A Novel Virtual Wet Lab-Using a Smartphone Camera Adapter and a Video Conference Platform to Provide Real-Time Surgical Instruction

PURPOSE

Proctored surgical instruction has traditionally been taught through in-person interactions in either the operating room or an improvised wet lab. Because of the COVID-19 pandemic, live in-person instruction was not feasible owing to social distancing protocols, so a virtual wet lab (VWL) was proposed and implemented. The purpose of this article is to describe our experience with a VWL as a Descemet membrane endothelial keratoplasty (DMEK) skills-transfer course. This is the first time that a VWL environment has been described for the instruction of ophthalmic surgery.

METHODS

Thirteen participant surgeons took part in VWLs designed for DMEK skills transfer in September and October 2020. A smartphone camera adapter and a video conference software platform were the unique media for the VWL. After a didactic session, participants were divided into breakout rooms where their surgical scope view was broadcast live, allowing instructors to virtually proctor their participants in real time. Participants were surveyed to assess their satisfaction with the course.

RESULTS

All (100%) participants successfully injected and unfolded their DMEK grafts. Ten of the 13 participants completed the survey. Respondents rated the experience highly favorably.

CONCLUSIONS

With the use of readily available technology, VWLs can be successfully implemented in lieu of in-person skills-transfer courses. Further development catering to the needs of the participant might allow VWLs to serve as a viable option of surgical education, currently limited by geographical and social distancing boundaries.

The teaching order of using direct laryngoscopy first may improve the learning outcome of endotracheal incubation: A preliminary, randomized controlled trial

BACKGROUND

Endotracheal intubation (ETI) is a life-saving procedure taught to medical students. We examined the influence of the order of teaching ETI through direct laryngoscopy (DL) and video laryngoscopy (VL) on learning by measuring the intubation time and learning curve of trainees, in order to explore ways to improve ETI performance.

METHODS

Twenty trainees were randomly divided into 2 groups. In the DL-first group, trainees used DL to perform ETI 10 times and then used VL 10 times, while the order was reversed in the VL-first group. Intubation time, number of intubation attempts, the Cormack-Lehane (CL) classification, and adverse events were recorded. The primary outcome was the cumulative summation (CUSUM). The CUSUM equation is defined as (Equation is included in full-text article.), where ct is the cumulative sum.

RESULTS

ETI was attempted on 400 patients. The difference in the mean times for the first 10 intubations between the 2 groups was not significant (P > .05). Mean intubation time for second series in the DL-first group was significantly shorter than that of the first series (P < .05), while there were no differences between the 2 series in the VL-first group (P > .05). The mean intubation time in the second series of the DL-first group was shorter than for the first series of the VL-first group (P < .05), while the mean intubation time of the first series by the DL-first group did not differ from the second series by the VL-first group (P > .05). Eighteen attempts were required to achieve an 80% intubation success rate for the DL-first group, while more than 20 attempts were required for the trainees in the VL-first group.

CONCLUSION

We consider that teaching trainees DL for tracheal intubation first.

CLINICAL TRIAL NUMBER

ChiCTR-OOR-16008364.

Cumulative sum analysis of learning curve for video-assisted mini-laparotomy partial nephrectomy in renal cell carcinoma

Video-assisted mini-laparotomy surgery (VAMS), a hybrid of open and laparoscopic surgical techniques, is an important surgical approach in the field of partial nephrectomy. The learning curve for VAMS partial nephrectomy has not been studied to date; we therefore, evaluated this learning curve.We prospectively evaluated 20 consecutive patients who underwent VAMS partial nephrectomy performed by a single surgeon (YEY) between March 2015 and December 2016. The learning curve was evaluated using the cumulative sum method. The measure of surgical performance was composed of 3 parameters (total operation time [Op time], warm ischemic time [WIT], and estimated blood loss [EBL]).Among the 20 patients who underwent VAMS partial nephrectomy, the mean age was 54.6 years. The mean Op time and WIT were 172.5 and 28.8 minutes, respectively. The learning curve for the Op time, WIT, and EBL consisted of 3 unique phases: phase 1 (the first 7 cases), phase 2 (the next 5 to 7 cases), and phase 3 (all subsequent cases). Phase 1 represents the initial learning curve, and the phase 2 plateau represents the period of expert competency. Phase 3 represents when one is competent in VAMS partial nephrectomy.The learning curve for VAMS partial nephrectomy is relatively short and after a learning curve of approximately 7 cases, the surgeon became familiar with VAMS partial nephrectomy; after 12 to 14 cases, the surgeon became competent in this procedure.

