Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition

Background Laparoscopic surgery requires a different set of skills than traditional open surgery. The acquisition of basic laparoscopic skills may help novices when learning laparoscopic procedures. This study tested the hypothesis that the combination of virtual reality and box trainers leads to better basic laparoscopic skill acquisition than either method alone or no training. Methods A randomized control trial involving preclinical medical students with no prior operative experience was performed. The students were grouped according to four training methods: virtual reality training, inanimate box training, a combination of both, and no training (control). The pre- and posttraining scores for four skills in the porcine laboratory were the metrics chosen for this study. Results A total of 65 students participated in this study. There were no differences among any of the pretraining scores (p > 0.05). The posttraining times differed between the four groups. Post hoc analyses showed statistically significant differences (p < 0.05) between the participants trained with both trainers and the control subjects. Conclusions Our data demonstrate that the combination of virtual reality training and inanimate box training leads to better laparoscopic skill acquisition than either training method alone or no training at all. Optimal preclinical laparoscopic training should incorporate both virtual reality trainers and inanimate box trainers. Presented in part at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) annual meeting, March 2004, Denver, CO     

Objective assessment of laparoscopic skills using a virtual reality stimulator

Background Virtual reality simulation has a great potential as a training and assessment tool of laparoscopic skills. The study was carried out to investigate whether the LapSim system (Surgical Science Ltd., Gothenburg, Sweden) was able to differentiate between subjects with different laparoscopic experience and thus to demonstrate its construct validity. Methods Subjects 24 were divided into two groups: experienced (performed > 100 laparoscopic procedures, n = 10) and beginners (performed <10 laparoscopic procedures, n = 14). Assessment of laparoscopic skills was based on parameters measured by the computer system. Results Experienced surgeons performed consistently better than the residents. Significant differences in the parameters time and economy of motion existed between the two groups in seven of seven tasks. Regarding error parameters, differences existed in most but not all tasks. Conclusion LapSim was able to differentiate between subjects with different laparoscopic experience. This indicates that the system measures skills relevant for laparoscopic surgery and can be used in training programs as a valid assessment tool.     

腹腔镜模拟训练系统用于腹腔镜手术基本技能训练的研究

目的:总结腹腔镜模拟训练系统对不同操作组腹腔镜手术基本技能的提高情况。方法:本科实习生组、研究生无腹腔镜操作经验组、本院进修医师无腹腔镜操作经验组,分别使用腹腔镜模拟训练系统练习镜下夹取黄豆、缝合及器械打结技术,2周后进行统计学分析。结果:操作训练前,本科实习生夹取黄豆、缝合技术及器械打结技术明显不如本院研究生及进修医师(P<0.05),经过2周训练,较简单的技能操作如夹取黄豆和研究生及进修医师无统计学差异(P>0.05),较复杂的技能操作如缝合技术、绕线打结练习训练前、后和本院研究生及进修医师相比差异有统计学意义(P<0.05);但是3组人员训练后与训练前相比,腹腔镜的基本技能操作均显著提高(P<0.05)。结论:腹腔镜模拟训练系统能提高腹腔镜手术操作者的基本技能,值得推广。     

Construct validation of a novel hybrid virtual-reality simulator for training and assessing laparoscopic colectomy; results from the first course for experienced senior laparoscopic surgeons

Objectives  The objective of the study was to determine whether the metrics from a left-sided laparoscopic colectomy (LC) simulator could distinguish between the objectively scored performance of minimally invasive colorectal expert and novice surgeons. We report our results from the first virtual reality-based laparoscopic colorectal training course for experienced laparoscopic surgeons. Methods  Eleven surgeons, experienced but novice in LC, constituted the novice group, and three experienced laparoscopic colorectal surgeons (>300 LCs) served as our experts. Novice subjects received didactic educational sessions and instruction in practice of LC from the experts. All subjects received instruction, demonstration, and supervision on the surgical technique to perform a LC on the simulator. All subjects then performed a laparoscopic colectomy on the simulator. Experts performed the same case as the novices. Outcomes measured by the simulator were time to perform the procedure, instrument path length, and smoothness of the trajectory of the instruments. Anatomy trays from the simulator were objectively scored for explicitly predefined intraoperative errors after each procedure. Results  Expert surgeons performed significantly better then the novice colorectal surgeons with regard to instrument path length, instrument smoothness, and time taken to complete the procedure. Of the 13 predetermined errors, experts made significantly fewer errors in total then the novices (mean score 2.67 versus 4.7, p = 0.03), and performed better in 8 out of 13 errors. Conclusion  The parameters assessed by the ProMIS VR simulator for laparoscopic colorectal training distinguished between novice and expert colorectal surgeons, despite using otherwise experienced novices who had extensive training before the procedure and expert mentoring during it. Experts performed the simulated procedure significantly faster with more efficient use of their instruments, and made fewer intraoperative errors. Thus the simulator demonstrated construct validity.     

