A groundbreaking new suturing device

BACKGROUND: Laparoscopic knot tying can be stressful. We reported two simple techniques, known as the Thumbs up! knot and the Tornado knot. We have further refined these procedures with the development of a new needle holder, called the Excalibur suturing needle holder. MATERIALS: This forceps differ from most conventional forceps in that the hinge is designed to stick out. The large hinge is stored out of the way when the forceps are closed, to prevent the thread accidentally catching. RESULTS: The thread is hooked on the projected hinge, which resembles the heel of a high-heel shoe. By using this forceps, the laparoscopic knot tying becomes easier for not only well experienced but also less experienced surgeons. CONCLUSIONS: The Excalibur, with its high heel, can complete knots with simple straight-line motion, making knot tying easier. This forceps will help reduce the stresses associated with intra-corporeal knot tying.     

Laparoscopic suturing and knot tying: a comparison of standard techniques to a mechanical assist device.

BACKGROUND: Suturing and knot tying are basic skills for surgeons. Performing these tasks laparoscopically can be a tedious, time-consuming endeavor associated with much frustration. We evaluated a mechanically assisted suture and pretied knot device (Quik-Stitch) for performing the basic tasks of suturing and knot tying. METHODS: We performed a time study using 1) intracorporeal suturing and knot tying, 2) intracorporeal suturing and extracorporeal knot tying, and 3) a mechanically assisted suture and pretied knot device (Quik-Stitch). From September 2000 through March 2001, time trials were conducted using each of the different techniques. Three attending surgeons, one with much experience and 2 with less experience, and 2 chief residents, with the least experience, participated in the study. RESULTS: For the experienced surgeon, the average times for intracorporeal knot tying, extracorporeal knot tying, and knot tying with Quik-Stitch were 97.3, 103.9, and 67.7 seconds, respectively. For the less experienced surgeons, the times were 237.2, 224.3, and 92.5 seconds, respectively. For the least experienced group, the times were 265.3, 263.0, and 128.7 seconds, respectively. CONCLUSIONS: The mechanically assisted suture device and pretied knot (Quik-Stitch by PARE Surgical, Inc, Englewood, CO, USA) provides significant time-saving to surgeons regardless of experience and thus reduces operating room costs. Less experienced surgeons and surgeons in training benefited the most by the use of this device.     

Halstedian technique revisited. Innovations in teaching surgical skills.

This paper reviews the laboratory models used to teach fundamental surgical skills in our general surgery residency. The laboratory modules allow supervision and self-instruction, practice, and videotape monitoring of the following techniques: skin incision, suturing, knot tying, hemostasis, vascular anastomosis, and intestinal anastomosis. Pigs' feet simulate human skin for exercises in skin incision, lesion excision, suturing, and basic plastic surgical techniques. Latex tubing and penrose drains allow experience in suturing, knot tying, and hemostasis. Polytetrafluoroethylene vascular prostheses permit quantification of the precision of needle passage and suturing by measurement of leakage of water through a vascular anastomosis. Reconstituted, lyophilized, irradiated bovine arteries and ileum provide models of biologic tissue for creating handsewn vascular anastomoses and sutured or stapled gastrointestinal anastomoses. A headlamp videocamera allows unobstructive recording of the resident's technical performance and provides subsequent visual feedback for self-improvement when compared to reference instructional videotapes. We feel that these innovations may enhance surgical dexterity of residents without the need for animal sacrifice. Our goal is to foreshorten the learning curve for basic surgical skills and improve performance in the clinical operating room.     