LOW-COST SIMULATOR ASSEMBLY FOR 3-DIMENSIONAL VIDEOSURGERY TRAINING

BACKGROUND

Three-dimensional videosurgery is already a reality worldwide. The trainee program for this procedure should be done initially and preferably in simulators.

AIM

Assemble low-cost simulator for three-dimensional videosurgery training.

METHODS

The simulator presented here was mounted in two parts, base and glasses. After, several stations can be inserted into the simulator for skills training in videosurgery.

RESULTS

It was possible to set up three dimensional (3D) video simulations with low cost. It has proved to be easy to assemble and allows the training surgeon of various video surgical skills.

CONCLUSION

This equipment may be used in undergraduate programs and advanced courses for residents and surgeons. The acrylic box allows the visualization of the task executed by the tutor and even by other experienced students.

Cumulative sum analysis of the learning curve for video-assisted minilaparotomy donor nephrectomy in healthy kidney donors

Video-assisted minilaparotomy surgery (VAMS) is a hybrid of open and laparoscopic surgical techniques, so has advantages of both approaches. Here, we examined the learning curve for this procedure.We retrospectively evaluated 50 consecutive patients who underwent VAMS donor nephrectomy performed by a single surgeon (YEY) between March 2015 and March 2016. The learning curve was evaluated using the cumulative sum (CUSUM) method. Measures of surgical performance included total operation time, warm ischemic time, and estimated blood loss.The mean patient age, body mass index, and body surface area were 43.5 years, 23.8 kg/m, and 1.7 m, respectively. The mean operation time and warm ischemic time were 160.0 minutes and 124.4 seconds. The learning curve of total operation time was best modeled as a second-order polynomial with equation CUSUMOT (minutes) = -0.3802 × case number + 20.315 × case number - 41.333 (R = 0.7707). The curve included 3 unique phases: phase 1 (the initial 17 cases), which is the initial learning curve; phase 2 (the middle 23 cases), expert competence, and phase 3 (the subsequent cases), mastery. In terms of warm ischemic time and estimated blood loss, the initial learning was achieved after 16 cases and after 9 to 10 cases, one could achieve competency.The VAMS donor nephrectomy learning curve is shorter than for laparoscopic or robotic hand-assisted donor nephrectomy. Surgeons can become familiar with the procedure and perform it without complications after approximately 16 to 17 operations.

Using GoPro to Give Video-Assisted Operative Feedback for Surgery Residents: A Feasibility and Utility Assessment

OBJECTIVE

As an adjunct to simulation-based teaching, laparoscopic video-based surgical coaching has been an effective tool to augment surgical education. However, the wide use of video review in open surgery has been limited primarily due to technological and logistical challenges. The aims of our study were to (1) evaluate perceptions of general surgery (GS) residents on video-assisted operative instruction and (2) conduct a pilot study using a head-mounted GoPro in conjunction with the operative performance rating system to assess feasibility of providing video review to enhance operative feedback during open procedures.

DESIGN

GS residents were anonymously surveyed to evaluate their perceptions of oral and written operative feedback and use of video-based operative resources. We then conducted a pilot study of 10 GS residents to assess the utility and feasibility of using a GoPro to record resident performance of an arteriovenous fistula creation with an attending surgeon. Categorical variables were analyzed using the chi-square test.

SETTING

Academic, tertiary medical center.

PARTICIPANTS

GS residents and faculty.

