The effect of continuous at-home training of minimally invasive surgical skills on skill retention

Comparison of laparoscopic performance using low-cost laparoscopy simulators versus state-of-the-art simulators: a multi-center prospective, randomized crossover trial

INTRODUCTION

Simulator training is an efficient method for the development of basic laparoscopic skills. We aimed to investigate if low-cost simulators are comparable to more expensive box trainers regarding surgeons usability, likability, and performance.

METHODS

This multi-center, randomized crossover study included 16 medical students, seven abdominal surgeons, and seven urological surgeons. Participants performed four laparoscopic tasks (peg transfer, circle cutting, balloon resection, suture and knot) on both, a "Low cost trainer" (LCT) or a "high cost trainer" (HCT) in a randomized order. The primary endpoint was the subjective rating of both training simulators in terms of camera view, depth perception, movement of instruments, pricing, and usability for training. Secondary endpoints were force parameters, task completion time, surgical errors, and psychological workload.

RESULTS

Participants rated the LCT better concerning view (p < 0.001), depth perception (p = 0.003), pricing (p < 0.001), and usability for digital training (p < 0.001), but worse in terms of instrument movement (p = 0.004). Overall, the LCT was rated better than the HCT (p = 0.015). Regarding force parameters, participants showed a significantly lower force exertion on the HCT during the peg transfer task (p = 0.008). The force exertion in the other tasks were comparable between both trainers. Participants were significantly faster using the HCT during the peg transfer (p = 0.049) and significantly slower in balloon resection (p = 0.049) and suture and knot task (p = 0.026). The assessment of the participants' workload showed no differences.

CONCLUSION

The LCT was generally rated better than the HCT. The differences concerning force exertion and task completion time showed better results during peg transfer at the HCT but were generally inconclusive and without systemic advantage for either trainer. However, the LCT could be a promising and cost-effective augmentation for modern laparoscopic training.

Comparison of distance versus in-person laparoscopy training using a low-cost laparoscopy simulator-a randomized controlled multi-center trial

INTRODUCTION

Simulation training programs are essential for novice surgeons to acquire basic experience to master laparoscopic skills. However, current state-of-the-art laparoscopy simulators are still expensive, limiting the accessibility to practical training lessons. Furthermore, training is time intensive and requires extensive spatial capacity, limiting its availability to surgeons. New laparoscopic simulators offer a cost-effective alternative, which can be used to train in a digital environment, allowing flexible, digital and personalized laparoscopic training. This study investigates if training on low-cost simulators in a digital environment is comparable to in-person training formats.

MATERIALS AND METHODS

From June 2023 to December 2023, 40 laparoscopic novices participated in this multi-center, prospective randomized controlled trial. All participants were randomized to either the ‟distance" (intervention) or the "in-person" (control) group. They were trained in a standardized laparoscopic training curriculum to reach a predefined level of proficiency. After completing the curriculum, participants performed four different laparoscopic tasks on the ForceSense system. Primary endpoints were overall task errors, the overall time for completion of the tasks, and force parameters.

RESULTS

In total, 40 laparoscopic novices completed digital or in-person training. Digital training showed no significant differences in developing basic laparoscopic skills compared to in-person training. There were no significant differences in median overall errors between both training groups for all exercises combined (intervention 3 vs. control 4; p value = 0.74). In contrast, the overall task completion time was significantly lower for the group trained digitally (intervention 827.92 s vs. control 993.42; p value = 0.015). The applied forces during the final assessment showed no significant differences between both groups for all exercises. Overall, over 90% of the participants rated the training as good or very good.

CONCLUSION

Our study shows that students that underwent digital laparoscopic training completed tasks with a similar number of errors but in a shorter time than students that underwent in-person training. Nevertheless, the best strategies to implement such digital training options need to be evaluated further to support surgeons' personal preferences and expectations.

Barriers to diffusion and implementation of pediatric minimally invasive surgery in Brazil

BACKGROUND

The main barriers to the broad implementation of pediatric minimally invasive surgery (MIS) are technological, technical, and epistemological barriers, as well as the rarity of certain pathologies. These issues are presumed to be more significant in low- and middle-income countries. This study aimed to identify and analyze the factors limiting the diffusion and implementation of pediatric MIS in Brazil.

