Development of a high-fidelity minimally invasive mitral valve surgery simulator

Objectives

The aim of this study was to develop a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator.

Ongoing deficits in resident training for minimally invasive surgery

Patient preference has driven the adoption of minimally invasive surgery (MIS) techniques and altered surgical practice. MIS training in surgical residency programs must teach new skill sets with steep learning curves to enable residents to master key procedures. Because no nationally recognized MIS curriculum exists, this study asked experts in MIS which laparoscopic procedures should be taught and how many cases are required for competency. Expert recommendations were compared to the number of cases actually performed by residents (Residency Review Committee [RRC] data). A detailed survey was sent nationwide to all surgical residency programs (academic and private) known to offer training in MIS and/or have a leader in the field. The response rate was approximately 52%. RRC data were obtained from the resident statistics summary report for 1998–1999. Experts identified core procedures for MIS training and consistently voiced the opinion that to become competent, residents need to perform these procedures many more times than the RRC data indicate they currently do. At present, American surgical residency programs do not meet the suggested MIS case range or volume required for competency. Residency programs need to be restructured to incorporate sufficient exposure to core MIS procedures. More expert faculty must be recruited to train residents to meet the increasing demand for laparoscopy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation). Supported in part by an educational grant from Tyco/U.S. Surgical Corporation.     

Survey of minimally invasive general surgery fellows training in robotic surgery

Minimally invasive surgery fellowships offer experience in robotic surgery, the nature of which is poorly defined. The objective of this survey was to determine the current status and opportunities for robotic surgery training available to fellows training in the United States and Canada. Sixty-five minimally invasive surgery fellows, attending a fundamentals of fellowship conference, were asked to complete a questionnaire regarding their demographics and experiences with robotic surgery and training. Fifty-one of the surveyed fellows completed the questionnaire (83 % response). Seventy-two percent of respondents had staff surgeons trained in performing robotic procedures, with 55 % of respondents having general surgery procedures performed robotically at their institution. Just over half (53 %) had access to a simulation facility for robotic training. Thirty-three percent offered mechanisms for certification and 11 % offered fellowships in robotic surgery. One-third of the minimally invasive surgery fellows felt they had been trained in robotic surgery and would consider making it part of their practice after fellowship. However, most (80 %) had no plans to pursue robotic surgery fellowships. Although a large group (63 %) felt optimistic about the future of robotic surgery, most respondents (72.5 %) felt their current experience with robotic surgery training was poor or below average. There is wide variation in exposure to and training in robotic surgery in minimally invasive surgery fellowship programs in the United States and Canada. Although a third of trainees felt adequately trained for performing robotic procedures, most fellows felt that their current experience with training was not adequate.     

Evaluating minimally invasive surgery training using low-cost mechanical simulations

Background: The goal of this study was to develop, test, and validate the efficacy of inexpensive mechanical minimally invasive surgery (MIS) model simulations for training faculty, residents, and medical students. We sought to demonstrate that trained and experienced MIS surgeon raters could reliably rate the MIS skills acquired during these simulations. Methods: We developed three renewable models that represent difficult or challenging segments of laparoscopic procedures; laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), and laparoscopic inguinal hernia (LH). We videotaped 10 students, 12 surgical residents, and 1 surgeon receiving training on each of the models and again during their posttraining evaluation session. Five MIS surgeons then assessed the evaluation session performance. For each simulation, we asked them to rate overall competence (COM) and four skills: clinical judgment (respect for tissue) (CJ), dexterity (economy of movement) (DEX), serial/simultaneous complexity (SSC), and spatial orientation (SO). We computed intraclass correlation (ICC) coefficients to determine the extent of agreement (i.e., reliability) among ratings. Results: We obtained ICC values of 0.74, 0.84, and 0.81 for COM ratings on LH, LC, and LA, respectively. We also obtained the following ICC values for the same three models: CJ, 0.75, 0.83, and 0.89; DEX, 0.88, 0.86, and 0.89; SSC, 0.82, 0.82, and 0.82; and SO, 0.86, 0.86, and 0.87, respectively. Conclusions: We obtained very high reliability of performance ratings for competence and surgical skills using a mechanical simulator. Typically, faculty evaluations of residents in the operating room are much less reliable. In contrast, when faculty members observe residents in a controlled, standardized environment, their ratings can be very reliable.     