RESULTS

A total of 59 GS residents were anonymously surveyed (response rate = 65.5%). A total of 40% (n = 24) of residents reported that structured evaluations rarely or never provided meaningful feedback. When feedback was received, 55% (n = 32) residents reported that it was only rarely or sometimes in regard to their operative skills. There was no significant difference in surveyed responses among junior postgraduate year (PGY 1-2), senior (PGY 3-4), or chief residents (PGY-5). A total of 80% (n = 8) of residents found the use of GoPro video review very or extremely useful for education; they also deemed video review more useful for operative feedback than written or communicative feedback. An overwhelming majority (90%, n = 9) felt that video review would lead to improved technical skills, wanted to review the video with the attending surgeon for further feedback, and desired expansion of this tool to include additional procedures.

CONCLUSIONS

Although there has been progress toward improving operative feedback, room for further improvement remains. The use of a head-mounted GoPro is a dynamic tool that provides high-quality video for operative review and has the potential to augment the training experience of GS residents. Future studies exploring a wide array of open procedures involving a greater number of trainees will be needed to further define the use of this resource.

[Educational suitability of endotracheal intubation using a video-laryngoscope]

PURPOSE

The purpose of this study is to determine the educational suitability of the video-laryngoscope in teaching endotracheal intubation to students.

METHODS

Medical students participated in a course on the use of a Macintosh direct laryngoscope and McGrath MAC videolaryngoscope for intubation. The course comprised a 1-hour lecture and 30 minutes of practice on a manikin. After the course, in each of the three simulated patient scenarios-normal airway, cervical spine fixation, and tongue edema-time to intubate, success rate, and chance of complications were measured. A questionnaire was administered before and after the course to determine thesuitability of intubation by video-laryngoscope for a medical education course. Also, changes in the perception and stance on the video-laryngoscope were evaluated.

RESULTS

Time to intubate decreased as attempts were repeated. The first-attempt success rate in the cervical spine fixation scenario was higher using the video-laryngoscope (p=0.028). Rates if tooth injury were lower in the cervical spine fixation (p=0.005) andtongue edema scenarios (p=0.021) using the video-laryngoscope. Based on the questionnaires, students responded positively with regard to their knowledge of the video-laryngoscope, its practical value, and its suitability for medical education (p<0.001). Also,the preference for the video-laryngoscope was greater (p=0.044). Students felt that repeated attempts and feedback on intubation were helpful.

CONCLUSION

The students' evaluations and surveys showed positive results to intubation by video-laryngoscope. Thus, based on its suitability for medical education it is reasonable to consider learning intubation using the video-laryngoscope.

[Optimization of education for laparoendoscopic technologies in Ukraine]

International experience of training of surgeons, including urologists, in laparoendoscopic technologies, was analyzed. Practical course "The Fundamentals of aparoscopic Surgery" (FLS) and the European program of education for basic laparoscopic urologic skills (E-BLUS), which are used in specialized centers, constitute a standard programs of development of basic endosurgical skills. Such centers in Ukraine are absent. The project of complex system of a simulating education, testing and certification of surgeons, who are trained in endovideosurgical technologies, is proposed. While performing surveying of Ukrainian surgeons there were revealed the problems in a process of their education and introduction of highly technological methods: insufficient equipment with modern apparatuses, absence of a standardized pro- gram of education. The staged program of education was elaborated, taking into account progressive international experience and adopted to our environment and con ditions.

Outcomes and predictive factors of "not self-completion" in gastric endoscopic submucosal dissection for novice operators

BACKGROUND

Endoscopic submucosal dissection (ESD) has become the standard endoscopic treatment for gastric neoplasms because of its safety and high rate of curability; however, it is not easy for novice operators to learn the technique of ESD. In this study, predictive factors of gastric neoplasms in which novices could not finish ESD by self-completion were evaluated.

METHODS

Eighty consecutive ESD procedures performed by four novice operators were retrospectively analyzed. Standard ESD procedures were performed using an insulation-tipped (IT) knife under supervision. Self-completion rates, procedure time, and complete resection rates were evaluated, and predictive factors for "not self-completion" were assessed.

