A Randomized Controlled Study to Evaluate the Impact of Instrument and Laparoscope Length on Performance and Learning Curve in Single-Incision Laparoscopic Surgery

Novices' learning curve in single-port surgery using three surgical training programs

BACKGROUND

The objective of this study was to evaluate the novices' learning curves and proficiency level reached in laparoendoscopic single-site (LESS) surgery using three surgical training programs.

MATERIAL AND METHODS

Participants were randomly divided into three groups, who trained in a specific practice regimen for 12 days using a laparoscopic box simulator and three tasks. Group A trained in three stages using conventional laparoscopic surgery (CLS) with straight instruments, and LESS with straight and articulating instruments for four days each. Group B trained in two stages in LESS with straight and articulating instruments for six days each. Group C trained only in LESS with articulating instruments exclusively for all 12 days. Performance was registered daily during the 12 days to evaluate the participants' progress.

RESULTS

Pre- and post-training analysis of the three groups showed significant differences in performance, denoting the significant improvement in their LESS skills, with no difference between the groups. Group C reached a high level of technical competence with their specific training program in LESS, obtaining a lower asymptote and slow learning rate.

CONCLUSION

Specific training programs in LESS settings using articulated instruments showed a slower learning rate than the other programs but better proficiency in the technique with the best surgical performance.

3D printed cannulas for use in laparoscopic surgery in feline patients: A cadaveric study and case series

OBJECTIVE

To evaluate custom 3D printed laparoscopic cannulas (3DPC) in a feline cadaveric abdominal surgery model and report their use in two live feline subjects.

STUDY DESIGN

Experimental cadaver study, live subject case series.

ANIMALS

Ten feline cadavers; two feline subjects.

METHODS

Custom 3DPCs were initially modeled in a PLA filament material and then created in an autoclavable dental resin for use in live patients. The surgery time, number of surgical collisions and cannula complications were recorded during cadaver procedures before and after use of 3DPCs. Cannula complications were recorded during live procedures and patients were followed to suture removal to record any incisional complications.

RESULTS

There was a significant reduction in mean surgical time (125.6 vs. 95.2 min, p = 0.03), mean number of instrument collisions (6.8 vs. 2.6, p = 0.03), and mean number of cannula complications (10 vs. 2.2, p = 0.03) with the use of only 3DPCs during the procedure. During the live procedures the use of the 3DPCs was successful and no postoperative complications occurred at the incision sites.

CONCLUSION

The use of customized 3DPCs may improve surgical dexterity and decrease complications in advanced procedures and was not associated with any clinical complications in two cats. The use of 3DPCs in veterinary medicine may allow for wider practice of laparoscopic techniques in small animals.

Transfer of training-Virtual reality training with augmented multisensory cues improves user experience during training and task performance in the real world

Virtual reality (VR) can create safe, cost-effective, and engaging learning environments. It is commonly assumed that improvements in simulation fidelity lead to better learning outcomes. Some aspects of real environments, for example vestibular or haptic cues, are difficult to recreate in VR, but VR offers a wealth of opportunities to provide additional sensory cues in arbitrary modalities that provide task relevant information. The aim of this study was to investigate whether these cues improve user experience and learning outcomes, and, specifically, whether learning using augmented sensory cues translates into performance improvements in real environments. Participants were randomly allocated into three matched groups: Group 1 (control) was asked to perform a real tyre change only. The remaining two groups were trained in VR before performance was evaluated on the same, real tyre change task. Group 2 was trained using a conventional VR system, while Group 3 was trained in VR with augmented, task relevant, multisensory cues. Objective performance, time to completion and error number, subjective ratings of presence, perceived workload, and discomfort were recorded. The results show that both VR training paradigms improved performance for the real task. Providing additional, task-relevant cues during VR training resulted in higher objective performance during the real task. We propose a novel method to quantify the relative performance gains between training paradigms that estimates the relative gain in terms of training time. Systematic differences in subjective ratings that show comparable workload ratings, higher presence ratings and lower discomfort ratings, mirroring objective performance measures, were also observed. These findings further support the use of augmented multisensory cues in VR environments as an efficient method to enhance performance, user experience and, critically, the transfer of training from virtual to real environment scenarios.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

Background

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

Methods

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

Results

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

Conclusions

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Using an abdominal phantom to teach urology residentes ultrasound-guided percutaneous needle placement

INTRODUCTION

To assess the effect of a hands-on ultrasound training session to teach urologic trainees ultrasound-guided percutaneous needle placement.

MATERIALS AND METHODS

University of California, San Francisco (UCSF) urology residentes completed a time trial, placing a needle into a phantom model target under ultrasound guidance. Participants were randomized into three educational exposure groups: Group 1's time trial occurred prior to any teaching intervention, group 2's after experiencing a hands-on training module, and group 3's after exposure to both the training module and one-on-one attending feedback. Needle placement speed and accuracy as well as trainees' perceived confidence in utilizing ultrasound were measured.

RESULTS

The study cohort consisted of 15 resident trainees. Seven were randomized to group 1, three to group 2, and five to group 3. All residents reported minimal prior ultrasound experience. Their confidence in using ultrasound improved significantly after completing the training module with the most significant improvement seen among junior residents. Time to needle placement was fastest after receiving attending feedback (46.6sec in group 3 vs. 82.7sec in groups 1 and 2, p<0.01). Accuracy also improved with attending feedback, though the number of repositioning attempts did not differ significantly between groups.

CONCLUSIONS

A hands-on training module and use of an abdominal phantom trainer increased resident confidence and skill in their use of ultrasound to guide percutaneous needle positioning. Attending feedback is critical for improving accuracy in needle guidance toward a target. Ultrasound-guided needle positioning is a teachable skill and can be applicable to multiple urologic procedures.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.