 3 JTs) were administered a questionnaire to rate their CST experience according to five criteria (tissue texture, organ size, operative field, "feel," and anatomic relationships) using a 4-point scale with 0 being the worst response. Scores were averaged per procedure per attendee groups and compared. LFN was also compared between a cadaver and a pig. Results: End-point (1): For LFN, cadaver scores were significantly higher than pig scores for anatomic relationships (P = .0001), operative field (P = .0053), and organ size (P = .0481). End-point (2): TRL and LFN were ranked together as being most realistic, followed by TEE and LUU, then LHD. End-point (3): Anatomic relationships and operative field consistently scored highly for all attendee groups. End-point (4): CSs and STs tended to award higher scores than JTs although differences were not statistically significant. Conclusions: CST is a valuable opportunity for PS trainees to experience highly realistic training in minimally invasive surgery. Pig training was inferior. IRB Number: 2019173.

The effects of unilateral transcranial direct current stimulation on unimanual laparoscopic peg-transfer task

INTRODUCTION

Efficient training methods are required for laparoscopic surgical skills training to reduce the time needed for proficiency. Transcranial direct current stimulation (tDCS) is widely used to enhance motor skill acquisition and can be used to supplement the training of laparoscopic surgical skill acquisition. The aim of this study was to investigate the effect of anodal tDCS over the primary motor cortex (M1) on the performance of a unimanual variant of the laparoscopic peg-transfer task.

METHODS

Fifteen healthy subjects participated in this randomized, double-blinded crossover study involving an anodal tDCS and a sham tDCS intervention separated by 48 h. On each intervention day, subjects performed a unimanual variant of laparoscopic peg-transfer task in three sessions (baseline, tDCS, post-tDCS). The tDCS session consisted of 10 min of offline tDCS followed by 10 min of online tDCS. The scores based on the task completion time and the number of errors in each session were used as a primary outcome measure. A linear mixed-effects model was used for the analysis.

RESULTS

We found that the scores increased over sessions (p < 0.01). However, we found no effects of stimulation (anodal tDCS vs. sham tDCS) and no interaction of stimulation and sessions.

CONCLUSION

This study suggests that irrespective of the type of current stimulation (anodal and sham) over M1, there was an improvement in the performance of the unimanual peg-transfer task, implying that there was motor learning over time. The results would be useful in designing efficient training paradigms and further investigating the effects of tDCS on laparoscopic peg-transfer tasks.

Continuum of Surgical Skill Acquisition for the Postgraduate Residents During COVID Pandemic: Role of Advanced Simulators in a Multipronged Modular Approach

Skill acquisition with required competencies as defined by the National Medical Commission for the postgraduate surgical residents can happen in a step-wise manner from novice or advanced beginner to competent levels. This requires well-defined program-specific objectives, teaching-learning and assessment methods as per the competency-based medical education curriculum. Various modalities of teaching for the residents are adapted during the COVID pandemic to maintain the continuum of learning. In this study, we have attempted to develop, implement, and evaluate the effectiveness of acquiring laparoscopic surgical skills using advanced simulators and with large live animal in a real-life situation by a modular training approach. This skill-based program was developed and implemented for final year General Surgery postgraduate residents of Yenepoya Medical College for training laparoscopic surgical competencies. The training was conducted at Advanced Simulation Centres of Yenepoya (Deemed to be University), Mangalore, Karnataka, India. Three training modules were prepared based on the competency-based medical education curriculum for incremental training with advanced simulators and large live animals in a real-life situation which included the sessions on briefing, scenarios, simulations, hands-on activities, debriefing, feedback, and assessment methods. Assessment after the modular training showed statistically significant improvement in their scores, and they scaled up their skill acquisition ladder after each module. The residents and faculty felt that integration from different specialties has increased their confidence levels and communication skills, exploring team dynamics with 1:1 mentorship to make them competent emphasizing the effectiveness of simulation-based training even during the pandemic.

Does the advanced training in laparoscopic suturing enhance laparoscopic suturing skill beyond fundamentals of laparoscopic surgery?

BACKGROUND

Laparoscopic suturing is associated with a steep learning curve. Hence, many general surgery graduate residents entering fellowship have reportedly not been able to proficiently suture laparoscopically despite achieving Fundamentals of Laparoscopic Surgery certification. To address this deficiency, the Advanced Training in Laparoscopic Suturing curriculum was developed. This study aimed to compare the effectiveness of the Advanced Training in Laparoscopic Suturing curriculum in improving laparoscopic suturing skills compared with Fundamentals of Laparoscopic Surgery training.