RESULTS

The overall self-completion rate and en bloc plus R0 resection rate were 87.5% (70/80) and 95.7 % (67/70), respectively. In "not self-completion" cases (n = 10), the procedure time was longer and resected specimens were larger than those in self-completion cases (83.7 ± 47.3 min vs. 189.5 ± 106.8 min, p < 0.05; 641.2 ± 487.8 vs. 1,116 ± 480.4 mm(2), p < 0.01). Predictive factors of "not self-completion" were tumor location in the middle or upper third of the stomach or in the greater curvature and size of resected specimens larger than 900 mm(2). The self-completion rate of ESD was decreased in cases with more than two predictive factors.

CONCLUSIONS

For novice operators, tumor location and resected areas are predictive factors for failure to finish gastric ESD by self-completion. Selection of cancer lesions could be a key factor for effectiveness of ESD training.

A comparison of direct versus indirect laryngoscopic visualization during endotracheal intubation of lightly embalmed cadavers utilizing the GlideScope®, Storz Medi Pack Mobile Imaging System™ and the New Storz CMAC™ videolaryngoscope

BACKGROUND

Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging System™, the Storz CMAC® VL System and the GlideScope®.

METHODS

After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected.

RESULTS

N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization.

CONCLUSION

Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation.

Videolaryngoscopy for intubation skills training of novice military airway managers

An estimated 10% of preventable battlefield deaths are due to Airway obstruction. Improved airway rescue strategies are needed with new tools for airway management by less experienced providers. Airway management and training are improved using video laryngoscopy (VL) compared to direct laryngoscopy (DL). We evaluated if novices could rapidly acquire fundamental skills and compared intubation time and laryngeal visualization using VL compared to DL in a manikin model of normal laryngeal anatomy. For 43 subjects mean intubation time did not differ for DL (25.9 +/- 24.5 seconds) vs. VL (26.4 +/- 31.5 seconds) {p = 0.94 paired t-test}. Self reported novice intubation time was 6.82 +/- 31.0 seconds greater with VL (31.6 +/- 34.6 seconds) vs. DL (24.8 +/- 18.5 seconds) {p = 0.255 paired t-test}. VL vs. DL time difference was not different between self-reported novice and non-novice groups. Mean Cormack-Lehane airway visualization grades (range 1-4) were higher with VL (1.95 +/- 0.97) vs. DL (1.02 +/- 0.15) {Students t-test p < 0.0001}. VL (69.7%) was preferred to DL (18.6%); no preference was indicated by 11.6%.

Effect of reduced stereoscopic camera separation on ring placement with a surgical telerobot

BACKGROUND

A custom, stereoscopic video camera was built to study the impact of decreased camera separation on a stereoscopically viewed, visual-manual task resembling some aspects of surgery.

MATERIALS AND METHODS

Twelve naïve subjects and one of the experimenters were first trained in a ring placement task using the stereo-laparoscope and subsequently switched to the stereo-camera, which was used with differing camera separations ranging from 100% of the laparoscope's separation to a biocular view corresponding to no separation (2D).

RESULTS

The results suggest firstly, that stereopsis (i.e., use of 3D laparoscopes) improves surgical performance over conventional 2D laparoscopes, and secondly that camera separation may be reduced 20-35% without appreciably degrading user performance. Even a 50% reduction in separation resulted in stereoscopically supported performance far superior compared to the 2D condition.

CONCLUSIONS

The results suggest that existing 3D laparoscopes which use 5-mm camera separation may well be significantly miniaturized without causing substantial performance degradation.

