The effect of simulation in improving students’ performance in laparoscopic surgery: a meta-analysis

A novel tool for assessing psychomotor proficiency in laparoscopic cholecystectomy using simulation-based training

INTRODUCTION

Laparoscopy is underutilized in lower- and middle-income countries (LMICs) due to limited access to training opportunities. Laparoscopic cholecystectomy is the gold standard for treating gallbladder disease in high-income countries (HICs), yet the open approach predominates in LMICs. A low-cost, simulation-based educational module for teaching laparoscopic cholecystectomy was developed by an international collaboration. A novel tool for verifying proficiency (CHOLE-VOP), incorporating a procedural checklist, a global rating scale (GRS), and a final competency rating, was designed and piloted to evaluate psychomotor skill acquisition in laparoscopic cholecystectomy.

METHODS

Fifty-two users completed the learning module, submitted a video recording of their performance on the tool, and performed self- and peer-assessment of videos using the CHOLE-VOP. A Kruskal-Wallis test was used to assess the CHOLE-VOP's ability to differentiate psychomotor performance across three experience levels [novice (no laparoscopic experience), intermediate (1-30 cases), and expert (> 30 cases)] and between settings (LMICs vs. HICs). Inter-rater agreement was measured between self-assessment and peer-assessment, across reviewer reviewer experience levels.

RESULTS

Among users [novices (14), intermediates (18), experts (17), unknown (3)], checklist scores significantly increased from novice (M = 28.16) to intermediate (M = 31.33) and expert (M = 32.66), P < 0.001. Both GRS and final ratings effectively discriminated between experience levels, P < 0.001. LMIC users had higher checklist scores (32.41 vs. 29.35, P = 0.008) and GRS scores (17.54 vs. 15.14, P = 0.002). Inter-rater agreement between self- and peer-assessments was moderate (ICC = 0.52), with poor agreement for novices (ICC = 0.24), who tended to overestimate their performance, and good agreement for intermediate users (ICC = 0.79).

CONCLUSION

The CHOLE-VOP successfully discriminated between experience levels in a simulated laparoscopic cholecystectomy training module. LMIC users outperformed HIC users in select skill parameters. Self-assessments, particularly among novices, showed limited concordance with peer-assessments.

Novel, intermediate-fidelity simulator for aortic arch surgery for the cardiothoracic surgical trainee

BACKGROUND

Training cardiothoracic surgeons in open aortic surgery is challenging due to limited operator experience, low patient volume and technically demanding skills to be performed within a deep thoracic cavity. Surgical simulation has become a cornerstone of cardiothoracic surgical training and has been shown to improve skill acquisition and performance in the operating theatre. Due to the complexity of aortic surgery, there is a paucity of simulators that are concomitantly accessible and of sufficient fidelity. The purpose of this study was to develop a reproducible, intermediate-fidelity simulator for aortic surgery.

METHOD

This novel simulator was constructed from plastic storage containers to simulate the depth of a thoracic cavity. Head vessels and distal arch were reconstructed within the stimulator with synthetic Dacron polyester grafts to maximize model fidelity. A porcine or bovine heart was used for the simulation of aortic root replacement and anastomosis to the distal arch graft.

RESULTS

The simulator was reproduced in a wet-lab skills session at an annual Australian cardiothoracic trainee meeting. Qualitative feedback was obtained from the current cardiothoracic trainees. It is a feasible model for the practice of aortic surgery.

CONCLUSION

As the surgical education paradigm shifts towards simulation, this easily reproducible, intermediate-fidelity model provides an effective avenue to equip the trainee for the operating room and is a method of surgical training that can be considered by colleges.

Pre-course instructional videos and home-based laparoscopic suturing simulation enhances the educational impact of a laparoscopic training course

Introduction

We developed a home-based laparoscopic suturing simulation (HBLSS) technique, which is intended to improve the impact of a structured laparoscopic training course.

Method

A group of sixteen students were provided with the educational video, and after two weeks, all students were observed and timed performing a laparoscopic reef knot. The students were then randomized into two cohorts. The exclusive video group continued using the video for a further two weeks. The second group were shown the HBLSS technique and told to use this in conjunction with the video for a further two weeks.