METHODS

Novices were enrolled in a prospective randomized controlled study. All novices followed proficiency-based training on Fundamentals of Laparoscopic Surgery peg-transfer and intracorporeal suturing. Students were then stratified based on their peg-transfer performance and randomized into an Advanced Training in Laparoscopic Suturing or Fundamentals of Laparoscopic Surgery group. The Advanced Training in Laparoscopic Suturing group trained on 3 of the 6 Advanced Training in Laparoscopic Suturing tasks (needle handling, offset forehand suturing, confined space suturing), while the Fundamentals of Laparoscopic Surgery group was assigned more stringent suturing performance goals. Each group trained for an additional 6 hours, after which the laparoscopic suturing performance of the 2 groups was compared on a Nissen fundoplication porcine model.

RESULTS

Thirty-nine medical students were enrolled in the study; 17 (11 males and 6 females) completed the study protocol (44%). Controlling for confounders including the student suturing performance at the end of stage-1 training, the Advanced Training in Laparoscopic Suturing group at the porcine model was significantly faster/safer (coefficient = 102.7, P = .037), and more skilled (coefficient = 19.1, P = .048) compared with the Fundamentals of Laparoscopic Surgery group.

CONCLUSION

Compared with Fundamentals of Laparoscopic Surgery training alone the Advanced Training in Laparoscopic Suturing curriculum further enhances the laparoscopic suturing skill of novices. These findings support incorporating Advanced Training in Laparoscopic Suturing into existing skills curricula.

Public Perceptions of General Surgery Residency Training

OBJECTIVE

Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety.

DESIGN

This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training.

CONCLUSIONS

Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.

Simulation in Hernia Surgery: Where Do We Stand?

Simulation seems to be the best method of improving medical attitude, technical skills, and operating times. A literature review of the available data in simulation for hernia surgery was performed. Surgical simulation has been included as a main requirement in residency programs and endorsed by several surgical societies. However, evaluating how simulation affects patient's outcomes is challenging. In addition, simulation training represents an institutional economic burden that could undermine its implementation and development. Published data support that simulation-based training is a highly efficient tool, thus, its implementation should be strongly encouraged.

Training for laparoscopic colorectal surgery creating an appropriate porcine model and curriculum for training

Background

Laparoscopic colorectal surgery (LCRS) was first described in 1991, and its safety, efficacy and patient benefit were adequately documented in literature. However, its penetration and acceptability is poor in most countries, due to its long learning curve and lack of surgeons training and confidence. A Minimal Access Surgery (MAS) Training Center in Mumbai has over the last 7 years trained more than 8000 surgeons in various MAS specialities. The centre has initiated courses for LCRS training.

Materials and Methods

The anatomy of the pig colon is very different from human anatomy. The pig colon anatomy is altered to mimic human colon anatomy in the porcine abdomen, permitting hands-on practice on most laparoscopic colorectal surgical procedures, as part of the LCRS training course, under mentorship of expert faculty, who simultaneously assess participants performance.

Results

Each participant performs and assists for at least three procedures and is evaluated at each step of the procedure by a structured format. The overall evaluation by Faculty which though subjective, is detailed and favourable. Feedback of each participant is good and acceptable as a very helpful course.

Conclusion

This porcine model is ideal for hands-on training for LCRS. Participants achieve a good degree of skill level and confidence in performing LCRS procedures on fresh bleeding porcine cadaver models. The centre is factual and pragmatic and stresses that it needs more than a course to make a safe surgeon; operation room mentorship is the finishing school.

Development and validation of a porcine organ model for training in essential laparoscopic surgical skills

OBJECTIVES

To develop a wet laboratory training model for learning core laparoscopic surgical skills and evaluating learners' competency level outside the operating room.

METHODS

Participants completed three tasks (task 1: tissue dissection around the aorta; task 2: tissue dissection and division of the renal artery; task 3: renal parenchymal closure). Each performance was video recorded and subsequently evaluated by two experts, according to the Global Operative Assessment of Laparoscopic Skills and task-specific metrics that we developed (Assessment Sheet of Laparoscopic Skills in Wet Lab score). Mean scores were used for analyses. The subjective mental workload was also assessed (NASA Task Load Index).

RESULTS

The 54 participants included 32 urologists, eight young trainees and 14 medical students. A total of 13 participants were categorized as experts (≥50 laparoscopic surgeries), eight as intermediates (10-49) and 33 as novices (0-9). There were significant differences in the Global Operative Assessment of Laparoscopic Skills and Assessment Sheet of Laparoscopic Skills in Wet Lab scores among the three groups in all three tasks. Higher NASA Task Load Index scores were observed in novices, and there were significant differences in tasks 1 (Kruskal-Wallis test, P = 0.0004) and 2 (P = 0.0002), and marginal differences in task 3 (P = 0.0745) among the three groups.

CONCLUSIONS

Our training model has good construct validity, and differences in the NASA Task Load Index score reflect previous laparoscopic surgical experiences. Our findings show the ability to assess both laparoscopic surgical skills and mental workloads, which could help educators comprehend trainees' level outside the operating room. Given the decreasing opportunity to carry out pure laparoscopic surgeries because of the dissemination of robotic surgery, especially in urology, our model can offer practical training opportunities.

