Development of a valid, cost-effective laparoscopic training program

Silicone as a smart solution for simulating soft tissue-an iterative approach to developing a high-fidelity sustainable training model for laparoscopic appendectomy

Background

Laparoscopic appendectomy (LA) is an effective treatment for the surgical care of appendicitis, with this minimally invasive approach allowing patients to typically spend less time in hospital and promptly return to normal life activities. Residents can acquire the competence and confidence needed in a safe learning environment prior to real patient encounters through simulation-based learning of these techniques. We propose a low cost, sustainable, high fidelity simulation-based training model for LA to compliment regular resident practice of these skills.

Methods

A team dedicated to developing this surgical simulation training model was established, equipped with the clinical knowledge and model engineering expertise. We used concepts of design-based research (DBR) to iteratively develop this model at key intervals. Our LA training model underwent four stages of model development prior to unified stakeholder consensus that this model was deemed effective and suitable for integration into formative surgical simulation curricula.

Results

This model simulates most of the key anatomical structures associated with performing an LA. In order to provide high fidelity haptic feedback, attempts were made to mimic the tensile properties of real tissue using different concentrations of silicone. The model can be utilized with laparoscopic box trainers of various sizes due to its scalability. It cost €9.67 to create, and single use appendix components cost €1.22 to build thereafter.

Conclusions

Surgical residents can benefit from the platform that simulation-based education offers to develop the psychomotor skills necessary to perform LA in a safe learning environment. We describe a model for LA, which allows learners to develop their skill proficiency in this area under expert supervision.

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.

Further Results of Incorporating Innovative Procedures in a Surgical Residency

The instruction in precipitously advancing surgical technologies remains a real challenge to every surgery program. Our institution's ongoing experience with an identified center for student and resident education and clinical investigation provides an option for addressing these needs in a general surgery residency. Over the past 8 years, we have developed and described previously the Center for Advanced Surgical Technologies (CAST) in a joint undertaking of the Department of Surgery and the Norton Hospital, an affiliated hospital on our medical school campus. The idea behind this program has been to focus and develop high-quality skills in the hospital in many areas of advanced technology. CAST has subsequently provided a vehicle for excellent clinical research as well as the development of specially focused advanced surgical technologies, fellowships, and a large number of publications that have often focused on new, advanced methods for imaging surgical disease and minimal access treatment. This program has had a very positive impact on the general surgery residency as a whole and has permitted a steadily advancing agenda of new technologies, while relegating recently emerged but perfected technologies into the central aspect of our accredited general surgery residency.

A systematic review of low-cost laparoscopic simulators

BACKGROUND

Opportunities for surgical skills practice using high-fidelity simulation in the workplace are limited due to cost, time and geographical constraints, and accessibility to junior trainees. An alternative is needed to practise laparoscopic skills at home. Our objective was to undertake a systematic review of low-cost laparoscopic simulators.

METHOD

A systematic review was undertaken according to PRISMA guidelines. MEDLINE/EMBASE was searched for articles between 1990 and 2014. We included articles describing portable and low-cost laparoscopic simulators that were ready-made or suitable for assembly; articles not in English, with inadequate descriptions of the simulator, and costs >£1500 were excluded. Validation, equipment needed, cost, and ease of assembly were examined.

RESULTS

Seventy-three unique simulators were identified (60 non-commercial, 13 commercial); 55 % (33) of non-commercial trainers were subject to at least one type of validation compared with 92 % (12) of commercial trainers. Commercial simulators had better face validation compared with non-commercial. The cost ranged from £3 to £216 for non-commercial and £60 to £1007 for commercial simulators. Key components of simulator construction were identified as abdominal cavity and wall, port site, light source, visualisation, and camera monitor. Laptop computers were prerequisite where direct vision was not used. Non-commercial models commonly utilised retail off-the-shelf components, which allowed reduction in costs and greater ease of construction.

CONCLUSION

The models described provide simple and affordable options for self-assembly, although a significant proportion have not been subject to any validation. Portable simulators may be the most equitable solution to allow regular basic skills practice (e.g. suturing, knot-tying) for junior surgical trainees.