Results

The entire cohort had an initial median time to form an intracorporeal reef knot of 190 s (range 459, IQR 128). After two additional weeks of using the educational video exclusively, the median time was reduced to 85 s (range 282, IQR 125), whereas the HBLSS and educational video group had a median post-training time of 28.5 s (range 36, IQR 18.5). There was a clear statistical difference between the exclusive video group and the HBLSS and video group (P = 0.008). There was also an improvement from the movement of both instruments to one instrument, reduced crossing of instruments and reduced transverse movement in the HBLSS and video group.

Conclusion

A combination of video-based teaching and HBLSS was associated with improved laparoscopic intra-corporeal knot-tying skills in comparison to the exclusive video-based teaching. This reflects the importance of imparting both cognitive and psychomotor skills to students practising laparoscopic surgery.

IMPACT OF A SIMULATED LAPAROSCOPIC TRAINING PROGRAM IN A THREE-YEAR GENERAL SURGERY RESIDENCY

Background:

A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents’ surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce.

Aim:

To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program.

Methods:

A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described.

Results:

Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05).

Conclusions:

The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.

Single incision laparoscopic proficiency correlates with residency training level

BACKGROUND

With experience, certain psychomotor skills should translate from standard laparoscopy to single-incision laparoscopy (SIL). We proposed to compare all surgical postgraduate year (PGY) levels and determine if experience translated to improved SIL skills.

METHODS

Surgical residents of all PGY levels (1-5) at our institution were included. Baseline surveys were obtained to determine resident level of exposure to both SIL and standard laparoscopic cases. Participants performed the following tasks: running of the bowel, endoloop placement, extracorporeal suture tying, and intracorporeal suture tying. Tasks were performed on a commercially provided simulated inanimate organ model. Participants were given 5 min to complete each task. Data were collected and analyzed by an impartial-certified Fundamentals of Laparoscopic Surgery proctor.

RESULTS

A total of 31 residents participated in the study. Overall, there was minimal SIL exposure among all residents. As expected, PGY level correlated with increased ability to complete assigned tasks within the allotted time. There was a statistically significant difference in the number of individuals able to complete a task based on PGY level for all given tasks (P = 0.005). With increased difficulty, the percentage of higher level residents able to complete the task decreased (100% PGY5 completed running of bowel versus 0% intracorporeal knot tying).

CONCLUSIONS

Certain psychomotor skills did appear to translate to SIL skills. However, further dedicated SIL training may help to better develop certain laparoscopic skills devoted to SIL.

Achieving Interface and Environment Fidelity in the Virtual Basic Laparoscopic Surgical Trainer

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.

Evidence for curricular and instructional design approaches in undergraduate medical education: An umbrella review

INTRODUCTION

An umbrella review compiles evidence from multiple reviews into a single accessible document. This umbrella review synthesizes evidence from systematic reviews on curricular and instructional design approaches in undergraduate medical education, focusing on learning outcomes.

METHODS

We conducted bibliographic database searches in Medline, EMBASE and ERIC from database inception to May 2013 inclusive, and digital keyword searches of leading medical education journals. We identified 18,470 abstracts; 467 underwent duplicate full-text scrutiny.

RESULTS

Thirty-six articles met all eligibility criteria. Articles were abstracted independently by three authors, using a modified Kirkpatrick model for evaluating learning outcomes. Evidence for the effectiveness of diverse educational approaches is reported.

DISCUSSION

This review maps out empirical knowledge on the efficacy of a broad range of educational approaches in medical education. Critical knowledge gaps, and lapses in methodological rigour, are discussed, providing valuable insight for future research. The findings call attention to the need for adopting evaluative strategies that explore how contextual variabilities and individual (teacher/learner) differences influence efficacy of educational interventions. Additionally, the results underscore that extant empirical evidence does not always provide unequivocal answers about what approaches are most effective. Educators should incorporate best available empirical knowledge with experiential and contextual knowledge.