A tale of two trainers: virtual reality versus a video trainer for acquisition of basic laparoscopic skills

Background

This study aimed to assess the transferability of basic laparoscopic skills between a virtual reality simulator (MIST-VR) and a video trainer box (D-Box).

Methods

Forty-six medical students were randomized into 2 groups, training on MIST-VR or D-Box. After training with one modality, a crossover assessment on the other was performed.

Results

When tested on MIST-VR, the MIST-VR group showed significantly shorter time (90.3 seconds vs 188.6 seconds, P <.001), better economy of movements (4.40 vs 7.50, P <.001), and lower score (224.7 vs 527.0, P <.001). However, when assessed on the D-Box, there was no difference between the groups for time (402.0 seconds vs 325.6 seconds, P = .152), total hand movements (THC) (289 vs 262, P = .792), or total path length (TPL) (34.9 m vs 34.6 m, P = .388).

Conclusion

Both simulators provide significant improvement in performance. Our results indicate that skills learned on the MIST-VR are transferable to the D-Box, but the opposite cannot be demonstrated.     

早期康复训练在预防腹腔镜前列腺癌根治术后尿失禁的应用研究

目的 探讨早期康复训练对预防腹腔镜前列腺癌根治术后尿失禁的应用效果.方法 将100例拟行腹腔镜前列腺癌根治术患者随机分成观察组和对照组各50例,观察组实施早期康复训练,术前及术后早期均进行提肛训练;对照组实施常规护理,仅在术后进行提肛训练.比较两组患者术后拔除尿管后尿失禁发生率、尿控功能恢复时间以及观察组术前不同提肛训练时间与术后尿失禁发生率的关系.结果 观察组术后尿失禁发生率、尿控功能恢复时间均明显低于对照组(P＜0.05);不同术前提肛训练时间尿失禁发生率比较差异无统计学意义(P＞0.05).结论 早期康复训练有助于预防腹腔前列腺癌根治术后尿失禁的发生,缩短尿控功能恢复时间.     

Virtual reality simulator training equals mechanical robotic training in improving robot-assisted basic suturing skills

Background This study aimed to investigate the effect of a virtual reality simulator on the learning of basic robotic suturing skills. Methods Two randomized groups of students underwent a controlled training program. Both groups completed an identical test before and after training. The increase in the number of stitches placed during the pretest and posttest was used as an objective measure of the training effect. To evaluate the subjective feeling of understanding and mastering, the students indicated this on a visual analog scale. Results Both groups showed a significant increase in the number of stitches placed during the posttest, and an increase in subjective feeling of understanding and mastering. The increase did not differ between the groups, indicating that the virtual reality simulator equaled the mechanical trainer in training of robotic suturing technique. Conclusions Training in basic robot-assisted suturing skills using a virtual reality simulator without additional training equaled training using a mechanical simulator.     

Face validity of a Wii U video game for training basic laparoscopic skills

Background

Although the positive effects of playing video games on basic laparoscopic skills have been studied for several years, no games are actually used in surgical training. This article discusses the face validity of the first video game and custom-made hardware, which takes advantage of these effects.

Methods

Participants were recruited at the Chirurgendagen 2013 and the Society of American Gastrointestinal and Endoscopic Surgeons 2014 annual meeting. In total, 72 laparoscopic surgeons completed a demo of the game and filled in a questionnaire.

Results

On a 1-to-10 scale, the mean score for hardware realism was 7.2 and the mean score for usefulness as a training tool was 8.4. Participants did not mind the fact that the workspace does not look like an abdominal cavity, but do have some trouble with the absence of tactile feedback.

Conclusion

We obtained face validity for both the hardware and the usefulness of Underground, a video game made for training basic laparoscopic skills.     

