Transferability of the robot assisted and laparoscopic suturing learning curves

Robot assisted surgery (RAS) is increasingly used, and besides conventional minimally invasive surgery (cMIS) surgeons are challenged to learn an increased array of skills. This study aimed to assess the influence of both learning curves on each other. A prospective randomized crossover study was performed. Participants without cMIS or RAS experience (Groups 1 and 2), and cMIS experienced, (Group 3) were recruited. Three suturing tasks (intracorporal suturing, tilted plane and anastomosis needle transfer) were performed on the EoSim cMIS simulator or RobotiX RAS simulator up to twenty repetitions. Subsequently, Groups 1 and 2 performed the tasks on the other modality. Outcomes were simulator parameters, validated composite and pass/fail scores. In total forty-three participants were recruited. Overall RAS suturing was better in Group 1 (cMIS followed by RAS tasks) and 3 (RAS tasks) versus Group 2 (RAS followed by cMIS tasks) for time (163 s and 157 s versus 193 s p = 0.004, p = 0.001) and composite scores (92/100 and 91/100 versus 89/100 p = 0.008, p = 0.020). The cMIS suturing was better for Group 2 versus 1 (time 287 s versus 349 s p = 0.005, composite score 96/100 versus 94/100 p = 0.002). Significant differences from the RAS suturing pass/fail were reached earlier by Group 3, followed by Groups 1 and 2 (repetition six, nine and twelve). In cMIS suturing Group 2 reached significant differences from the pass/fail earlier than Group 1 (repetition four versus six). Transferability of skills was shown for cMIS and RAS, indicating that suturing experience on cMIS or RAS is beneficial in learning either approach.

Development of a posterior sagittal anorectal surgical teaching model

Background

An Anorectal Malformation (ARM) is a rare congenital malformation, which requires proper correction to ensure the best long-term prognosis. These procedures are relatively infrequent and complex, in which a structured approach is important. Therefore, training on an affordable model could be beneficial.

Methods

A low-cost ARM model was developed. The base was reusable and the perineal body disposable. Both expert pediatric surgeons (Experts) and residents/fellows (Target group) were recruited for this study. After testing the model, they completed a questionnaire regarding the realism and didactic value of the model, using a 5-point Likert scale.

Results

Forty-four participants were recruited (Target group n = 20, Experts n = 24). The model has high mean scores of 3.8–4.4 for the total group and even higher on several aspects by the Target group. The experts regarded the haptics and manipulation of the fistula less realistic than the Target group (3.7 versus 4.3, p = 0.021 and 4.2 versus 4.6, p = 0.047). It was considered to be a very good training tool (mean 4.3), without significant differences between the groups.

Conclusions

These results show general consensus that this model is a potent training tool for the component steps of the repair of an ARM with recto-perineal fistula by sagittal approach.

Duhamel versus transanal endorectal pull through (TERPT) for the surgical treatment of Hirschsprung's disease

For the surgical treatment of Hirschsprung's disease, several surgical techniques are used to resect the distal aganglionic colon. Two frequently used techniques are the Duhamel procedure and the transanal endorectal pull-through procedure. During the '8th Pediatric Colorectal Course' in Nijmegen, November 2015, a workshop was organized to share experiences of both techniques by several experts in the field and to discuss (long term) outcomes. Specifically, the objective of the meeting was to discuss the main controversies in relation to the technical execution of both procedures in order to make an initial assessment of the limitations of available evidence for clinical decision-making and to formulate a set of preliminary recommendations for current clinical care and future research.

Outcome in anorectal malformation type rectovesical fistula: a nationwide cohort study in The Netherlands

PURPOSE

Outcomes of patients with an ARM-type rectovesical fistula are scarcely reported in medical literature. This study evaluates associated congenital anomalies and long-term colorectal and urological outcome in this group of ARM-patients.

METHODS

A retrospective Dutch cohort study on patients treated between 1983 and 2014 was performed. Associated congenital anomalies were documented, and colorectal and urological outcome recorded at five and ten years of follow-up.

RESULTS

Eighteen patients were included, with a mean follow-up of 10.8years. Associated congenital anomalies were observed in 89% of the patients, 61% considered a VACTERL-association. Total sacral agenesis was present in 17% of our patients. At five and ten years follow-up voluntary bowel movements were described in 80% and 50%, constipation in 80% and 87%, and soiling in 42% and 63% of the patients, respectively. Bowel management was needed in 90% and one patient had a definitive colostomy. PSARP was the surgical reconstructive procedure in 83%. Urological outcome showed 14 patients (81%) to be continent. No kidney transplantations were needed.