Ureteroscopy and cystoscopy training: comparison between transparent and non-transparent simulators

BACKGROUND

Simulators have been widely used to train operational skills in urology, how to improve its effectiveness deserves further investigation. In this paper, we evaluated training using a novel transparent anatomic simulator, an opaque model or no simulator training, with regard to post-training ureteroscopy and cystoscopy proficiency.

METHODS

Anatomically correct transparent and non-transparent endourological simulators were fabricated. Ten experienced urologists provided a preliminary evaluation of the models as teaching tools. 36 first-year medical students underwent identical theoretical training and a 50-point examination of theoretical knowledge. The students were randomly assigned to receive training with the transparent simulator (Group 1), the non-transparent simulator (Group 2) or detailed verbal instruction only (Group 3). 12 days after the training session, the trainees' skills at ureteral stent insertion and removal were evaluated using the Uro-Scopic Trainer and rated on an Objective Structured Assessment of Technical Skills (OSATS) scale.

RESULTS

The new simulators were successfully fabricated in accordance with the design parameters. Of the ten urologists invited to evaluate the devices, 100% rated the devices as anatomically accurate, 90% thought both models were easy to use and 80% thought they were good ureteroscopy and cystoscopy training tools. The scores on the theoretical knowledge test were comparable among the training groups, and all students were able to perform ureteral stent insertion and removal. The mean OSATS scores of groups 1, 2 and 3 were 21.83 ± 3.64, 18.50 ± 4.03 and 15.58 ± 2.23 points, respectively, (p = 0.001).

CONCLUSIONS

Simulator training allowed students to achieve higher ureteroscopic and cystoscopic proficiency, and transparent simulators were more effective than non-transparent simulators.

Evaluation of single incision laparoscopic surgery "low-fidelity" simulation training

GOAL

Evaluate the learning curve of SILS (Single Incision Laparoscopic Surgery) on a simulator, based on two tests of the Fundamentals of Laparoscopic Surgery certification program (FLS(®)), in a population of novice medical students, and compare their performance to those of senior surgeons practicing both "conventional" laparoscopic surgery and SILS.

MATERIALS AND METHODS

Monocentric prospective study with four groups: two groups of novice medical students, and two groups of senior surgeons. The two FLS(®) tests used for evaluation were the peg transfer and the precision cutting tasks.

RESULTS

No statistically significant differences were found between the novice groups, whether they started their first session directly, or immediately after watching a video presentation of the exercises. For the novice medical students, the average completion time of both tests improved significantly between the first and the sixth sessions with a short learning curve. The group of experienced seniors performed fastest in both tests. For the peg transfer task, the skills of the novice medical students were comparable to those of non-experienced seniors after the 4th session and improved after 6 sessions (P=0.017). For the precision cutting task, the average timing of the novice group became better than that of the non-experienced seniors, starting from the third session.

CONCLUSIONS

FLS(®) "low fidelity" simulator training is effective for the training of novice medical students. To minimize the risk of technical errors, novice medical students should practice a minimum of six simulator-training sessions before starting their practical learning of SILS in the operating room.

Impact of tutorial assistance in laparoscopic sigmoidectomy for acute recurrent diverticulitis

PURPOSE

Adequate training and close supervision by an experienced surgeon are crucial to assure the patient safety during laparoscopic training. This study evaluated the impact of tutorial assistance on the duration of surgery and postoperative complications after laparoscopic sigmoidectomy.

METHODS

The data from 235 patients undergoing laparoscopic sigmoidectomy were collected. Operating surgeons were classified as either residents/registrars (group A, tutorial assistance) or consultants operating autonomously (group B). Groups were compared concerning the duration of surgery and in-hospital complications using a multivariable regression model accounting for the most relevant confounders.

RESULTS

The median duration of the operation in group A (n = 75) was 221 min, and that in group B (n = 160) 189 min (p < 0.001). The risk of developing any in-hospital complication (Clavien-Dindo classification I-V) was 36.0 % in Group A and 32.5 % in group B (95 % CI -16.6, 9.6 %). The risk of developing moderate to severe surgical complications (Clavien-Dindo classification II-V) was 16.0 % in group A and 12.5 % in group B (95 % CI -13.3, 6.3 %).