A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill

BACKGROUND: Studies have demonstrated the beneficial effect of training novice laparoscopic surgeons using virtual reality (VR) simulators, although there is still no consensus regarding an optimal VR training curriculum. This study aims to establish and validate a structured VR curriculum to provide an evidence-based approach for laparoscopic training programmes. METHODS: The minimally invasive VR simulator (MIST-VR) has 12 abstract laparoscopic tasks, each at 3 graduated levels of difficulty (easy, medium, and hard). Twenty medical students completed 2 sessions of all tasks at the easy level, 10 sessions at the medium level, and finally 5 sessions of the 2 most complex tasks at the hard level. At the medium level, subjects were randomized into 2 equal groups performing either all 12 tasks (group A) or the 2 most complex tasks (group B). Performance was measured by time taken, path length, and errors for each hand. The results were compared between groups, and to those of 10 experienced laparoscopic surgeons. RESULTS: Baseline performance of both groups was similar at the easy level. At the medium level, learning curves for all 3 parameters reached plateau at the second (group A, P < .05) and sixth (group B, P < .05) repetitions. Performance at the hard level was similar between the 2 groups, and all achieved the pre-set expert criteria. CONCLUSION: A graduated laparoscopic training curriculum enables trainees to familiarise, train and be assessed on laparoscopic VR simulators. This study can aid the incorporation of VR simulation into established surgical training programmes.     

Usefulness of a virtual reality simulator or training box for endoscopic surgery training

This study investigated whether the use of a simulator for endoscopic surgery training improves the performance of actual operations. For the study, 16 medical students were divided into three groups: a virtual reality (VR) simulator group (n = 6), a training box (TB) group (n = 6), and a control group (n = 4). The VR and TB groups received 2 h of training per day for 5 days, after which they were requested to perform intestinal dissection, to close a gastric perforation, and to perform cholecystectomy in pigs. Performance was assessed on the basis of the operating time and the error score. Although there were no differences between the three groups in terms of the total operating time or error score, the VR and TB groups required less time for closure of the gastric perforation than the control group. In addition, the operating time decreased as actual operating experience increased in the VR group. In the TB group, the time for closure of a gastric perforation was shorter when the supervisor had seen the operation before training. These findings demonstrated that a simulator is useful for acquiring psychomotor skills, but does not immediately enable clinical performance of an operation. More actual experience and good supervision are essential for increasing the effectiveness of training with the VR and TB simulators, respectively.     

腹腔镜保留肾单位术三级培训模式初探

目的 介绍腹腔镜保留肾单位术的三级培训模式.方法 三级培训模式的内容包括体外模拟阶段、动物模型训练和临床实践操作.以小型猪作为实验模型建立腹腔镜保留肾单位术的标准操作方式.临床实践操作又细分为三步进行,包括辅助手术、开展相对简单的腹腔镜手术和进行LNSS. 结果 4名学员均成功完成全部三级培训内容.其中体外模拟培训累计时间平均为70 h.经过体外模拟培训后全部学员均能够熟练地掌握腔镜器械下缝针打结等基本操作技能.4名学员均完成动物模型LNSS 20例,其中半肾切除术6例.肾上极或下极平均手术时间由最初的(120.0±10.9)min降低到在完成12台LNSS时的(69.0±5.2)min,差异有统计学意义(P<0.01).学员在开展后腹腔镜肾囊肿去顶术和上段输尿管切开取石术等相对简单的手术7～9例后,各自成功地完成LNSS手术3例,均未出现术中并发症.LNSS平均手术时间为87 rain,肾脏热缺血时间平均为25 min.结论 "三级培训模式"能够帮助年轻医生掌握LNSS这类高难度复杂性泌尿外科腹腔镜手术,显著地降低手术并发症的发生,提高手术疗效,有利于腹腔镜手术的推广应用.     

Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies

BACKGROUND: Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices. METHODS: Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident's first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors. RESULTS: The VR-trained group consistently made significantly fewer errors (P = .0037). On the other hand, residents in the control group made, on average, 3 times as many errors and used 58% longer surgical time. CONCLUSIONS: The results of this study show that training on the VR simulator to a level of proficiency significantly improves intraoperative performance during a resident's first 10 laparoscopic cholecystectomies.     

Virtual reality and computer-enhanced training devices equally improve laparoscopic surgical skill in novices

BACKGROUND: The study aim was to compare the effectiveness of virtual reality and computer-enhanced videoscopic training devices for training novice surgeons in complex laparoscopic skills. METHODS: Third-year medical students received instruction on laparoscopic intracorporeal suturing and knot tying and then underwent a pretraining assessment of the task using a live porcine model. Students were then randomized to objectives-based training on either the virtual reality (n=8) or computer-enhanced (n=8) training devices for 4 weeks, after which the assessment was repeated. RESULTS: Posttraining performance had improved compared with pretraining performance in both task completion rate (94% versus 18%; P<0.001*) and time [181+/-58 (SD) versus 292+/-24*]. Performance of the 2 groups was comparable before and after training. Of the subjects, 88% thought that haptic cues were important in simulators. Both groups agreed that their respective training systems were effective teaching tools, but computer-enhanced device trainees were more likely to rate their training as representative of reality (P<0.01). CONCLUSIONS: Training on virtual reality and computer-enhanced devices had equivalent effects on skills improvement in novices. Despite the perception that haptic feedback is important in laparoscopic simulation training, its absence in the virtual reality device did not impede acquisition of skill.     