A cross-sectional pilot study to investigate patient attitudes and perception regarding the use of real time digital recording of urological procedures for research and teaching purposes

Little conclusive evidence exists regarding the best way to educate and evaluate skill acquisition of advanced surgical trainees, despite it being recognised as one of the most important aspects of training. Many laparoscopic trainers have been produced with complex engineering at great cost, but, there seems to be a reluctance to use the most precious entity available to us; the patient. We thus propose the use of real time digital recording of urological procedures for research and teaching purposes. This study was prompted by the lack of literature regarding such issues. A 19 question questionnaire was circulated at a single urology out-patient department (Essex, England) over a 6 month period to evaluate attitudes and perceptions of urological patients on potentially having their procedure digitally recorded for educational and research purposes. 11 patients declined, 187 questionnaires were included in the final analysis. Male patients are more willing to consent than female patients. Older patients resulted to have a higher propensity in being recorded for medical teaching. Greater than 50% believe being recorded is intrusive but the majority do not think privacy is an issue. Lastly, the vast majority require a formal debrief post operatively. Our results show that a percentage of the public are potentially willing to be digitally recorded but many financial and social barriers exist. We have also highlighted areas of possible future research, namely the reluctance behind young urology patients to consent and questions regarding how best to educate possible study participants to ensure proper informed consent is gained.

Advanced training in laparoscopic abdominal surgery: a systematic review

BACKGROUND

Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator.

METHODS

Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles.

RESULTS

Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid.

CONCLUSION

Higher-quality studies are required to appraise educational value in this field.

A systematic review on low-cost box models to achieve basic and advanced laparoscopic skills during modern surgical training

INTRODUCTION

Low-cost box models (BMs) are a valuable tool alternative to virtual-reality simulators. We aim to provide surgical trainees with a description of most common BMs and to present their validity to achieve basic and advanced laparoscopic skills.

MATERIALS AND METHODS

A literature search was undertaken for all studies focusing on BMs, excluded were those presenting data on virtual-reality simulators only. Databases were screened up to December 2011.

RESULTS

Numerous studies focused on various BMs to improve generic tasks (ie, instrument navigation, coordination, and cutting). Only fewer articles described models specific for peculiar operations. All studies showed a significant improvement of basic laparoscopic skills after training with BMs. Furthermore, their low costs make them easily available to most surgical trainees.

CONCLUSIONS

BMs should be developed by all surgical trainees during their training. Fields for future improvement regard endoscopy and complex laparoscopic operations for which ad hoc BMs are not available.

What is the cost associated with the implementation and maintenance of an ACS/APDS-based surgical skills curriculum?

PURPOSE

The purpose of this study was to evaluate the cost associated with the American College of Surgery (ACS)/Association of Program Directors in Surgery (APDS)-based surgical skills curriculum (SSC) within a general surgery residency program.

METHODS

The Penn Surgical Simulation Center (PSSC) of the University of Pennsylvania was established by the Department of Surgery during the 2006-2007 academic year and became a Level-I ACS Accredited Education Institute in 2008. Each academic year, 38 junior residents are assigned to a 4-week dedicated simulation rotation based on the ACS/APDS-based SSC. In conjunction with voluntary participation by faculty, a salaried educational fellow is responsible for maintaining the schedule and administering the surgical skills training modules. The costs associated with the ACS/APDS-based SSC were divided in initial implementation capital expenses and annual operational maintenance expenses.

RESULTS

The overall capital expenditures associated with the implementation of the curriculum were $4.204 million. These costs included the purchase of low and high-fidelity simulation equipment and initial construction costs to renovate a previous operating room (OR) and recovery suite into the Penn Medicine Clinical Simulation Center (PMCSC) which has housed the PSSC since 2008. The annual operational expenses are $476,000 and include the salary for the educational fellow, disposables, and other supplies, and the PMCSC average student fees. The annual cost per resident for the 4-week dedicated simulation rotation is $12,516. This figure does not include the average cost for teaching efforts including the simulation teaching per participating faculty member which is $30,000 in Relative Teaching Value Units per year.

CONCLUSIONS

The expenditures associated with the implementation and maintenance of the ACS/APDS-based surgical skills curriculum in a surgical residency program are significant. This center's experience might be useful to programs deciding on more cost-effective means of implementing the ACS/APDS-SSC into their training.

