Evaluation of minimally invasive surgical skills training: comparing a neonatal esophageal atresia/tracheoesophageal fistula model with a dry box

Young pediatric surgeons without endoscopic surgical skill qualification safely perform advanced endoscopic surgery under the supervision of expert qualified surgeons

BACKGROUND

Young pediatric surgeons should receive adequate training in various minimally invasive surgeries (MIS). However, it is essential to maintain patient safety and outcomes during the learning process. In Japan, the endoscopic surgical skill qualification (ESSQ) system in pediatric surgery was initiated by the Japan Society for Endoscopic Surgery (JSES) in 2009 to objectively evaluate the skill of endoscopic surgeons. This study compared perioperative outcomes between pediatric surgeons with ESSQ qualifications and those without (non-ESSQ).

METHODS

We retrospectively reviewed the medical records of children with choledochal cyst (CC), lobectomy, and biliary atresia (BA) who underwent MIS at our hospital from 2013 to 2023. We assessed the performance of nonqualified surgeons assisted by supervisors with ESSQ qualifications.

RESULTS

This study included the records of 101 surgical cases with CC (operated by ESSQ: 36, non-ESSQ: 65), 78 patients with BA (operated by ESSQ: 35, non-ESSQ: 43), and 67 patients with lobectomy (operated by ESSQ: 31, non-ESSQ: 36). For the CC and lobectomy groups, there were no significant differences in operating time, blood loss, and postoperative complications (PO) between the ESSQ and non-ESSQ groups. In BA, the operative times for the ESSQ and non-ESSQ groups were 310 and 377 min, respectively (p = 0.001). Furthermore, no significant differences were observed in blood loss, PO, jaundice-clearance ratio, and jaundice-free survival rate with the native liver between the two groups.

CONCLUSION

The results indicate that young pediatric surgeons can safely perform MIS while practicing under the supervision of experienced ESSQ-qualified surgeons.

Evaluating suturing skill improvement for pediatric minimally invasive esophageal anastomosis model: an observational cohort study based on simulator training

The study aimed to evaluate the enhancement of minimally invasive surgery (MIS) suturing skills through intensive simulator training, to compare various experimentally measured movement parameters with the established scoring system and to identify movement parameters that may be crucial for achieving proficiency. 55 participants of the intensive practical course of endoscopic surgery in children were included. Training commenced with daily single surgical knot practice, progressed to executing on the final day an anastomosis resembling those performed in esophageal atresia repair. The training effectiveness was gauged by the successful completion of anastomosis. Skills were evaluated by simulator equipped with specialized sensors, which converted data into a set of instrument movement parameters. Additionally, two researchers assessed skills using recorded videos and the objective structured assessment of technical skills (OSATS) questionnaire. Significant improvements in single surgical knot proficiency were noted each day, specifically in metrics: time, movement economy, smoothness, acceleration, instrument activity, and overall score. Strong correlation was observed between automated and human assessments. 48/55 participants attempted anastomosis on the final day, among whom 70% (34/48) attained success (median score 5.1/10, only 16.7% scored above 7/10). Movement economy and instrument distance covered emerged as the most relevant predictors of the anastomosis success. Intensive simulation training significantly enhances endoscopic suturing skills.

Developing an Effective Off-the-job Training Model and an Automated Evaluation System for Thoracoscopic Esophageal Atresia Surgery

BACKGROUND

Pediatric minimally invasive surgery requires advanced technical skills. Off-the-job training (OJT), especially when using disease-specific models, is an effective method of acquiring surgical skills. To achieve effective OJT, it is necessary to provide objective and appropriate skill assessment feedback to trainees. We aimed to construct a system that automatically evaluates surgical skills based on forceps movement using deep learning (DL).