CONCLUSION

In our national cohort of ARM-patients type rectovesical fistula that included a significant proportion of patients with major sacral anomalies, the vast majority remained reliant on bowel management to be clean after ten years follow-up, despite "modern" PSARP-repair. Continence for urine is achieved in the majority of patients, and end-stage kidney failure is rare.

Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease (Br J Surg 2010; 97: 1318-1330)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Suturing training in Augmented Reality: gaining proficiency in suturing skills faster

Background

Providing informative feedback and setting goals tends to motivate trainees to practice more extensively. Augmented Reality simulators retain the benefit of realistic haptic feedback and additionally generate objective assessment and informative feedback during the training. This study researched the performance curve of the adapted suturing module on the ProMIS Augmented Reality simulator.

Methods

Eighteen novice participants were pretrained on the MIST-VR to become acquainted with laparoscopy. Subsequently, they practiced 16 knots on the suturing module, of which the assessment scores were recorded to evaluate the gain in laparoscopic suturing skills. The scoring of the assessment method was calculated from the “time spent in the correct area” during the knot tying and the quality of the knot. Both the baseline knot and the knot at the top of the performance curve were assessed by two independent objective observers, by means of a standardized evaluation form, to objectify the gain in suturing skills.

Results

There was a statistically significant difference between the scores of the second knot (mean 72.59, standard deviation (SD) 16.28) and the top of the performance curve (mean 95.82, SD 3.05; p < 0.001, paired t-test). The scoring of the objective observers also differed significantly (mean 11.83 and 22.11, respectively; SD 3.37 and 3.89, respectively; p < 0.001) (interobserver reliability Cronbach’s alpha = 0.96). The median amount of repetitions to reach the top of the performance curve was eight, which also showed significant differences between both the assessment score (mean 88.14, SD 13.53, p < 0.001) and scoring of the objective observers of the second knot (mean 20.51, SD 4.14; p < 0.001).

Conclusions

This adapted suturing module on the ProMIS Augmented Reality laparoscopic simulator is a potent tool for gaining laparoscopic suturing skills.

Face validity study of the ProMIS augmented reality laparoscopic suturing simulator

To prevent unnecessary mistakes and avoidable complications in laparoscopic surgery, there has to be proper training. A safe way to train surgeons for laparoscopy is simulation. This study addresses the face validity of ProMIS, an Augmented Reality laparoscopic simulator, as a tool for training suturing skills in laparoscopic surgery. A two-paged, 12-item structured questionnaire, using a five-point-Likert scale, was presented to 50 surgeons/surgical interns. The participants were allotted to two groups: an "expert" (>50 procedures; N=23) and a referent group (<50 procedures; N=27). Non-parametric statistics were used to determine statistical differences. General consensus existed in both expert and referent groups, delineating ProMIS as a useful tool in teaching suturing skills surgeons/surgical interns (mean + or - st dev, resp, score 4.91 + or - 0.42 and 4.93 + or - 0.38) with regard to realism, tactile feedback, and suturing techniques. Significant differences in opinion regarding the ergonomics and design of ProMIS between the expert and referent groups existed. The ProMIS Augmented Reality laparoscopic simulator is regarded as a useful tool in laparoscopic training in both expert and referent groups. Although significant differences in opinion existed with regards to ergonomics and design of ProMIS, they were present between experts and novices.

Acquiring basic endoscopy skills by training on the GI Mentor II

BACKGROUND

Achieving proficiency in flexible endoscopy requires a great amount of practice. Virtual reality (VR) simulators could provide an effective alternative for clinical training. This study aimed to gain insight into the proficiency curve for basic endoscope navigation skills with training on the GI Mentor II.

METHODS

For this study, 30 novice endoscopists performed four preset training sessions. In each session, they performed one EndoBubble task and managed multiple VR colonoscopy cases (two in first session and three in subsequent sessions). Virtual reality colonoscopy I-3 was repeatedly performed as the last VR colonoscopy in each session. The assignment for the VR colonoscopies was to visualize the cecum as quickly as possible without causing patient discomfort. Five expert endoscopists also performed the training sessions. Additionally, the performance of the novices was compared with the performance of 20 experienced and 40 expert endoscopists.

RESULTS

The novices progressed significantly, particularly in the time required to accomplish the tasks (p < 0.05, Friedman's analysis of variance [ANOVA], p < 0.05, Wilcoxon signed ranks). The experts did not improve significantly, except in the percentage of time the patient was in excessive pain. For all the runs, the performance of the novices differed significantly from that of both the experienced and the expert endoscopists (p < 0.05, Mann-Whitney U). The performance of the novices in the latter runs differed less from those of both the experienced and the expert endoscopists.

CONCLUSIONS

The study findings demonstrate that training in both VR colonoscopy and EndoBubble tasks on the GI Mentor II improves the basic endoscope navigation skills of novice endoscopists significantly.