微创肿瘤手术临床研究结果的启示与思考:如何提高微创外科手术的质量控制

以腹腔镜微创技术为代表的肿瘤微创外科发展已近30年。尽管手术技术及操作流程不断进步,但近来的临床研究结果显示:微创手术在部分恶性肿瘤中的肿瘤学疗效仍有争议。无论真相如何,手术的质量控制至关重要。严格把握手术指征,为肿瘤患者提供最合适的治疗方式有助于手术质量控制与风险降低。通过构建系统化培训体系,规范微创手术操作可保证肿瘤微创手术的质量。针对新兴微创手术技术,以严谨、审慎的态度加以开展,对于手术质量控制尤为重要。在微创外科高度发展的今天,除继续"保持速度",还应更好地"保证质量"才能使微创手术给更多的肿瘤患者带来获益。     

Anaesthesia,minimally invasive surgery and pregnancy

Minimally invasive surgery is being performed more frequently in pregnant patients. Numerous published reports have documented the safety and advantages of laparoscopic cholecystectomy and laparoscopic appendectomy during pregnancy. Pregnancy is associated with a variety of changes in the respiratory and cardiovascular systems, which make the parturient undergoing laparoscopic surgery particularly susceptible to hypoxia, hypercarbia and hypotension. This chapter provides a review of those physiological changes of pregnancy of particular concern for anaesthesiologists, and of the physiological responses to intra-abdominal carbon dioxide insufflation, not only in healthy patients, but also in the altered physiological state associated with pregnancy. We also describe our approach to anaesthetic management for minimally invasive surgery during pregnancy. With appropriate precautions, including vigilant monitoring and anticipation and treatment of the potential adverse effects of carbon dioxide pneumoperitoneum, anaesthesiologists may provide safe care for these patients, and pregnant women can benefit from the advantages of minimally invasive surgery.     

Ethical and educational considerations in minimally invasive surgery training for practicing surgeons

There is an opportunity to improve the training of practicing surgeons in minimal access techniques. Such improvement is desirable because it would allow for the introduction of innovation in a way that maximizes the benefit for patients while minimizing the harm that can result from the introduction of new techniques after inadequate training. This goal is consistent with basic biomedical principles that govern the behavior of surgeons. Individuals who place themselves in the role of a teacher of surgeons accept another level of responsibility and are governed not only by biomedical ethics but also by the ethics of teaching. Adherence to these two different governing ethical principles compels these teachers to apply the best educational principles in the development of educational courses. Review of motor skill learning theory would suggest that effective feedback and adequate practice opportunities are essential for the acquisition of motor skill and should be integrated into all skills-type continuing medical educational courses. The present trend is toward more objectivity in skill evaluation although evidence that this actually improves evaluation is lacking. Curriculum development and evaluation of this specific type of training course should follow those general principles proposed for the development of effective continuing medical education.     

New model for skills assessment and training progress in minimally invasive surgery

Background With the spread of minimally invasive surgery and training in this field, development of metrics for skills assessment and training progress has become increasingly important. Our approach was to use the tracking of motion for the definition of objectives metrics.Methods We have developed an inanimate model and tracked the 3D coordinates of the instrument tips with an ultrasound system. Besides already validated parameters (time, error time, and distance efficiency ratio) we examined the transit and the speed profile for their evidentiary power. Performances of experts (who have already performed >100 laparoscopic operations) and novices (<20 laparoscopic operations) were evaluated.Result The standardized time, the error time as a precision indicator, and the transit profile parameter for spatial perception could significantly (p < 0.05) distinguish between experts and novices. Furthermore, these parameters and the distance efficiency ratio improved significantly during a training course in laparoscopic surgery.Conclusion Our model showed changes of the mentioned parameters with experience. According to our results, it can be used for skills assessment and as a training progress measurement system. We propose transit profile as an additional important parameter for assessment.     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in sick patients. Establishment of CO₂ pneumoperitoneum produces adverse pathophysiological changes due to increased intra-abdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia with endotracheal intubation is the most common anaesthetic technique, but supraglottic airway devices can sometimes be used. Neuroaxial anaesthesia has been used in some laparoscopic procedures as the sole anaesthetic technique. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in those with significant co-morbidity. Establishment of carbon dioxide (CO₂) pneumoperitoneum produces adverse pathophysiological changes due to increased intraabdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia is most commonly used but neuraxial anaesthesia is possible, although spontaneous ventilation may be difficult. Endotracheal intubation has been a popular technique but supraglottic airway devices are less traumatic, easier to insert and more modern versions provide a good airway seal as well as gastric drainage, should it be required. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.     

