Effective and efficient learning in the operating theater with intraoperative video-enhanced surgical procedure training

Development and Evaluation of a Quality Assessment Tool for Laparoscopic Sleeve Gastrectomy Videos: A Review and Comparison of Academic and Online Video Resources

BACKGROUND

Video recording of surgical procedures is increasing in popularity. They are presented in various platforms, many of which are not peer-reviewed. Laparoscopic sleeve gastrectomy (LSG) videos are widely available; however, there is limited evidence supporting the use of reporting guidelines when uploading LSG videos to create a valuable educational video. We aimed to determine the variations and establish the quality of published LSG videos, in both peer-reviewed literature and on YouTube, using a newly designed checklist to improve the quality and enhance the transparency of video reporting.

METHODS

A quality assessment tool was designed by using existing research and society guidelines, such as the Bariatric Metabolic Surgery Standardization (BMSS). A systematic review using PRISMA guidelines was performed on MEDLINE and EMBASE databases to identify video case reports (academic videos) and a similar search was performed on the commercial YouTube platform (commercial videos) simultaneously. All videos displaying LSG were reviewed and scored using the quality assessment tool. Academic and commercial videos were subsequently compared and an evidence-based checklist was created.

RESULTS

A total of 93 LSG recordings including 26 academic and 67 commercial videos were reviewed. Mean score of the checklist was 5/11 and 4/11 for videos published in articles and YouTube, respectively. Academic videos had higher rates of describing instruments used, such as orogastric tube (P < 0.001) and stapler information (P = 0.04). Fifty-four percent of academic videos described short-term patient outcomes, while not reported in commercial videos (P < 0.001). Sleeve resection status was not universally reported.

CONCLUSIONS

Videos published in the academic literature are describing steps in greater detail with more emphasis on specific technical elements and patient outcomes and thus have a higher educational value. A new quality assessment tool has been proposed for video reporting guidelines to improve the reliability and value of published video research.

The Utilization of Video Technology in Surgical Education: A Systematic Review

BACKGROUND

The use of surgical video has great potential to enhance surgical education, but there exists limited information about how to effectively use surgical videos. We performed a systematic review of video technology in surgical training and provided evidence-based recommendations for its effective use.

MATERIALS AND METHODS

A systematic review of literature on surgical video in residency education was conducted. All articles meeting inclusion criteria were evaluated for technical characteristics pertaining to video usage. Included studies were critically appraised using a quality-scoring system. Recommendations were provided for the effective implementation of video in surgical education based on associations with improved training outcomes.

RESULTS

Twenty articles met inclusion criteria. In these studies, the source of video acquisition was primarily laparoscopy (40.0% of papers), and the main perspective of video was endoscopy (45.0%). Features of videos included supplementation with other educational tools (55.0%), schematic diagrams or images (50.0%), audio (40.0%), and narration (25.0%). Videos were primarily viewed preoperatively (60.0%) or postoperatively (50.0%). The intended viewer for videos was usually residents (70.0%) but also included attendings/faculty (30.0%). When compared with a nonvideo training group, video training was associated with improved resident knowledge (100%), improved operative performance (81.3%), and greater participant satisfaction (100%).

CONCLUSIONS

Based on this review, we recommend that surgical training programs incorporate schematics and imaging into video, supplement video with other education tools, and utilize audio in video. For video review, we recommend that residents review video preoperatively and postoperatively for learning and that attendings review video postoperatively for assessment.

Laparoscopy Instructional Videos: The Effect of Preoperative Compared With Intraoperative Use on Learning Curves

OBJECTIVE

Previous studies have shown that the use of intraoperative instructional videos has a positive effect on learning laparoscopic procedures. This study investigated the effect of the timing of the instructional videos on learning curves in laparoscopic skills training.

DESIGN

After completing a basic skills course on a virtual reality simulator, medical students and residents with less than 1 hour experience using laparoscopic instruments were randomized into 2 groups. Using an instructional video either preoperatively or intraoperatively, both groups then performed 4 repetitions of a standardized task on the TrEndo augmented reality. With the TrEndo, 9 motion analysis parameters (MAPs) were recorded for each session (4 MAPs for each hand and time). These were the primary outcome measurements for performance. The time spent watching the instructional video was also recorded. Improvement in performance was studied within and between groups.

SETTING

Medical Center Leeuwarden, a secondary care hospital located in Leeuwarden, The Netherlands.

PARTICIPANTS

Right-hand dominant medical student and residents with more than 1 hour experience operating any kind of laparoscopic instruments were participated. A total of 23 persons entered the study, of which 21 completed the study course.

RESULTS

In both groups, at least 5 of 9 MAPs showed significant improvements between repetition 1 and 4. When both groups were compared after completion of repetition 4, no significant differences in improvement were detected. The intraoperative group showed significant improvement in 3 MAPs of the left-nondominant-hand, compared with one MAP for the preoperative group.

CONCLUSION

No significant differences in learning curves could be detected between the subjects who used intraoperative instructional videos and those who used preoperative instructional videos. Intraoperative video instruction may result in improved dexterity of the nondominant hand.