Simulating Surgical Skills in Animals: Systematic Review, Costs & Acceptance Analyses

Background: Modern surgery demands high-quality and reproducibility. Due to new working directives, resident duty hours have been restricted and evidence exists that pure on-the-job training provides insufficient exposure. We hypothesize that supplemental simulations in animal models provide a realistic training to augment clinical experiences. This study reviews surgical training models, their costs and survey results illustrating academic acceptance.

Methods: Animal models were identified by literature research. Costs were analyzed from multiple German and Austrian training programs. A survey on their acceptance was conducted among faculty and medical students.

Results: 915 articles were analyzed, thereof 91 studies described in-vivo animal training models, predominantly for laparoscopy (30%) and microsurgery (24%). Cost-analysis revealed single-training costs between 307€ and 5,861€ depending on model and discipline. Survey results illustrated that 69% of the participants had no experience, but 66% would attend training under experienced supervision. Perceived public acceptance was rated intermediate by medical staff and students (4.26; 1–low, 10 high).

Conclusion: Training in animals is well-established and was rated worth attending in a majority of a representative cohort to acquire key surgical skills, in light of reduced clinical exposure. Animal models may therefore supplement the training of tomorrow's surgeons to overcome limited hands-on experience until virtual simulations can provide such educational tools.

Transferability of Simulation-Based Training in Laparoscopic Surgeries: A Systematic Review

Objective

The implementation of simulation-based training in residency programs has been increased, but the transferability of surgical skills in the real operating room is not well documented. In our survey, the role of simulation in surgical training will be evaluated. Study Design. In this systemic review, randomized control trials, which assessed the transferability of acquired skills through simulation in the real operating setting, were included. A systematic search strategy was undertaken using a predetermined protocol.

Results

Eighteen randomized clinical trials were included in this survey. Two studies investigated inguinal hernia repair, six laparoscopic cholecystectomy, five gynecologic procedures, two laparoscopic suturing, and two camera navigation during laparoscopic procedures. Simulation-trained participants showed superiority in surgical performance in comparison with untrained surgeons. The operation time, accuracy, incidence of intraoperative errors, and postoperative complications were statistically better in the simulation-trained group in comparison with the conventional-trained group.

Conclusion

Simulation provides a safe, effective, and ethical way for residents to acquire surgical skills before entering the operating room.

The effect of verbal feedback, video feedback, and self-assessment on laparoscopic intracorporeal suturing skills in novices: a randomized trial

BACKGROUND

Laparoscopic skill acquisition involves a steep learning curve and laparoscopic suturing is an exceptionally challenging task. By improving the way feedback is given, trainees can learn these skills more effectively. This study aims to establish the most effective form of structured feedback on laparoscopic suturing skill acquisition in novices, by comparing the effects of expert verbal feedback, video review with expert feedback (video feedback), and video review with self-assessment.

METHODS

A prospective randomized blinded trial comparing verbal feedback, video feedback, and self-assessment. Novices in laparoscopic surgery were tasked with performing laparoscopic suturing with intracorporeal knot tying. Time was given for practice, and pre- and post-feedback assessments were undertaken. Suturing performance was measured using a task-specific checklist and global ratings. A post-study questionnaire was used to measure participant-perceived confidence, knowledge, and experience levels.

RESULTS

Fifty-one participants were randomized and allocated equally into the three groups. Performance in all three groups improved significantly from baseline. Video feedback had the largest improvement margin with checklist and global score improvements of 17.1% (± 9.9%) and 14.7% (± 9.3%), respectively. Performance improvements between groups were statistically significant in the global components (p = 0.004) but not the checklist components (p = 0.186). Global score improvement was significantly better in the video feedback group but was statistically insignificant between the self-assessment and verbal feedback groups. Questionnaire responses demonstrated positive results in confidence, knowledge, and experience levels, across all three study groups, with no differences between the groups (p > 0.05).

CONCLUSION

Structured video feedback facilitates reflection and self-directed learning, which improves the ability to develop proficiency in surgical skills. Combining both self-assessment and video feedback may be beneficial over verbal feedback alone due to the advantages of video review. These techniques should therefore be considered for implementation into surgical education curricula.

An evaluation of live porcine simulation training for robotic surgery

To assess the role of live porcine simulation in robotic surgical skills training. A qualitative and quantitative survey was conducted of participants of a live porcine robotic simulation course undertaken in a regional training centre. Data on participants' experience, robotic surgical ability, the educational impact and outcomes from the course were collected. Thirty-nine participants from four different countries completed the survey. Clinical experience varied; however, prior robotic surgical experience (median 0 cases, range 0-100) and technical ability were low. The perceived usefulness, effectiveness and realism of the training course were all highly scored. Participants rated the most useful course components as port placement and docking, basic robotic skills training and repair of a bladder injury. Training resulted in significant increases in technical ability (p < 0.0001). Following the course, 49% of participants continued to either train or perform robotic surgery. This survey demonstrates that live porcine simulation for robotic surgery is a highly valued, acceptable and feasible form of training. The majority of participants were relatively inexperienced but nonetheless significant improvements in technical ability were reported. The results of this survey support the use of live porcine training for robotic surgery.