Video-assisted versus conventional microsurgical training: a comparative study in the rat model

Recent technical development has led to remarkable performances in video-guided surgical procedures. A video-endoscopic system (VES) is evaluated as an alternative magnifying solution for microsurgical procedures and compared to table-top microscopes in terms of technical and surgical aspects. Six surgical residents without microsurgical experience, alternating both systems, performed each 12 aortic end-to-end anastomoses on Sprague-Dawley rats using the triangulation technique. All anastomoses underwent quality review, total and single suture time, suture spacing, vessel bite, vessel overlapping and wall penetration were evaluated and graded. Overall anastomosis quality score was 52.28 (out of a maximum of 140) using the microscope and 42.7 using the VES. Despite significant differences in total anastomosis time, the learning curves are similar for the two systems and no major differences were noted in terms of overall anastomosis quality. Video-assisted microsurgery can become a useful instrument for microsurgery training.

Optimizing laparoscopic task efficiency: the role of camera and monitor positions

BACKGROUND

Alterations of video monitor and laparoscopic camera position may create perceptual distortion of the operative field, possibly leading to decreased laparoscopic efficiency. We aimed to determine the influence of monitor/camera position on the laparoscopic performance of surgeons of varying skill levels.

METHODS

Twelve experienced and 12 novice participants performed a one-handed task with their dominant hand in a modified laparoscopic trainer. Initially, the camera was fixed directly in front of the participant (0 degrees) and the monitor location was varied between three positions, to the left of midline (120 degrees), directly across from the participant (180 degrees), and to the right of the midline (240 degrees). In the second experiment monitor position was constant straight across from the participant (180 degrees) while the camera position was adjusted between the center position (0 degrees), to the left of midline (60 degrees), and to the right of midline (300 degrees). Participants completed five trials in each monitor/camera setting. The significance of the effects of skill level and combinations of camera and monitor angle were evaluated by analysis of variance (ANOVA) for repeated measures using restricted maximum likelihood estimation.

RESULTS

Experienced surgeons completed the task significantly faster at all monitor/camera positions. The best performance in both groups was observed when the monitor and camera were located at 180 degrees and 0 degrees, respectively. Monitor positioning to the right of midline (240 degrees) resulted in significantly worse performance compared to 180 degrees for both experienced and novice surgeons. Compared to 0 degrees (center), camera position to the left or the right resulted in significantly prolonged task times for both groups. Novice subjects also demonstrated a significantly lower ability to adjust to suboptimal camera/monitor positions.

CONCLUSION

Experienced subjects demonstrated superior performance under all study conditions. Optimally, the camera should be directly in front and the monitor should be directly across from a surgeon. Alternatively, the monitor/camera could be placed opposite to the surgeon's non-dominant hand. The suboptimal camera/monitor conditions are especially difficult to overcome for inexperienced subjects. Monitor and camera positioning must be emphasized to ensure optimal laparoscopic performance.

Simulation training in video-assisted urologic surgery

The current system of surgical education is facing many challenges in terms of time efficiency, costs, and patient safety. Training using simulation is an emerging area, mostly based on the experience of other high-risk professions like aviation. The goal of simulation-based training in surgery is to develop not only technical but team skills. This learning environment is stress-free and safe, allows standardization and tailoring of training, and also objectively evaluate performances. The development of simulation training is straightforward in endourology, since these procedures are video-assisted and the low degree of freedom of the instruments is easily replicated. On the other hand, these interventions necessitate a long learning curve, training in the operative room is especially costly and risky. Many models are already in use or under development in all fields of video-assisted urologic surgery: ureteroscopy, percutaneous surgery, transurethral resection of the prostate, and laparoscopy. Although bench models are essential, simulation increasingly benefits from the achievements and development of computer technology. Still in its infancy, virtual reality simulation will certainly belong to tomorrow's teaching tools.

Video-endoscope assisted teaching during sub-periosteal orbital surgery

PURPOSE

The authors report the novel use of the video-endoscope as an adjunct in teaching orbital surgery, in particular within the sub-periosteal orbital space. This is of most use during situations where visualisation is of critical importance and direct supervision is not possible.