Analysis of a structured training programme in laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is an established treatment for almost all gallbladder diseases with bile duct injury rates similar to open cholecystectomy. These laparoscopic skills must be passed on to junior surgeons without compromising patient safety.

MATERIALS AND METHODS

We analysed our structured training programme over 6years (May 2000 to May 2006) by following three trainee surgeons during their training and beyond. During this period, 1,000 laparoscopic cholecystectomies were carried out with five consultant surgeons supervising and three new trainees who completed their accreditation in laparoscopic cholecystectomy.

RESULTS

There were 694 patients operated on by consultant surgeons (Group 1), 202 by trainee surgeons (Group 2) and 104 by newly trained surgeons (Group 3). There were no differences between the groups in terms of age and gender. However, there was a significant difference in gallbladder disease among the three groups; Group 2 had more gallstone pancreatitis patients (P < 0.019). There were no differences among the three groups in conversion rates, bile duct injury rates, general complication rates or length of stay. However, the duration of operation in Group 2 was significantly longer compared to the other two groups (P < 0.0001).

CONCLUSION

This programme is effective in training junior surgeons and does not compromise patient safety.

Evaluation of resident laparoscopic performance using global operative assessment of laparoscopic skills

BACKGROUND

The Global Operative Assessment of Laparoscopic Skills (GOALS), developed by Vassiliou and colleagues, has construct validity in the assessment of surgical residents' laparoscopic skills in dissection of the gallbladder from the liver bed. We hypothesized that GOALS would have construct validity for the entire laparoscopic cholecystectomy procedure and also for laparoscopic appendectomy.

METHODS

Using GOALS, attending surgeons evaluated PGY1 through PGY5 surgical resident performance during laparoscopic cholecystectomy (LC, n = 51) and laparoscopic appendectomy (LA, n = 43). Scores for five domains (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) were recorded on a Web-based operative report generator at the conclusion of all cases. Domain scores were recorded using a 5-point Likert scale. Difficulty of the case was similarly rated on a 5-point scale. For analysis, residents were divided into two groups: novice (PGY1 to 3) and experienced (PGY4 to 5). Biostatistical analysis was performed using a two-sample t-test. Paired t-test was used to compare mean scores of residents who performed both LA and LC.

RESULTS

For both LC and LA, the experienced group scored higher than novices did in all five domains. The differences were significant in all domains. Using the mean of the scores from all 5 domains for both LC and LA, the experienced residents scored significantly better than novices did (LC 3.93 versus 2.76, p < 0.001) (LA 4.22 versus 2.75, p < 0.001). No significant differences were noted in difficulty of the cases (p = 0.060 for LC and p = 0.19 for LA).

CONCLUSIONS

This study provides additional evidence in support of GOALS as an assessment tool for objectively measuring technical skills in laparoscopic surgery.

Implementation of an Intuitive Writing Interface and a Laparoscopic Robot for Gynaecological Laser Assisted Surgery

The research reported in this paper aims at applying the human handwriting skill to improve and facilitate the control of laser-assisted laparoscopic surgery operations performed by gynaecological surgeons. For the purpose, a laparoscopic robot was interfaced with a digitizing tablet. This interface, further called the intuitive writing interface (IWI), directly converts the hand trajectory, handwritten on the tablet, into an input signal to the robot. It replaces the traditional complex manipulations performed by the surgeon during manual laparoscopic surgery by natural handwriting. It provides the surgeon with an intuitive ‘what-you-draw-is-what-you-cut’ control facility by employing his/her familiar handwriting skills to control the laser ablation process accurately.

The system was successfully built and tested in vitro. Performance tests on the robot resulted in tracking errors in the order of 1 mm in the target plane at an ablation speed of 20 mm/s. The high accuracy of the system was successfully demonstrated by cutting characters 4 mm high on an apple. These results indicate that laser ablation performance is upgraded by the IWI to the accuracy levels of human handwriting, which is much higher than can be obtained with manual laser laparoscopy.