A new platform for laparoscopic training: initial evaluation of the ex-vivo live multivisceral training device

BACKGROUND

Various training models have been developed for laparoscopic training. Inanimate models including cadavers, ex-vivo simulator, and virtual reality (VR), are less realistic and often fail to display specific events such as bleeding, bile leakage, etc. Animal models provide more realistic experience, but constraints like cost involved, anesthetic requirement, and ethical approval have limited its application. We have designed a new training ex-vivo simulator-Smagister to address these issues.

METHODS

The Smagister consists of a normothermic machine perfusion platform, multivisceral organ of porcine abdominal cavity (liver, gallbladder, pancreas, stomach, intestine, kidney, uterus, bladders, etc.), high-definition display, and software system. Blood gas analysis and number of peristalsis per hour were recorded. A questionnaire was used to subjectively assess vitality of the organ cluster every hour. Three laparoscopic procedures including cholecystectomy (LC), enterotomy closure (LEC) and hepatectomy (LLR) were performed on Smagister, with demonstration of specific events for each procedure. Six experts compared the procedures with actual surgery in terms of feasibility to complete procedures and demonstration of complications.

RESULTS

The fluctuation of perfusate glucose (6.1-8.2 mmol/L) and lactate (5.82-6.55 mmol/L) suggested metabolic function of the multivisceral organs. The mean number of peristalsis was 2.2/min. The simulated surgical view and anatomic structures closely resembled actual surgery during continuous perfusion (3.5 ± 1.0, 3.8 ± 0.8, respectively). The evaluation scores of haptic feedbacks were 3.8 ± 0.8, resembling live tissue handling. LC, LEC, and LLR were performed well on the Smagister, with clear display of the specific events. All six experts considered Smagister as a suitable training modality for both basic and advanced laparoscopic surgery.

CONCLUSION

The amalgamation of live animal model and ex-vivo simulation in Smagister centralizes the virtue of both modalities, expands the training field, and provides high-fidelity laparoscopic training for both novice and senior surgeons.

Development of a program for teaching practical skills in visceral and digestive surgery by simulation

Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.

Surgical apprenticeship in the era of simulation

The new tools for transmission of knowledge and skills (simulation, surgery broadcast, virtual reality, augmented reality…) offer novel opportunities for training through mentoring. The peer network is widened; the dissemination of knowledge is accelerated. The new ways of teaching bring benefit to each aspect of the surgical profession: clinical reasoning, performance of technical procedures, stress management, communication and management of severe or exceptional adverse events. Previously, confined to surgical teams, mentoring has been extended to simulation centers, which are becoming virtual hospitals, and it has been prolonged on the Internet via social networks. In the sphere of digital mentoring, objectives are henceforth more structured, skills assessment is more standardized, phases of apprenticeship are redefined, and individualized training contracts are formalized.

Restricted working hours in Austrian residency programs : Survey results

Background

New regulations for working hours of medical doctors have been implemented in Austria based on the European directive 2003/88/EG, limiting on-duty working hours to 48 h per week. Clinical work is, therefore, substantially reduced compared to previous decades, and little is known on physician and students’ opinions on this matter. We illustrate survey results concerning on-job training, its difficulties, and implications for restricted working hours.

Methods

We conducted an internal survey among M.D. and Ph.D. students and medical staff members at the Medical University of Vienna using the MedCampus system (CAMPUSOnline, Graz, Austria) and SPSS (V.21, IBM Corp, Armonk, NY, USA).

Results

Participants were 36.5% staff members and 63.5% students. Students rated continuous education of physicians high at 9.19 ± 1.76 and staff members at 8.90 ± 2.48 on a 1–10 (1 unimportant, 10 most important) scale. Students rated limited time resources, while staff considered financial resources as the greatest challenge for in-hospital education. Overall, 28.85% thought that restricted working hours can positively influence education, while 19.04% thought the opposite and 52.11% were undecided.

Discussion

Considering the limited available time and financial resources, education of tomorrow’s medical doctors remains an important but difficult task. While participants of our survey rated education as very important despite its many challenges, the opinions towards limited working hours were not as clear. Given that over 50% are still undecided whether reduced work hours may also positively influence medical education, it clearly presents an opportunity to include the next generations of physicians in this undertaking.

Simulation platforms to assess laparoscopic suturing skills: a scoping review

BACKGROUND

Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted.