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.     

Intensive laparoscopic training: the impact of a simplified pelvic-trainer model for the urethrovesical anastomosis on the learning curve

We prospectively evaluated the learning curve (LC) for laparoscopic urethrovesical anastomosis (L-UVA) in an operator-training model and program using an innovative simplified pelvic-trainer model. Over a period of 12 months, 30 LRP were performed by one urologist skilled in open surgery but inexperienced in laparoscopy. During the first 15 procedures no systematic training was done. Consequentially, a systematic simplified daily program was performed on the pelvic trainer with a videolaparoscopic unit. The training lesson consisted of intracorporal knotting and suturing, linear and circular interrupted suture anastomosis. At the end of each lesson, time and performance error scores were recorded and progression curve was plotted for each task. The performances of each training tasks were plotted against the performance of L-UVA during the LRP. The significance of progression was evaluated using logarithmic regression analysis. A steady improvement in time and accuracy of performance skill was shown during the first 20 lessons (p<0.001). These improved skill acquisitions were proportionally correlated with the time and the accuracy (water-tight) of L-UVA performance during the last 15 L-RPE. Compared to the first 15 L-RPE, where no systematic training was performed, time and accuracy of L-UVA performance in the last 15 L-RPE were improved from a mean 51 (median 48, range: 38–75) to 26 (median 24, range 18–33) min (p<0.001) and from 10 to 15 watertight anastomoses (p<0.001), respectively. Using a continuing, systematic, simplified training model the LC of L-UVA can be improved significantly in a short time.     

Computer-enhanced laparoscopic training system (CELTS): bridging the gap

Background There is a large and growing gap between the need for better surgical training methodologies and the systems currently available for such training. In an effort to bridge this gap and overcome the disadvantages of the training simulators now in use, we developed the Computer-Enhanced Laparoscopic Training System (CELTS).Methods CELTS is a computer-based system capable of tracking the motion of laparoscopic instruments and providing feedback about performance in real time. CELTS consists of a mechanical interface, a customizable set of tasks, and an Internet-based software interface. The special cognitive and psychomotor skills a laparoscopic surgeon should master were explicitly defined and transformed into quantitative metrics based on kinematics analysis theory. A single global standardized and task-independent scoring system utilizing a z-score statistic was developed. Validation exercises were performed.Results The scoring system clearly revealed a gap between experts and trainees, irrespective of the task performed; none of the trainees obtained a score above the threshold that distinguishes the two groups. Moreover, CELTS provided educational feedback by identifying the key factors that contributed to the overall score. Among the defined metrics, depth perception, smoothness of motion, instrument orientation, and the outcome of the task are major indicators of performance and key parameters that distinguish experts from trainees. Time and path length alone, which are the most commonly used metrics in currently available systems, are not considered good indicators of performance.Conclusion CELTS is a novel and standardized skills trainer that combines the advantages of computer simulation with the features of the traditional and popular training boxes. CELTS can easily be used with a wide array of tasks and ensures comparability across different training conditions. This report further shows that a set of appropriate and clinically relevant performance metrics can be defined and a standardized scoring system can be designed.     

A training module for laparoscopic urology.

OBJECTIVES: A fellowship training model in laparoscopic urological surgery has been established for interested urologists to help them proceed from the pelvic trainer/animal laboratory environment to safe clinical practice. The objective of the model is to provide trainees with clinical experience under direct mentor supervision before embarking on independent laparoscopic urological surgery at their own base hospitals. METHODS: The fellowship model incorporates 9 fluid phases: Phase 1 to complete basic and advanced training courses. Phase 2 to practice at home or in the office using pelvic trainers. Phase 3 to proceed to an animal laboratory course. Phase 4 to visit centers of international repute to observe high-volume laparoscopic urology. Phase 5 to observe the mentor perform several major renal laparoscopic cases. Phase 6 to perform several hand-assisted renal procedures under direct mentor guidance at the mentor hospital. Phase 7 to perform several laparoscopic or retroperitoneoscopic renal procedures, or both, under direct mentor guidance at the mentor hospital. Phase 8 to mentor assisted trainees to start laparoscopic surgery at their own hospitals. Phase 9 to practice laparoscopic urology independently. RESULTS: So far, 9 trainees have participated in the fellowship. Six have reached phase 9 with independent practice, 2 others are in phase 8, and 1 is in phase 7. Skills development has been steady, with progressive acquisition of surgical dexterity and spatial orientation. CONCLUSION: This fluid fellowship model provides urologists with clinically applicable teaching experience to learn a relatively new surgical concept safely and effectively, thereby promoting clinical governance. It may be possible for other centers to establish similar fluid "mini" fellowships to help disseminate laparoscopic surgical skills.     