METHODS

Using our original esophageal atresia OJT model, participants were tasked with performing esophageal anastomosis. All tasks were recorded for image analysis. Based on manual objective skill assessments, each participant's surgical skills were categorized into two groups: good and poor. The motion of the forceps in both groups was used as training data. Employing this training data, we constructed an automated system that recognized the movement of forceps and determined the quality of the surgical technique.

RESULTS

Thirteen participants were assigned to the good skill group and 32 to the poor skill group. These cases were validated using an automated skill assessment system. This system showed a precision of 75%, a specificity of 94%, and an area under the receiver operating characteristic curve of 0.81.

CONCLUSIONS

We constructed a system that automatically evaluated the quality of surgical techniques based on the movement of forceps using DL. Artificial intelligence diagnostics further revealed the procedures important for suture manipulation.

LEVELS OF EVIDENCE

Level IV.

Evaluation of skill acquisition characteristics depending on the size of a dry box

BACKGROUND

Few studies have analyzed the effect of the size of the working space in training on the acquisition of endoscopic skills. In this study, adult- and infant-sized dry boxes (DBs) were used to verify how the size of the working space in training affects forceps manipulation and learning curve.

MATERIAL AND METHODS

Seventy-two medical students were enrolled. The task was peg transfer. The training environment was divided into adult- and infant-sized DBs. Skill evaluations were also divided into adult- and infant-sized DBs (four groups in total). The forceps manipulation characteristics and task completion time were compared before and after training.

RESULTS

Regarding skill evaluations using adult-sized DBs, there were no significant differences between the infant- and adult-sized DB-trained groups. Regarding skill evaluations using infant-sized DBs, there were no significant differences between the groups before training. After training, there was no significant difference in the total path length or average acceleration of the forceps between the groups. However, the infant-sized DB-trained group had a significantly faster average forceps velocity and faster task completion time than the adult-sized DB-trained group.

CONCLUSION

Training with a small DB is more efficient in acquiring smoother and faster forceps manipulation in a small working space.

An analysis of the correlation between the efficacy of training using a high-fidelity disease-specific simulator and the clinical outcomes of laparoscopic surgery for congenital biliary dilatation in pediatric patients

PURPOSE

The present study clarified the efficacy of repeating laparoscopic surgery training using a disease-specific simulator and investigated the clinical outcomes of laparoscopic surgery for congenital biliary dilatation (CBD) in pediatric patients after training.

METHODS

A high-fidelity laparoscopic hepaticojejunostomy simulator was used. Four pediatric surgeons performed practice laparoscopic hepaticojejunostomy three times using the simulator. The details of forceps manipulation during the task were analyzed. The clinical outcomes of 13 CBD cases treated with laparoscopic surgery in our institution were also evaluated based on medical records.

RESULTS

The time required to complete the task became significantly shorter each successive time (1st: 1062.18 ± 346.79 s vs. 3rd: 717.44 ± 260.80 s, p = 0.039). There were no significant differences in the total path length of the right forceps (1st: 55.56 ± 23.21 m vs. 3rd: 28.25 ± 17.01 m, p = 0.17), total path length of the left forceps (1st: 47.79 ± 20.79 m vs. 3rd: 31.83 ± 17.62 m, p = 0.17), average velocity of the right forceps (1st: 58.78 ± 21.29 mm/s vs.44.98 ± 10.25 mm/s, p = 0.47), or the average velocity of the left forceps (1st: 50.39 ± 19.25 mm/s vs. 52.26 ± 19.59 mm/s, p = 0.78). Regarding the clinical outcome, all CBD patients underwent laparoscopic surgery performed by practiced pediatric surgeons who had no experience. The operative time was 545.53 ± 91.01 min, and the blood loss was 24.2 ± 25.8 ml. There were no cases of open conversion, intraoperative adverse events, or anastomotic leakage.

CONCLUSION

Disease-specific simulator training significantly decreased the task performance time by improving the forceps manipulation economy. In addition, simulator training may improve the operative safety and quality of laparoscopic hepaticojejunostomy in pediatric CBD patients.