METHODS

A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence."

RESULTS

Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies.

CONCLUSION

We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Immersive Anatomy Atlas-Empirical Study Investigating the Usability of a Virtual Reality Environment as a Learning Tool for Anatomy

We developed a prototype of a virtual, immersive, and interactive anatomy atlas for surgical anatomical training. The aim of this study was to test the usability of the VR anatomy atlas and to measure differences in knowledge acquirement between an immersive content delivery medium and conventional learning (OB). Twenty-eight students of the 11th grade of two german high schools randomly divided into two groups. One group used conventional anatomy books and charts whereas the other group used the VR Anatomy Atlas to answer nine anatomy questions. Error rate, duration for answering the individual questions, satisfaction with the teaching unit, and existence of a medical career wish were evaluated as a function of the learning method. The error rate was the same for both schools and between both teaching aids (VR: 34.2%; OB: 34.1%). The answering speed for correctly answered questions in the OB group was approx. twice as high as for the VR group (mean value OB: 98 s, range: 2–410 s; VR: 50 s, 1–290 s). There was a significant difference between the students of the two schools based on a longer processing time in the OB condition in School B (mean OB in School A: 158 s; OB in School B: 77 s). The subjective survey on the learning methods showed a significantly better satisfaction for VR (p = 0.012). Medical career aspirations have been strengthened with VR, while interest of the OB group in such a career tended to decline. The immersive anatomy atlas helped to actively and intuitively perform targeted actions that led to correct answers in a shorter amount of time, even without prior knowledge of VR and anatomy. With the OB method, orientation difficulties and/or the technical effort in the handling of the topographical anatomy atlas seem to lead to a significantly longer response time, especially if the students are not specially trained in literature research in books or texts. This seems to indicate that the VR environment in the sense of constructivist learning might be a more intuitive and effective way to acquire knowledge than from books.

Endosuture trainer box simulator as a tool for training and teaching in bariatric laparoscopic surgery

Background

Video surgery requires acquisition of psychomotor skills that are different from those required for open surgery. The aim of this study was to assess the EndoSuture Trainer Box Simulator (ESTBS), a new bariatric laparoscopic skills simulator, as a tool for surgical education, comparing it with a standard laparoscopic trainer (SLT).

Methods

A randomized prospective crossover study was designed to compare ESTBS versus SLT as a tool for training bariatric laparoscopic skills. Participants were assigned to perform a task simulating Nissen fundoplication operation. All subjects evaluated the simulators concerning to their performance on simulating laparoscopic procedures by the use of a questionnaire comparing: triangulation, resistance and resilience, spatial perception (stereotaxy), ergonomics and positioning, inverted movements, visibility, design, technical and technological resources for training and education. The overall score was defined as the median value obtained. A total of 37 participants were enrolled in the study, including 29 experienced surgeons (78.37%) and 08 surgical residents (21.63%).

Results

A superior performance was observed with ESTBS as compared to SLT upon 7 of the 10 items evaluated in the questionnaire. Additionally, the overall score of ESTBS (median of 4, very good) was significantly higher (P < 0.0001) than that of SLT (median of 3, good). For the items, triangulation, resistance and resilience, ergonomics, design, training, technology and teaching, the evaluation for the ESTBS was very good and excellent, which was significantly higher than obtained by SLT. Also, ESTBS was cheaper.

Conclusions

The ESTBS was shown to present excellent technical and technological performances and appears to constitute a useful cost-effective promising instrument for teaching and training bariatric surgical laparoscopic skills.

Implementation and validation of a retroperitoneal dissection curriculum

BACKGROUND

Competency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency.

OBJECTIVE

Our goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance.

STUDY DESIGN

A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3-5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation.

RESULTS

Thirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5-7.25) precurriculum to 8 (7-9) postcurriculum (P < .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23-28.25) precurriculum to 30 (29.75-32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27-32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r = 0.53, P = .01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26).

CONCLUSION

A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.

Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons' brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = - 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = - 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.

A scoping review of assessment tools for laparoscopic suturing

BACKGROUND

A needs assessment identified a gap in teaching and assessment of laparoscopic suturing (LS) skills. The purpose of this review is to identify assessment tools that were used to assess LS skills, to evaluate validity evidence available, and to provide guidance for selecting the right assessment tool for specific assessment conditions.

METHODS

Bibliographic databases were searched till April 2017. Full-text articles were included if they reported on assessment tools used in the operating room/simulation to (1) assess procedures that require LS or (2) specifically assess LS skills.

RESULTS

Forty-two tools were identified, of which 26 were used for assessing LS skills specifically and 26 for procedures that require LS. Tools had the most evidence in internal structure and relationship to other variables, and least in consequences.

CONCLUSION

Through identification and evaluation of assessment tools, the results of this review could be used as a guideline when implementing assessment tools into training programs.