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient.

Electronic databases were interrogated to better define the terms “surgeon”, “specialized surgeon”, and “specialist surgeon”; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy.

Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee’s progress.

Conclusions. The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor’s ability, the trainee’s own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

A systematic review of performance assessment tools for laparoscopic cholecystectomy

BACKGROUND

Multiple tools are available to assess clinical performance of laparoscopic cholecystectomy (LC), but there are no guidelines on how best to implement and interpret them in educational settings. The purpose of this systematic review was to identify and critically appraise LC assessment tools and their measurement properties, in order to make recommendations for their implementation in surgical training.

METHODS

A systematic search (1989-2013) was conducted in MEDLINE, Embase, Scopus, Cochrane, and grey literature sources. Evidence for validity (content, response process, internal structure, relations to other variables, and consequences) and the conditions in which the evidence was obtained were evaluated.

RESULTS

A total of 54 articles were included for qualitative synthesis. Fifteen technical skills and two non-technical skills assessment tools were identified. The 17 tools were used for either: recorded procedures (nine tools, 60%), direct observation (five tools, 30%), or both (three tools, 18%). Fourteen (82%) tools reported inter-rater reliability and one reported a Generalizability Theory coefficient. Nine (53%) had evidence for validity based on clinical experience and 11 (65%) compared scores to other assessments. Consequences of scores, educational impact, applications to residency training, and how raters were trained were not clearly reported. No studies mentioned cost.

CONCLUSIONS

The most commonly reported validity evidence was inter-rater reliability and relationships to other known variables. Consequences of assessments and rater training were not clearly reported. These data and the evidence for validity should be taken into consideration when deciding how to select and implement a tool to assess performance of LC, and especially how to interpret the results.

Cerebrospinal fluid reconstitution via a perfusion-based cadaveric model: feasibility study demonstrating surgical simulation of neuroendoscopic procedures

Cadaveric surgical simulation carries the advantage of realistic anatomy and haptic feedback but has been historically difficult to model for intraventricular approaches given the need for active flow of CSF. This feasibility study was designed to simulate intraventricular neuroendoscopic approaches and techniques by reconstituting natural CSF flow in a cadaveric model. In 10 fresh human cadavers, a simple cervical laminectomy and dural opening were made, and a 12-gauge arterial catheter was introduced. Saline was continuously perfused at physiological CSF pressures to reconstitute the subarachnoid space and ventricles. A neuroendoscope was subsequently inserted via a standard right frontal bur hole. In 8 of the 10 cadavers, adequate reconstitution and endoscopic access of the lateral and third ventricles were achieved. In 2 cadavers, ventricular access was not feasible, perhaps because of a small ventricle size and/or deteriorated tissue quality. In all 8 cadavers with successful CSF flow reconstitution and endoscopic access, identifying the foramen of Monro was possible, as was performing septum pellucidotomy and endoscopic third ventriculostomy. Furthermore, navigation of the cerebral aqueduct, fourth ventricle, prepontine cistern, and suprasellar cistern via the lamina terminalis was possible, providing a complementary educational paradigm for resident education that cannot typically be performed in live surgery. Surgical simulation plays a critical and increasingly prominent role in surgical education, particularly for techniques with steep learning curves including intraventricular neuroendoscopic procedures. This novel model provides feasible and realistic surgical simulation of neuroendoscopic intraventricular procedures and approaches.

European Society of Pediatric Endoscopic Surgeons (ESPES) guidelines for training program in pediatric minimally invasive surgery

PURPOSE

The aim of this paper was to propose structured guidelines for a European pediatric MIS training program created by ESPES.

METHODS

A questionnaire, focused on how the pediatric training program in MIS has to be structured, was proposed to all participants at the ESPES Congress in Marseille in 2013.

RESULTS

We received 178 questionnaires but only 139 questionnaires were fully completed and analyzed. All respondents agree that the training program has to be divided into 4 steps: (1) theoretical part: 2 theoretical courses in laparoscopy (101/139 respondents, 72.7 %), 1 theoretical course in retroperitoneoscopy (99/139 respondents, 71.2 %) and 1 in thoracoscopy (91/139 respondents, 65.5 %); (2) experimental part: 10-20 h of training on pelvic trainer (103/139 respondents, 74.1 %) and 10 h of training on animal models (91/139 respondents, 65.5 %); (3) stages in European centers of reference for MIS: a 1-3 months stage (96/139 respondents, 69.1 %); (4) personal experience: 30 procedures as cameraman (98/139 respondents, 70.5 %) and >50 basic MIS procedures as main surgeon under supervision (114/139 respondents, 82 %).

CONCLUSIONS

On the basis of our survey ESPES MIS training curriculum for pediatric surgeons must contain the following educational components: (1) theoretical knowledge; (2) practice-based learning and improvement in experimental setting; (3) stages in European centers of reference for MIS; (4) personal operative experience. At the end of the training program, ESPES will analyze the candidate training booklet and release for each applicant an ESPES certification after an exam.