MATERIALS AND METHODS

This technique was used for 16 cases of orbital surgery during a 12-month period. There were 5 orbital fracture repairs, 8 orbital decompressions (4 via a swinging eyelid and 4 via a transcaruncular approach), an infraorbital nerve biopsy, an eosinophilic granuloma and an orbitofrontal cholesterol granuloma. All procedures were performed by the trainee under consultant supervision with the endoscope being used when direct visualisation was not possible for the consultant. A rigid Storz 3-chip video-endoscope with 0, 30 and 70-degree tips was used to enable visual supervision.

RESULTS

The endoscope was of particular use in procedures involving the posterior orbital floor, orbital roof and medial orbital wall. It also enabled safe supervision of curettage of an orbital roof lesion which abutted the dura. The technique was easy to use; it provided good local illumination and a magnified view for supervision.

CONCLUSION

This technique is a valuable adjunct in allowing the trainee to safely perform selected complex orbital surgery under video-endoscopic supervision.

Multicenter Construct Validity for Southwestern Laparoscopic Videotrainer Stations

BACKGROUND

The "Southwestern" videotrainer stations have demonstrated concurrent validity (transferability to the operating room). The purpose of this study was to evaluate the Southwestern stations for construct validity (the ability to discriminate between subjects at different levels of experience).

MATERIALS AND METHODS

From two surgical training programs, Institutional Review Board approved protocol data were collected from 142 subjects, including novice (medical students and R1, n = 66), intermediate (R2-R4, n = 67), and advanced (R5 and expert surgeons, n = 9) groups. All participants performed three repetitions on each of five stations. Completion time was scored for each task. Laparoscopic experience was determined from residency case log databases and from expert surgeon personal case logs. Results for the three groups were compared using one-way ANOVA, including relevant pair-wise comparisons. Correlations between number of laparoscopic cases performed and task scores were determined by Pearson's and Spearman's rho-correlation coefficients.

RESULTS

The mean number of laparoscopic cases performed prior to completing the five tasks was 0 for novices, 9 for intermediates, and 431 for the advanced group. Significant differences (P < 0.001) were noted between groups for all five tasks and composite score. Task scores and composite scores significantly correlated with laparoscopic experience (P < 0.01).

CONCLUSION

These data suggest that differences in laparoscopic ability are detected by performance on the videotrainer; thus, construct validity is demonstrated. Moreover, scores accurately reflect laparoscopic experience. Further validation may allow such simulators to be used for testing and credentialing purposes.

Teaching subfascial perforator veins surgery: survey on a 2-day hands-on course

BACKGROUND

The present paper describes a training method with objective evaluation to enhance video-assisted surgical skills in subfascial endoscopic perforator veins surgery (SEPS). Training was scheduled during a 2-day intensive course.

METHODS

Hands-on exercises were performed (i) on a simulator to assess whether specific training exercises were helpful in attainment of skills; (ii) on a known animal model that uses the swine abdominal wall and which allows practice in endoscopic dissection and perforator veins (PV) using appropriate instrumentation in an environment that is a reasonable surrogate for the human calf; and (iii) assisting a senior surgeon performing SEPS. Thirty surgeons without experience in SEPS were trained to perform a sequence of standardized drills connected with the SEPS technique. The SEPS simulator consisted of an artificially constructed subfascial space of the leg in which false perforator veins had to be localized, and cut. The participants performed a sequence of drills three times in order to improve their dexterity. The same exercises were then performed on a swine model. The model consisted of the arteries and veins penetrating the rectus fascia and passing into the overlying cutaneous trunci muscle and hypodermis on either side of the midline between the arch of the ribs cranially and the umbilicus caudally. Trainees were required to achieve operative space in the animal subcutaneous fat, to reach and identify the "perforating" subcutaneous vessels, and to interrupt some of them with a 5-mm clamp coagulator ultrasonic scalpel. The time required to perform each dexterity drill was recorded in seconds. Finally, the day after, trainees were asked to drive the senior operator during clinical SEPS performed on eight patients, suggesting the following manoeuvres in order to: (i) enter the subfascial space of the leg; (ii) make operative space; (iii) identify the incompetent perforator vein(s); and (iv) coagulate and divide them with the ultrasonic scalpel. Each of these four steps scored 1 point.