Perception versus reality: elucidating motivation and expectations of current fellowship council minimally invasive surgery fellows

BACKGROUND

The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career.

METHODS

A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship.

RESULTS

Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice.

CONCLUSIONS

Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice.

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.

In vivo porcine training model of laparoscopic common bile duct repair with T-tube insertion under the situation of iatrogenic common bile duct injury

Purpose

We introduce a training porcine model for laparoscopic common bile duct (CBD) repair with T-tube insertion. The model could be the feasible training tool for a surgeon learning hepatobiliary surgery.

Methods

Totally laparoscopic CBD repair with T-tube insertion was performed on 9 pigs by 9 trainees naïve in hepatobiliary surgery. Similar to the situation of iatrogenic injury, CBD was transected by laparoscopic scissors at the middle part about 1 cm in length, and the transected CBD was repaired through end-to-end anastomosis with T-tube insertion. A secureness of anastomosis was confirmed by saline leakage test and all animals were sacrificed after the surgery.

Results

All novice surgeons completed operations successfully without complications. Total mean operative time was 85 ± 1.7 minutes and the mean time spent performing the CBD repair with T-tube insertion was 71 ± 3 minutes. There was no bile leakage after primary anastomosis in all animals.

Conclusion

This porcine training model for laparoscopic CBD repair with T-tube insertion could be a feasible and effective training tool for surgeons with little experience in laparoscopic hepatobiliary surgery.

Assessment of a new kind of surgical simulator. The physical surgical simulator

PURPOSE

To evaluate whether the use of the physical surgical simulator may benefit the development of laparoscopic skills.

METHODS

Ten medical students were divided into two groups: the first one performed ten weekly training sessions with a physical surgical simulator - ETX A2 LAP and, afterwards, one laparoscopic cholecystectomy in a porcine model, while the second group performed only a laparoscopic cholecystectomy. Both groups were compared regarding bleeding, total surgical time, time to perform each surgical step and qualitative parameters, based on a previously validated tool.

RESULTS

There was no difference in any of the evaluated parameters.

CONCLUSION

We did not find any evidence of benefit in the use of the physical simulator for surgical performance in medical students.

What are the Training Gaps for Acquiring Laparoscopic Suturing Skills?

INTRODUCTION

Advanced laparoscopic suturing is considered a challenging skill to acquire. The aim of this study was to investigate the learning process for advanced laparoscopic suturing in the operating room to understand the obstacles trainees face when trying to master the skill.

METHODS

A qualitative methodology using semistructured interviews and field observations was used. Data were analyzed using a Grounded Theory approach. Participants were general surgery residents and surgeons with advanced minimally invasive surgery (MIS) experience.

RESULTS

Ten MIS surgeons across different institutions and 15 local general surgery residents were interviewed. The semistructured interviews and field observations of 9 advanced MIS operations (27h) yielded the following 6 themes around the acquisition of laparoscopic suturing skills for residents: complexity, training misalignment, variability of opportunities, inconsistency of techniques, lack of feedback, and differing expectations.

CONCLUSION

There are several unmet training needs around laparoscopic suturing skills. Training for advanced laparoscopic skills requires more emphasis on coaching and the development of advanced models. This study heralded the need to incorporate advanced laparoscopic skills into the surgical simulation curriculum.

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training (box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon’s performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.

A Virtual Reality Training Curriculum for Laparoscopic Colorectal Surgery

OBJECTIVE

Training within a competency-based curriculum (CBC) outside the operating room enhances performance during real basic surgical procedures. This study aimed to design and validate a virtual reality CBC for an advanced laparoscopic procedure: sigmoid colectomy.

DESIGN

This was a multicenter randomized study. Novice (surgeons who had performed <5 laparoscopic colorectal resections as primary operator), intermediate (between 10 and 20), and experienced surgeons (>50) were enrolled. Validity evidence for the metrics given by the virtual reality simulator, the LAP Mentor, was based on the second attempt of each task in between groups. The tasks assessed were 3 modules of a laparoscopic sigmoid colectomy (medial dissection [MD], lateral dissection [LD], and anastomosis) and a full procedure (FP). Novice surgeons were randomized to 1 of 2 groups to perform 8 further attempts of all 3 modules or FP, for learning curve analysis.

SETTING

Two academic tertiary care centers-division of surgery of St. Mary's campus, Imperial College Healthcare NHS Trust, London and Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, were involved.

PARTICIPANTS

Novice surgeons were residents in digestive surgery at St. Mary's and Nord Hospitals. Intermediate and experienced surgeons were board-certified academic surgeons.