Anaesthesia and minimally invasive surgery

As with so many different forms of anaesthesia, anaesthesia for minimally invasive surgery is dependent on the type of surgery being performed and the impact of the surgical procedure itself on the human body. With an increase in the number of surgical specialties embracing laparoscopic procedures, anaesthetists must consider the risks and benefits to the patient. On the whole, laparoscopic procedures are well tolerated. The advantages of laparoscopic surgery compared with open procedures are associated with reduced morbidity and mortality. The reductions in acute pain and postoperative respiratory tract infections and ileus allow earlier mobilization and lead to earlier discharge. Laparoscopy also improves the cosmetic appearance. It improves the view of the operative field and enables alternative anatomical views to be seen. Anaesthesia per se is fairly standard in minimally invasive surgery, but it is the comprehension of the effects of the position of the patient and that of the pneumoperitoneum that can make the difference between a successful or less elegant outcome.     

Effectiveness of telesimulation for pediatric minimally invasive surgery essential skills training

BackgroundIn the context of the COVID-19 pandemic and social distancing rules, access to in-person training activities had temporarily been interrupted, speeding up the implementation of telesimulation for minimally invasive surgery (MIS) essential skills training (T-ESTM, Telesimulation - Essential Skills Training Module) in our center. The aim of this study was to explore the effectiveness of T-ESTM.MethodsT-ESTM was scheduled into 2 sessions of 3 h through the Zoom® virtual meeting platform. The academic lectures, the tutorials for box-trainer set-up and 7 performance tasks were accessed through an online campus previous to the remote encounter for personalized guidance and debriefing.Initial (pre-telementoring) and final (post 6-hour telementoring) assessment scoring as well as timing for Task 2 (circle-cutting pattern), 3 (extracorporeal Roeder knot) and 5 (intracorporeal Square knot) were registered.Results61 participants were recruited. The mean age was 31±5 years. 65% were surgical residents. 48% performed low complexity procedures. 52% had previous experience with simulation training.In Task 2, there was a 21% improvement in the final score obtained, as well as a significant decrease in time of 33%; in Task 3, there was an increase of 39% in the scoring and a decrease of 49% in the timing; and in Task 5, participants improved their technique a 30% and decreased the performance time a 47%. All the differences were statistically significant.DiscussionOur data support T-ESTM as a reproducible and effective educational tool for remote MIS essential skills hands-on training.Level of Evidence: II     

Intraoperative enteroscopy in minimally invasive surgery

PURPOSE: The purpose of this study was to assess the efficacy and safety of intraoperative enteroscopy (IOE) in patients undergoing minimally invasive surgery. METHODS: Twelve patients underwent minimally invasive surgery and IOE at Miyazaki University Hospital. Patients included 11 men and 1 woman. After extraction of the intestine via minilaparotomy, enterotomy was performed, and a sterilized enteroscope was inserted. RESULTS: Length of the skin incision was 5.7+/-0.2 cm (mean+/-standard error). Length of the small intestine observed enteroscopically was 334+/-19 cm. Distance from the ligament of Treitz to the orally observed jejunum was 11.8+/-3.6 cm. In 5 of 9 patients with Crohn disease, additional lesions were found by IOE that were not found by preoperative examination. One additional tumor was found in 1 patient with ileal tumor. Postoperative complications occurred in 2 patients. CONCLUSION: IOE is efficacious in patients undergoing minimally invasive surgery.     

甲状腺微创外科进展

随着国内外腔镜技术及微创理念的不断推广,腔镜甲状腺手术出现了各种不同的手术方式和快速发展,笔者就常见的腔镜甲状腺手术径路、建腔方式及新技术、新理念作一综述。