CONCLUSIONS

We were unable to demonstrate a clear impact of tutorial assistance on the risk of postoperative complications. Although associated with a longer duration of surgery, laparoscopic sigmoidectomy for acute recurrent sigmoid diverticulitis conducted by a junior supervised surgeon appears to be a safe surgical modality.

Simulation Training in Health Care

In this chapter, we discuss the application of human factors and ergonomics to developing effective simulation training in health care. Simulation provides a safe, effective method for training and assessing human performance. In aviation, simulation-based training and assessment has been widely used, significantly improving safety. This progress would have been impossible without the involvement of human factors and ergonomics. Although aviation and health care have similarities, there also are differences that complicate the widespread implementation of simulation in health care.

[Improve your skills!: evaluation of a 2.5-day basic course in vascular surgery for surgical trainees]

BACKGROUND

The traditional surgical training in the operating room (OR) is often complemented by participation in workshops and on simulators. The foundation Vascular International offers basic courses for vascular surgery techniques with training on pulsatile circulation, lifelike anatomical models. The aim of this study was to assess the efficacy of a 2.5-day intensive course on basic skills in vascular surgery.

MATERIAL AND METHODS

A total of 24 participants (67% male with an average age of 35 years) performed a vein patch-plasty before and after the basic vascular surgery instruction course. Endpoints of the study were the time needed for suturing and the technical quality, which were evaluated by two course trainers on a scale of 0-10. Furthermore, the participants were asked to evaluate their own technical competence. The statistical analysis was carried out using MS Excel (t-test and analysis of correlation).

RESULTS

A significantly shortened time for the suturing (19.5 min versus 14.1 min, p < 0.001) and improved quality of the vein patch were found after the workshop (p < 0.05) with a high correlation between the two observers (r = 0.885). The participants also evaluated their own surgical competence better at the end of the training but there was no correlation between the self-assessment and the quality of the patch (r = 0.146 before and r = 0.109 after the workshop).

CONCLUSIONS

A significant improvement in the time needed for suturing and the quality of the vein patch-plasty was shown in this study. Further studies are necessary to demonstrate the long-term success and possible shortening of the learning curve in hospitals with professional training. With regard to the current curriculum of surgical trainees in Germany basic vascular surgery courses should be considered as a potential valuable part of the surgical common trunk.

Evaluation of skill-acquisition process in mitral valve repair techniques: a simulation-based study

INTRODUCTION

Increased patient awareness, duty-hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgical education. A bovine heart model was designed for training in mitral valve repair procedures. In this article, we aimed to share our experience with this model and to test the validity of simulation with respect to skill acquisition during the training course.

METHODS

After reviewing instructional video recordings of mitral valve repair techniques, 5 junior residents (first and second year) and 5 senior residents (year 4 or higher), who had no experience in mitral valve repair surgery previously, performed mitral valve repair techniques on bovine heart model in a three-month period. Nine different internet videos demonstrating surgical techniques were watched prior to performance in each case. Different text books were studied before the study course. Following repair in each case, the left ventricle of each bovine heart was statically pressurized, the coaptation depth was measured, and the regurgitation (if any) was scored. Each performance was recorded. At the end of the study, video records were evaluated in a blind fashion by 3 different surgeons experienced in mitral valve repair techniques. The monthly scores obtained were statistically analyzed.

RESULTS

The mean coaptation depth values measured on a monthly basis were as follows: 2.75±0.63, 4.90±0.91, and 6.55±0.88 for the junior residents and 4.30±0.65, 5.45±0.68, and 7.00±0.64mm for the senior residents. Regurgitation scores noted were 2.20±0.52, 1.65±0.58, and 0.10±0.30 for the junior residents and 1.50±0.60, 0.65±0.67, and 0.70±0.65 for the senior residents During the study period, the practice improved in terms of the aforementioned parameters in both groups (p<0.05).