RESULTS

All the trainees showed a steady improvement in skill acquisition on the SEPS simulator (P < 0.001), and on the animal model with the single-port technique (P < 0.001). These results reflect positively on the animal model using the dual-port technique, and on the scores achieved in the operating theatre during clinical SEPS.

CONCLUSIONS

The validity of the 2-day course was demonstrated by significant improvement in performance with increasing skill on the training models, and in clinical practice.

Training competent minimal access surgeons: review of tools, metrics, and techniques across the spectrum of technology

Technology has transformed the face of surgical technique among the disciplines of surgery. This revolution has created a strong demand from the public for the availability of minimally invasive surgical (MIS) interventions. Significant pressure has been placed on both industry and medicine to develop, test, and implement devices and procedures at a rapid pace. Unfortunately, this pace has at times surpassed the system's ability to train and prepare a corps of surgeons competent in both the technical and cognitive aspects of minimal access surgery. The economic constraints of surgical practice, coupled with recently introduced work-hour restrictions, have made the delivery of minimally invasive surgical education a challenging endeavor. Much work has been done in academic and private institutions to address this need. Solutions traversing the spectrum of technology have been developed, tested, and implemented in training. The purpose of this review is to highlight these solutions on the basis of their validity, utility, and overall contribution toward achieving the goal of producing competent minimally invasive surgeons. The body of literature suggests multiple valid training and assessment constructs exist. However, the overall utility of many validated "high-end" training technologies is limited by cost and access. Efforts should be aimed at creating valid training and assessment paradigms that can be applied by the broadest group of trainees, from medical students to surgeons, in active practice.

[Televised education: experience in Senegal]

As a possible response to the shortage of qualified teachers in Africa, a promising pilot study using television is being carried out at the A. Le Dantec University Hospital in Dakar, Senegal. Trainees at the Dakar Medical School receive long-distance coaching mainly in video-assisted surgery from experts at several partner centers in Europe, namely: Rangueil Hospital in Toulouse, France, IRCAD in Strasbourg, France and Saint Peter's Hospital in Brussels, Belgium. Results support more widespread use of televised courses.

The transfer of basic skills learned in a laparoscopic simulator to the operating room

BACKGROUND

The aim of the study was to evaluate whether basic surgical skills achieved by training in LapSim, a computerbased laparoscopic simulator, could be transferred to the operating room.

METHODS

For this study, 24 medical students undergoing courses in surgery were randomly assigned to train with LapSim or to serve as control subjects. After they had undergone simulator training 2 h per week for 5 weeks, their basic skills in laparoscopic surgery were assessed in a porcine model. The time to perform each task was measured, and four senior surgeons independently graded the overall performance on a 9-step differential rating scale.

RESULTS

The participants randomized to train with LapSim showed significantly better results for all tasks in both parts of the study than the untrained participants, according to the expert evaluation. Time consumption was accordingly lower in the training group in the control group.

CONCLUSIONS

The results show that basic skills achieved by systematic training with a laparoscopic simulator such as LapSim can be transferred to the operating room.

Robotics, telesurgery and telementoring--their position in modern urological laparoscopy

OBJECTIVES

Laparoscopic surgery in general is handicapped by the reduction of the range of motion from six to four degrees of freedom. This has a major impact on technically difficult procedures such as laparoscopic radical prostatectomy. Solutions for this problems include the understanding of the geometry of laparoscopy with sophisticated training programs, but lie also in newly developed surgical robots, computer simulators and telementoring. This article evaluates the value of these alternatives based on own experiences and an analysis of the current literature.

METHODS

Own experiences with robot-assisted surgery include 406 laparoscopic radical prostatectomies using a voice-controlled camera-arm (AESOP) as well as 6 telesurgical interventions with the Da Vinci-system. Additionally, substantial experimental studies have been performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and computer simulation. Moreover, the current literature of the last 10 years on telesurgery and telementoring has been reviewed.