Development of a standardized training course for laparoscopic procedures using Delphi methodology

BACKGROUND

Content, evaluation, and certification of laparoscopic skills and procedure training lack uniformity among different hospitals in The Netherlands. Within the process of developing a new regional laparoscopic training curriculum, a uniform and transferrable curriculum was constructed for a series of laparoscopic procedures. The aim of this study was to determine regional expert consensus regarding the key steps for laparoscopic appendectomy and cholecystectomy using Delphi methodology.

METHODS

Lists of suggested key steps for laparoscopic appendectomy and cholecystectomy were created using surgical textbooks, available guidelines, and local practice. A total of 22 experts, working for teaching hospitals throughout the region, were asked to rate the suggested key steps for both procedures on a Likert scale from 1-5. Consensus was reached with Crohnbach's α ≥ 0.90.

RESULTS

Of the 22 experts, 21 completed and returned the survey (95%). Data analysis already showed consensus after the first round of Delphi on the key steps for laparoscopic appendectomy (Crohnbach's α = 0.92) and laparoscopic cholecystectomy (Crohnbach's α = 0.90). After the second round, 15 proposed key steps for laparoscopic appendectomy and 30 proposed key steps for laparoscopic cholecystectomy were rated as important (≥4 by at least 80% of the expert panel). These key steps were used for the further development of the training curriculum.

CONCLUSION

By using the Delphi methodology, regional consensus was reached on the key steps for laparoscopic appendectomy and cholecystectomy. These key steps are going to be used for standardized training and evaluation purposes in a new regional laparoscopic curriculum.

Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator - either a video box or a mirrored box - is an option to supplement standard training. However, the impact of this modality on trainees with no prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training versus no training, another box model, animal model, or cadaveric model training for surgical trainees with no prior laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We included all randomised clinical trials comparing box model trainers versus no training in surgical trainees with no prior laparoscopic experience. We also included trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager for analysis. For each outcome, we calculated the standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

Twenty-five trials contributed data to the quantitative synthesis in this review. All but one trial were at high risk of bias. Overall, 16 trials (464 participants) provided data for meta-analysis of box training (248 participants) versus no supplementary training (216 participants). All the 16 trials in this comparison used video trainers. Overall, 14 trials (382 participants) provided data for quantitative comparison of different methods of box training. There were no trials comparing box model training versus animal model or cadaveric model training. Box model training versus no training: The meta-analysis showed that the time taken for task completion was significantly shorter in the box trainer group than the control group (8 trials; 249 participants; SMD -0.48 seconds; 95% CI -0.74 to -0.22). Compared with the control group, the box trainer group also had lower error score (3 trials; 69 participants; SMD -0.69; 95% CI -1.21 to -0.17), better accuracy score (3 trials; 73 participants; SMD 0.67; 95% CI 0.18 to 1.17), and better composite performance scores (SMD 0.65; 95% CI 0.42 to 0.88). Three trials reported movement distance but could not be meta-analysed as they were not in a format for meta-analysis. There was significantly lower movement distance in the box model training compared with no training in one trial, and there were no significant differences in the movement distance between the two groups in the other two trials. None of the remaining secondary outcomes such as mortality and morbidity were reported in the trials when animal models were used for assessment of training, error in movements, and trainee satisfaction. Different methods of box training: One trial (36 participants) found significantly shorter time taken to complete the task when box training was performed using a simple cardboard box trainer compared with the standard pelvic trainer (SMD -3.79 seconds; 95% CI -4.92 to -2.65). There was no significant difference in the time taken to complete the task in the remaining three comparisons (reverse alignment versus forward alignment box training; box trainer suturing versus box trainer drills; and single incision versus multiport box model training). There were no significant differences in the error score between the two groups in any of the comparisons (box trainer suturing versus box trainer drills; single incision versus multiport box model training; Z-maze box training versus U-maze box training). The only trial that reported accuracy score found significantly higher accuracy score with Z-maze box training than U-maze box training (1 trial; 16 participants; SMD 1.55; 95% CI 0.39 to 2.71). One trial (36 participants) found significantly higher composite score with simple cardboard box trainer compared with conventional pelvic trainer (SMD 0.87; 95% CI 0.19 to 1.56). Another trial (22 participants) found significantly higher composite score with reverse alignment compared with forward alignment box training (SMD 1.82; 95% CI 0.79 to 2.84). There were no significant differences in the composite score between the intervention and control groups in any of the remaining comparisons. None of the secondary outcomes were adequately reported in the trials.

AUTHORS' CONCLUSIONS

The results of this review are threatened by both risks of systematic errors (bias) and risks of random errors (play of chance). Laparoscopic box model training appears to improve technical skills compared with no training in trainees with no previous laparoscopic experience. The impacts of this decreased time on patients and healthcare funders in terms of improved outcomes or decreased costs are unknown. There appears to be no significant differences in the improvement of technical skills between different methods of box model training. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the impacts of box model training on surgical skills in both the short and long term, as well as clinical outcomes when the trainee becomes competent to operate on patients.