METHODS

A nationwide cross-sectional survey was conducted via an online questionnaire in Brazil from January 2022 to July 2022. The sample was taken by convenience from the population of pediatric surgeons in Brazil. A total of 187 surgeons were included. The collected data were divided into three sections to evaluate technological, technical, and epistemological limitations to pediatric MIS implementation.

RESULTS

Although 85% of the participants had previous training, a lack of adequate training was identified as a significant limiting factor, particularly among those who had taken only short courses (42.3% vs. 64.3%, p = 0.033). Only 14% of the participants reported performing MIS for major pediatric procedures. With respect to intracorporeal suturing, 38.1% of the surgeons with extensive training considered it a limiting factor compared with 60.7% (p = 0.029) of those without prior training. Among those without previous training, 61% cited a lack of financial support or encouragement from their department as the reason. Additionally, 65% of the surgeons considered the lack of basic instruments a limiting factor. Although 95% of the participants agreed that simulation training is indispensable, pediatric surgery fellowship programs in Brazil do not include a standardized curriculum or mandatory training in MIS, and only 47% reported providing training space for their current fellows.

CONCLUSION

A combination of technological, technical, and epistemological barriers hinders the implementation of pediatric MIS. Despite its limitations, this study serves as a foundational guide for future analysis and overcoming the identified barriers.

Experts in Minimally Invasive Surgery are Outperformed by Trained Novices on Suturing Skills

INTRODUCTION

Learning minimally invasive suturing can be challenging, creating a barrier to further implementation, especially with the development of easier methods. Nevertheless, mastering intracorporeal knot tying is crucial when alternative techniques prove inadequate. Therefore, the minimally invasive surgery (MIS) suturing skills of MIS experts are compared with a group of novices during their learning curve on a simulator.

METHODS

The novice participants repeatedly performed the intracorporeal suturing task on the EoSim MIS simulator (up to a maximum of 20 repetitions). The experts (>50 MIS procedures and advanced MIS experience) completed the same task once. The first and last exercises of the novices and the expert tasks were all blindly recorded and assessed by two independent assessors using the Laparoscopic Suturing Competency Assessment Tool (LS-CAT). Additionally, objective assessment parameters, "time" and "distance", using instrument tracking, were collected. The scores of the experts were then compared with the novices.

RESULTS

At the end of the training, novices significantly outperformed the experts on both the expert assessment (LS-CAT: 16.8 versus 26.8, P = 0.001) and objective parameters (median time: 190 s versus 161 s, P < 0.001; median distance: 6.1 m versus 3.6 m, P < 0.001). Although the experts showed slightly better performance than the novices during their first task, the difference was not significant on the expert assessment (LS-CAT experts 16.8, novices 20.5, P = 0.057).

CONCLUSIONS

Our findings underscore the significance of continued MIS suturing training for both residents and surgeons. In this study, trained novices demonstrated a significant outperformance of experts on both quantitative and qualitative outcome parameters within a simulated setting.

Objective assessment for open surgical suturing training by finger tracking can discriminate novices from experts

It is difficult, time consuming and expensive to assess manual skills in open surgery. The aim of this study is to investigate the construct validity of a low-cost, easily accessible tracking technique for basic open suturing tasks. Medical master students, surgical residents, and surgeons at the Radboud University Medical Center were recruited between September 2020 until September 2021. The participants were divided, according to experience, in a novice group (≤10 sutures performed) and an expert group (>50 sutures performed). For objective tracking, a tablet with SurgTrac software was used, which tracked a blue and a red tag placed on respectively their left and right index finger. The participants executed four basic tasks on a suturing model: 1) knot tying by hand, 2) transcutaneous suturing with an instrument knot, 3) 'Donati' (vertical mattress suture) with an instrument knot and 4) continuous intracutaneous suturing without a knot. In total 76 participants were included: 57 novices and 19 experts. All four tasks showed significant differences between the novice group and expert group for the parameters time (p<0.001), distance (p<0.001 for Task 1, 2 and 3 and p=0.034 for Task 4) and smoothness (p<0.001). Additionally, Task 3 showed a significant difference for the parameter handedness (p=0.006) and Task 4 for speed (p=0.033). Tracking index finger movements using SurgTrac software on a tablet while executing basic open suturing skills on a simulator shows excellent construct validity for time, distance and motion smoothness in all four suturing tasks.