RESULTS

A total of 20 novice surgeons, 7 intermediate surgeons, and 6 experienced surgeons were enrolled. Evidence for validity based on experience was identified in MD, LD, and FP for time (p = 0.005, p = 0.003, and p = 0.001, respectively), number of movements (p = 0.013, p = 0.005, and p = 0.001, respectively), and path length (p = 0.03, p = 0.017, and p = 0.001, respectively), and only for time (p = 0.03) and path length (p = 0.013) in the anastomosis module. Novice surgeons' performance significantly improved through repetition for time, movements, and path length in MD, LD, and FP. Experienced surgeons' benchmark criteria were defined for all construct metrics showing validity evidence.

CONCLUSIONS

A CBC in laparoscopic colorectal surgery has been designed. Such training may reduce the learning curve during real colorectal resections in the operating room.

Validating a standardized laparoscopy curriculum for gynecology residents: a randomized controlled trial

BACKGROUND

Residency programs struggle with integrating simulation training into curricula, despite evidence that simulation leads to improved operating room performance and patient outcomes. Currently, there is no standardized laparoscopic training program available for gynecology residents.

OBJECTIVE

The purpose of this study was to develop and validate a comprehensive ex vivo training curriculum for gynecologic laparoscopy.

STUDY DESIGN

In a prospective, single-blinded randomized controlled trial (Canadian Task Force Classification I) postgraduate year 1 and 2 gynecology residents were allocated randomly to receive either conventional residency training or an evidence-based laparoscopy curriculum. The 7-week curriculum consisted of cognitive didactic and interactive sessions, low-fidelity box trainer and high-fidelity virtual reality simulator technical skills, and high-fidelity team simulation. The primary outcome measure was the technical procedure score at laparoscopic salpingectomy with the use of the objective structured assessment of laparoscopic salpingectomy tool. Secondary outcome measures related to performance in multiple-choice questions and technical performance at box trainer and virtual reality simulator tasks. A sample size of 10 residents per group was planned (n = 20). Results are reported as medians (interquartile ranges), and data were compared between groups with the Mann-Whitney U, chi-square, and Fisher's exact tests (P ≤ .05).

RESULTS

In July 2013, 27 residents were assigned randomly (14 curriculum, 13 conventional). Both groups were similar at baseline. Twenty-one residents (10 curriculum, 11 conventional) completed the surgical procedure-based assessment in the operating room (September to December 2013). Our primary outcome indicated that curriculum-trained residents displayed superior performance at laparoscopic salpingectomy (P = .043). Secondary outcomes demonstrated that curriculum-trained residents had higher performance scores on the cognitive multiple-choice questions (P < .001), the nontechnical skills multiple-choice questions (P = .016), box trainer task time (P < .001), and all virtual reality simulator parameters.

CONCLUSION

Participation in a comprehensive simulation-based training curriculum for gynecologic laparoscopy leads to a superior improvement in knowledge and technical performance in the operating room compared with conventional residency training.

Initial validation of a training program focused on laparoscopic radical nephrectomy

OBJECTIVE

To assess a training model focused on laparoscopic nephrectomy.

MATERIAL AND METHODS

16 residents participated in the study, who attended a training program with a theoretical session (1hour) and a dry (7hours) and a wet lab (13hours). During animal training, the first and last nephrectomies were assessed through the completion time and the global rating scale "Objective and Structured Assessment of Technical Skills" (OSATS). Before and after the course, they performed 3 tasks on the virtual reality simulator LAPMentor (1) eye-hand coordination; 2) hand-hand coordination; and 3) transference of objects), registering time and movement metrics. All participants completed a questionnaire related to the training components on a 5-point rating scale.

RESULTS

The participants performed the last nephrectomy faster (P<.001) and with higher OSATS scores (P<.001). After the course, they completed the LAPMentor tasks faster (P<.05). The number of movements decreased in all tasks (1) P<.001, 2) P<.05, and 3) P<.05), and the path length in tasks 1 (P<.05) and 2 (P<.05). The movement speeds increased in tasks 2 (P<.001) and 3 (P<.001). With regards to the questionnaire, the usefulness of the animal training and the necessity of training on them prior to their laparoscopic clinical practice were the questions with the highest score (4.92±.28).

CONCLUSIONS

The combination of physical simulation and animal training constitute an effective training model for improving basic and advanced skills for laparoscopic nephrectomy. The component preferred by the urology residents was the animal training.