Safety features include the use of pen contact with the tablet as a safety switch, and back drivability in the robot joints for easy manual positioning and evacuation in case of emergency.

Training, assessment and competency in gynaecologic surgery

The trainee gynaecologist requires specific teaching to achieve competency in gynaecological surgery. Basic skills such as knot tying and suturing should be acquired outside the operating theatre. They can be learned on simulations, including bench models, using synthetic materials, life-like models and animal tissue. Video training equipment is useful for the development of basic laparoscopic hand-eye coordination. Intermediate and advanced skills require simulations using more sophisticated bench models, live animals and virtual reality computerised systems. Structured teaching and assessment methods are essential. Surgical skills training models should be reliable and valid, and can be incorporated into an objective structured clinical examination, which could be used to assess individual development and allow progression through a training programme. Simulation training does translate into improved operative performance. Supervised operating experience on patients is crucial to training and should be assessed regularly using a global rating form with constructive feedback to facilitate improvement.

Successful Collaborative Model for Trauma Skills Training of Surgical and Emergency Medicine Residents in a Laboratory Setting

OBJECTIVES

To determine whether interdepartmental educational and technical resources could be combined to successfully train surgery and emergency medicine residents in common diagnostic and therapeutic trauma skills outside the traditional hospital setting.

DESIGN

Curriculum improvement survey.

SETTING

Surgical Skills Laboratory, Temple University School of Medicine, Philadelphia, Pennsylvania.

PARTICIPANTS

A total of 35 surgery residents (PGY 1 to 5) and 26 emergency medicine residents (PGY 1 to 3).

METHODS

Emergency medicine attendings used human volunteers to train surgery residents in Focused Assessment with Sonography in Trauma (FAST). Trauma surgery attendings used a porcine model to teach emergency medicine residents tracheostomy, peripheral venous cutdown, diagnostic peritoneal lavage, tube thoracostomy, and bilateral thoracotomy. Upon completion of the courses, all residents were surveyed using a 5-point Likert scale to assess this teaching model.

RESULTS

The percentage of residents reporting an improvement in knowledge levels after the course increased significantly (p < 0.003) for all skill modules (FAST, 14% vs 73%; tracheostomy, 20% vs 64%; peripheral venous cutdown, 25% vs 71%; diagnostic peritoneal lavage, 16% vs 60%; tube thoracostomy, 42% vs 92%; thoracotomy, 15% vs 42%). A significant (p < 0.05) increase in comfort levels during performance of the procedures in the clinical setting was also anticipated for all skills modules (FAST, 11% vs 60%; tracheostomy, 12% vs 50%; peripheral venous cutdown, 15% vs 31%; diagnostic peritoneal lavage, 12% vs 58%; tube thoracostomy, 35% vs 73%; thoracotomy, 0% vs 15%). PGY 1 to 4 surgery residents and PGY 1 and 2 emergency medicine residents perceived the greatest benefit (p < 0.05) from their respective courses. The overwhelming majority (89% to 100%) of surgery and emergency medicine residents felt the course was valuable and transferable to the clinical trauma setting.

CONCLUSIONS

Interdepartmental collaboration between the Department of Surgery and Department of Emergency Medicine offered a unique training relationship that was a positive educational experience for all residents.

Priority setting for horizon scanning of new health technologies in Denmark: views of health care stakeholders and health economists

In the context of the establishment of a Danish Horizon Scanning System (HSS) the views of health care stakeholders and health economists were solicited by means of postal surveys on the need for adaptation of a priority setting instrument for health technology assessment (HTA). The aim was to investigate if the instrument needed adaptation for priority setting in the context of a Danish HSS and, if so, how the instrument should be changed. A literature study served to enhance interpretation of the findings of the surveys and to formulate changes in the instrument that synthesize or bridge any differing views between the two groups. The results show that the instrument should apply a health care perspective, and that technologies should be prioritised on the basis of the criteria: marginal benefits, marginal costs, budget impact, impact on access to care, and additional criteria with an impact on health policy, such as the educational needs and organisational changes associated with the new technology. The proposed changes are regarded as an intermediate step in the process of producing a fully adapted instrument that can serve as a formal support for priority setting of new health technologies for assessment in the Danish HSS.