RESULTS

The geometry of laparoscopy includes the angles between the instruments which have to be in a range of 25 degrees to 45 degrees; the angles between the instrument and the working plane that should not exceed 55 degrees; and the angle between the shaft of the needle holder and the needle which has to be adapted according to the anatomical situation in range of 90 to 110 degrees. 3-D-systems did not yet proved to be effective due to handling problems such as shutter glasses, video-helmets or reduced brightness. At the moment, there are only two robotic surgical systems (ZEUS, Da Vinci) in clinical use for telesurgery, of which only the Da Vinci provides stereovision and all six degrees of freedom (DOF). In the meantime, more than 200 laparoscopic radical prostatectomies have been performed with this system. Until now, however, there was no evidence of any advantages over the conventional laparoscopic approach. The ZEUS in combination with the telecommunication system SOKRATES is the only device enabling to realize telemanipulation and telementoring over long distances (i.e. transatlantic).

CONCLUSION

Robotic surgery represents a turning point of surgical research. However, broad use of robotic systems is limited mainly because of the high investment and running costs. Whereas there will be a clear role of audio-visual telementoring in future training concepts, the need of telemanipulation/telesurgery has not yet been clarified. New technological concepts promote the development of hand-held mechanical manipulators (i.e. 6-DOF-needle-holder) used in combination with mono-tasking computerized robots (i.e. AESOP) resulting in a significant cost reduction.

[Training in laparoscopy: from the laboratory to the operating room]

OBJECTIVES

To review all different steps in the process of learning laparoscopic surgery, presenting the guidelines that surgeon and his/her team should follow to successfully complete the process.

METHODS

We describe two levels of training: Basic, that is initiated with handling of instruments in simulators, and Advanced, which culminates with the practice of specific procedures in animal models.

RESULTS

At the basic level eye-hand coordination is acquired through exercises under direct vision in mechanical simulators. Later on, the use of optic and camera will allow to achieve eye-hand-TV monitor coordination. To use experimental and organic tissues permits to practice organic dissection and suture. Training at the advanced level is performed in research animals and makes up team work. Animal species selection, team composition, and anatomical protocol are of utmost importance to successfully complete the second phase.

CONCLUSIONS

Training in laparoscopic surgery is a complex process that implies surgeon's interaction with the rest of the team. Basic and advanced training must be available for all team members in order to assure satisfactory results in the difficult initial phase that should be mentored by an expert in laparoscopic surgery.

[Video-assisted parathyroidectomy: learning curve]

STUDY AIM

Minimally invasive video-assisted parathyroidectomy (MIVAP) was introduced in 1997 for the treatment of sporadic primary hyperparathyroidism (sPHPT). The study aim was to review the entire series of patients operated on in order to analyse the learning curve of this procedure.

PATIENTS AND METHODS

Between February 1997 to January 2001, 185 patients underwent MIVAP. All these patients were divided into three groups: group A (GA) included 63 patients operated on between February 1997 and September 1998; group B (GB) 64 patients operated on between October 1998 and January 2000; Group C (GC) 64 patients operated on between January 2000 and January 2001. Mean operative time, complications and conversions rates of the three groups were compared.

RESULTS

The three groups were well matched for age and gender. Mean operative time was significantly shorter in patients of GC (28.3 +/- 13.6 min) when compared with GA (62.3 +/- 24.6 min) and GB (48.4 +/- 18.1 min). Conversion was required in 3 cases of GA (4.8%), in 8 cases of GB (12.8%) and in 4 cases of GC (6.5%). One transient postoperative recurrent nerve palsy and 4 cases of transient postoperative hypocalcemia were observed among patients of GA. No complications were registered in the other groups.

CONCLUSIONS

This study shows that with increasing experience, the operative time of MIVAP was dramatically reduced, as well as postoperative complications rate. The higher percentage of conversion in groups B and C may be explained by the fact that, with increasing experience, more difficult and ambiguous cases were operated with this technique.