Can skills assessment on a virtual reality trainer predict a surgical trainee’s talent in laparoscopic surgery?

Background A number of studies have investigated several aspects of feasibility and validity of performance assessments with virtual reality surgical simulators. However, the validity of performance assessments is limited by the reliability of such measurements, and some issues of reliability still need to be addressed. This study aimed to evaluate the hypothesis that test subjects show logarithmic performance curves on repetitive trials for a component task of laparoscopic cholecystectomy on a virtual reality simulator, and that interindividual differences in performance after considerable training are significant. According to kinesiologic theory, logarithmic performance curves are expected and an individual’s learning capacity for a specific task can be extrapolated, allowing quantification of a person’s innate ability to develop task-specific skills. Methods In this study, 20 medical students at the University of Basel Medical School performed five trials of a standardized task on the LS 500 virtual reality simulator for laparoscopic surgery. Task completion time, number of errors, economy of instrument movements, and maximum speed of instrument movements were measured. Results The hypothesis was confirmed by the fact that the performance curves for some of the simulator measurements were very close to logarithmic curves, and there were significant interindividual differences in performance at the end of the repetitive trials. Conclusions Assessment of perceptual motor skills and the innate ability of an individual with no prior experience in laparoscopic surgery to develop such skills using the LS 500 VR surgical simulator is feasible and reliable.     

Nonsurgical skills do not predict baseline scores in inanimate box or virtual-reality trainers

INTRODUCTION: Laparoscopic basic skills are best trained in the nonclinical setting. Box trainers and virtual-reality trainers have been shown to be useful in training laparoscopic skills. Certain nonsurgical skills may predict baseline skills in these trainers. This study tested the hypothesis that baseline scores could be predicted in inanimate box trainers and virtual-reality trainers by nonsurgical skills. METHODS: Only preclinical medical students were included in the study. All students were given a survey ascertaining if they played computer games, typed, sew, played a musical instrument, and utilized chopsticks. Students utilized a box trainer (BT) and/or virtual-reality trainer (VR). Nonparametric two-tailed Mann-Whitney tests were utilized to compare students that possessed certain nonsurgical skills versus those who did not. RESULTS: There were 18 students in the VR group and 33 students in the BT group. In the VR group, students who played computer games, typed, utilized chopsticks, or played a musical instrument had better scores and fewer errors than those who did not but this did not reach statistical significance in any comparison (p = NS). In the BT group, none of the nonsurgical skills predicted times or errors. Males performed better than females in the VR group (p < 0.001); but this gender discrepancy was not seen in the BT group. CONCLUSIONS: Nonsurgical skills do not predict baseline scores in either trainer. The gender differences in VR training need to be further explored.     

The importance of haptic feedback in laparoscopic suturing training and the additive value of virtual reality simulation

Introduction Previous studies on the difference between physical, augmented and virtual reality (VR) simulation state that haptic feedback is an important feature in laparoscopic suturing simulation. Objective assessment is important to improve skills during training. This study focuses on the additive value of VR simulation for laparoscopic suturing training. Methods All participants of several European Association for Endoscopic Surgery (EAES)-approved laparoscopic skills courses (N = 45) filled out a questionnaire on their opinion on laparoscopic suturing training. Additionally, participants with little or no laparoscopic suturing experience were allotted to two groups: group A (N = 10), who started training on the box trainer and subsequently the VR simulator (SimSurgery), and group B (N = 10), who began on the VR simulator followed by the box. Finally, suturing and knot-tying skills were assessed by an expert observer, using a standard evaluation form (eight items on five-point-Likert scale). The same was done after the initial training on the box in group A, as a control. Significant differences were calculated with the independent-sample t-test and the paired t-test. Results The total score of group A was higher than both group B and control (means of 30.80, 27.60, 28.20, respectively), but not significantly. The only tendency to a significant difference between group A and B was found in ‘taking proper bites’ (mean 4.10 versus 3.60, p = 0.054). All the participants scored the features of the box trainer significantly higher than those of the VR simulator (p < 0.001), 46.7% was of the opinion that the box alone would be sufficient for laparoscopic suturing training. Conclusion From this study we can conclude that VR simulation does not have a significant additional value in laparoscopic suturing training, over traditional box trainers. One should consider that the future development in VR simulation should focus on basic skills and component tasks of procedural training in laparoscopic surgery, rather than laparoscopic suturing.