Applied Research on Laparoscopic Simulator in the Resident Surgical Laparoscopic Operation Technical Training

The purpose of this study was to estimate the effects of surgical laparoscopic operation course on laparoscopic operation skills after the simulated training for medical students with relatively objective results via data gained before and after the practice course of laparoscopic simulator of the resident standardized trainees. Experiment 1: 20 resident standardized trainees with no experience in laparoscopic surgery were included in the inexperienced group and finished simulated cholecystectomy according to simulator videos. Simulator data was collected (total operation time, path length, average speed of instrument movement, movement efficiency, number of perforations, the time cautery is applied without appropriate contact with adhesions, number of serious complications). Ten attending doctors were included in the experienced group and conducted the operation of simulated cholecystectomy directly. Data was collected with simulator. Data of two groups was compared. Experiment 2: Participants in inexperienced group were assigned to basic group (receiving 8 items of basic operation training) and special group (receiving 8 items of basic operation training and 4 items of specialized training), and 10 persons for each group. They received training course designed by us respectively. After training level had reached the expected target, simulated cholecystectomy was performed, and data was collected. Experimental data between basic group and special group was compared and then data between special group and experienced group was compared. Results of experiment 1 showed that there is significant difference between data in inexperienced group in which participants operated simulated cholecystectomy only according to instructors' teaching and operation video and data in experienced group. Result of experiment 2 suggested that, total operation time, number of perforations, number of serious complications, number of non-cauterized bleeding and the time cautery is applied without appropriate contact with adhesions in special group were all superior to those in basic group. There was no statistical difference on other data between special group and basic group. Comparing special group with experienced group, data of total operation time and the time cautery is applied without appropriate contact with adhesions in experienced group was superior to that in special group. There was no statistical difference on other data between special group and experienced group. Laparoscopic simulators are effective for surgical skills training. Basic courses could mainly improve operator's hand-eye coordination and perception of sense of the insertion depth for instruments. Specialized training courses could not only improve operator's familiarity with surgeries, but also reduce operation time and risk, and improve safety.

Simball Box for Laparoscopic Training With Advanced 4D Motion Analysis of Skills

Background. Laparoscopic skills training and evaluation outside the operating room is important for all surgeons learning new skills. To study feasibility, a video box trainer tracking 4-dimensional (4D) metrics was evaluated as a laparoscopic training tool. Method. Simball Box is a video box trainer with authentic surgical instruments and camera with video recording, equipped with 4D motion analysis registered through trocars using machine vision technology. Residents attending a 3-day laparoscopy course were evaluated performing a laparoscopic surgical knot at start, middle, and end. Metrics were obtained. Feedback data were presented in reference to expert/tutorial performance. Results. Ten right-handed residents were included. Median time (range) to finish the task was 359 (253-418), 129 (95-166), and 95 (52-156) seconds; 655%, 236%, and 174% of tutorial performance, with significance pre-/midcourse ( P < .0001), pre-/postcourse ( P < .0001), and mid-/postcourse ( P = .0050). Combined median total instrument motion decreased pre-/midcourse from 1208 (845-1751) to 522 cm (411-810 cm); P = .042 to 405 cm (246-864 cm) postcourse; pre-/postcourse P < .0001; 673%, 291%, 225% of tutorial performance. Total angular distance in radians (range) was 150 (87-251), 65 (42-116), and 50 (33-136) with significance pre-/midcourse ( P = .022) and pre-/postcourse ( P = .0002). Right-handed average speed (cm/s) increased: 1.94 (1.11-2.27) pre-, 2.39 (1.56-2.83) mid-, 2.60 (1.67-3.19) postcourse with significance pre-/midcourse ( P = .022) and pre-/postcourse ( P = .002). Average acceleration (mm/s2) and motion smoothness (µm/s3) failed to show any difference. Conclusion. For laparoscopic training and as a promising evaluation device, Simball Box obtained metrics mirroring progression well.

Porcine cadaver organ or virtual-reality simulation training for laparoscopic cholecystectomy: a randomized, controlled trial

OBJECTIVES

As conventional laparoscopic procedural training requires live animals or cadaver organs, virtual simulation seems an attractive alternative. Therefore, we compared the transfer of training for the laparoscopic cholecystectomy from porcine cadaver organs vs virtual simulation to surgery in a live animal model in a prospective randomized trial.

DESIGN

After completing an intensive training in basic laparoscopic skills, 3 groups of 10 participants proceeded with no additional training (control group), 5 hours of cholecystectomy training on cadaver organs (= organ training) or proficiency-based cholecystectomy training on the LapMentor (= virtual-reality training). Participants were evaluated on time and quality during a laparoscopic cholecystectomy on a live anaesthetized pig at baseline, 1 week (= post) and 4 months (= retention) after training.

SETTING

All research was performed in the Center for Surgical Technologies, Leuven, Belgium.

PARTICIPANTS

In total, 30 volunteering medical students without prior experience in laparoscopy or minimally invasive surgery from the University of Leuven (Belgium).

RESULTS

The organ training group performed the procedure significantly faster than the virtual trainer and borderline significantly faster than control group at posttesting. Only 1 of 3 expert raters suggested significantly better quality of performance of the organ training group compared with both the other groups at posttesting (p < 0.01). There were no significant differences between groups at retention testing. The virtual trainer group did not outperform the control group at any time.

CONCLUSIONS

For trainees who are proficient in basic laparoscopic skills, the long-term advantage of additional procedural training, especially on a virtual but also on the conventional organ training model, remains to be proven.