CONCLUSIONS

This simulation model of mitral valve repair helped in skill acquisition on monthly basis in both resident groups.

Clinical needs finding: developing the virtual experience-a case study

We describe an innovative program at the University of California, Davis for students to engage in clinical needs finding. Using a team-based approach, students participated in clinical rotations to observe firsthand the needs of clinicians at the university affiliated medical center. The teams were asked to develop documentary-style videos to capture key experiences that would allow future viewers to use the videos as "virtual" clinical rotations. This was conceived as a strategy to allow students in prohibitively large classes, or students in programs at institutions without associated medical or veterinary school programs, to experience clinical rotations and perform needs assessments. The students' perspectives on the experience as well as instructor analysis of best practices for this type of activity are presented and discussed. We found that the internship experience was valuable to the students participating, by not only introducing the practice of needs finding but also increasing the students' confidence in the practice of engineering design and their ability to work independently. The videos produced were of such high quality that instructors from other institutions have requested copies for instructional use. Virtual clinical rotations through video experiences may provide a reasonable substitute for students who do not have the ability to participate in rotations in person.

Using simulation to improve the cognitive and psychomotor skills of novice students in advanced laparoscopic surgery: a meta-analysis

Advances in simulation technologies have enhanced the ability to introduce the teaching and learning of laparoscopic surgical skills to novice students. In this meta-analysis, a total of 18 randomized controlled studies were identified that specifically looked at training novices in comparison with a control group as it pertains to knowledge retention, time to completion and suturing and knotting skills. The combined random-effect sizes (ESs) showed that novice students who trained on laparoscopic simulators have considerably developed better laparoscopic suturing and knot tying skills (d = 1.96, p < 0.01), conducted fewer errors (d = 2.13, p < 0.01), retained more knowledge (d = 1.57, p < 0.01) than their respective control groups, and were significantly faster on time to completion (d = 1.98, p < 0.01). As illustrated in corresponding Forest plots, the majority of the primary study outcomes included in this meta-analysis show statistically significant support (p < 0.05) for the use of laparoscopic simulators for novice student training on both knowledge and advanced surgical skill development (28 of 35 outcomes, 80%). The findings of this meta-analysis support strongly the use of simulators for teaching laparoscopic surgery skills to novice students in surgical residency programs.

A novel low-fidelity simulator for both mitral valve and tricuspid valve surgery: the surgical skills trainer for classic open and minimally invasive techniques

OBJECTIVES

Simulators have been proven to equip trainee surgeons with better skills than the traditional, standard approach to skill development. The purpose of this study was to develop a low-fidelity, low-cost, reusable and portable simulation device, which could provide training in nearly the full range of mitral valve surgery techniques, in both the classic, open approach as well as the minimally invasive approach.

METHODS

This novel simulator is made up of commonly available components. The basic elements are a classic baby bottle, with the associated feeding teat and screw ring, in combination with a sheet of dental dam. The detailed process for making this simulator is outlined in this article. Maximum suture tensile strength on the different components was tested with a digital force gauge. Reusability and the rate of wear as a result of suturing were documented. Total cost was calculated in euros (€).

RESULTS

This study resulted in a simulation model very similar in size to the actual anatomical dimensions of the mitral valve. Various pathological conditions, according to Carpentier's Functional Classification, could be simulated. This led to the possibility of providing training in several mitral valve surgical techniques. As the model developed, it became clear that it could also be used to practice tricuspid valve surgery techniques. Maximum mean suture tensions on the silicone teat and dental dam were 42.11 and 11.15 N/m(2), respectively. The feeding teat started wearing after approximately 45 suture placements. Total cost of the study model was €5.14.

CONCLUSIONS

This relatively simple, low-cost, low-fidelity model can provide simulation training in nearly the full range of mitral valve and tricuspid valve surgical techniques, in both the classic open approach and the minimally invasive approach-and do so almost anywhere. Especially when used by young cardiothoracic surgeons in training, this model may contribute to the development of technical skills and procedural knowledge required for adequate performance in the operating room.