Influence of instrument size on endoscopic task performance in pediatric intracorporeal knot tying

Background The widespread availability of adult minimal access surgical (MAS) equipment together with resource constraints have led pediatric surgeons to adopt the adult setup. This study examined the influence of instrument size on task outcome and physical impact on the surgeon in pediatric endoscopic intracorporeal knot tying. Methods Sixteen surgeons participated in this study in which they had to tie surgeon’s knots inside a neonatal simulator box with an endoscopic field of 40 mm. All surgeons tied 20 knots using paired pediatric needle-holders and 20 knots using paired adult needle-holders in a randomized order. Knot quality score (KQS) and wrap length were used as indices of knot quality and wrap tightness. Electromyographic (EMG) recordings of the upper limb muscle groups were used to indicate muscular recruitment. A questionnaire on discomfort and instrument preference was also completed by the surgeons. Results A total of 640 knots were analyzed. Median time was shorter for pediatric needle-holders than for adult needle-holders (94 s vs. 103 s; p < 0.001); however, KQS (0.271 vs. 0.260; p = 0.509) and the tightness around the tube (86 mm vs. 86 mm; p = 0.255) were not significantly different. The proportion of knots that completely slipped was also similar for both needle-holders (19% vs. 22%; p = 0.322). The normalized EMG values when using adult needle-holders were significantly higher than when using pediatric needle-holders in all upper limb muscle groups with the exception of left forearm extensors (p = 0.460). The surgeons reported less discomfort with the pediatric needle-holders in the right forearm and hand, and 13 surgeons expressed overall preference for the smaller instruments. Conclusion Endoscopic knot tying was performed faster in the neonatal simulator box using pediatric needle-holders while maintaining knot quality. Upper limb muscular recruitment was reduced resulting in less discomfort for the surgeon. Presented at the 10th World Congress of Endoscopic Surgery incorporating the 14th International Congress of the European Association for Endoscopic Surgery (EAES), Berlin, Germany, 13-16 September 2006 Preliminary data of this study were presented at the British Association of Paediatric Surgeons Annual Conference, Stockholm, Sweden, 20 July 2006     

Double-Gloving Impairs the Quality of Surgical Knot Tying: A Randomised Controlled Trial

Background

Double-gloving is endorsed by a number of healthcare authorities worldwide, on the basis that it promotes patient and surgeon safety; adoption of this practice amongst surgeons remains limited, based upon anecdotal reporting that double-gloving may compromise surgical technique due to impaired dexterity and sensation. The aim of this study is to formally investigate and demonstrate the effect of double-gloving upon the quality of knot tying, an essential surgical skill.

Methods

An international cohort of practising general surgeons hand tied surgical knots, under both single-gloved and double-gloved conditions, using monofilament and braided sutures, at two different gauges. Half of the participants tied single-gloved first. The mechanical strength of the knots was determined by tensile testing, and each knot was given a knot quality score (KQS), a validated assessment of knot quality.

Results and conclusions

1466 knots were tested. Double-gloving was shown to reduce KQS for all suture types, compared to knots tied under single-gloved conditions (p = 0.001). There was no difference in the KQS of the double-gloved ties between those who routinely double-gloved and those who did not (p = 0.640). The OR showed that double-gloving reduced the KQS by 24 % overall, with the effect being much more prominent when the finer 4.0 suture was used, as knot quality was reduced by almost 50 % (95 % CI 13–93 %). Double-gloving impairs the quality of knot tying, and therefore, surgeons should consider other precautions to ensure patient and surgeon safety. These findings also question the validity of recommendations that surgeons should double-glove as a routine.

     

Laparoscopic suturing evaluation among surgical residents

BACKGROUND: Laparoscopic suturing is an integral part of advanced laparoscopic surgery training. The objective of this study was to evaluate the performance and preference of surgical residents performing intracorporeal and extracorporeal knot-tying techniques using conventional and Endo Stitch instruments. The residents were also evaluated on their suturing techniques using conventional instruments, the Endo Stitch, and the Suture Assistant. METHODS: Using an inanimate laparoscopic trainer model, 39 residents were evaluated as they performed laparoscopic knot tying exercises. Endpoints of the study were execution time and subjective preference of surgical residents with respect to the type of instrument used for knot tying. Forty-three residents were evaluated as they performed laparoscopic suturing exercises with three different types of suturing instruments using the same endpoints. RESULTS: The intracorporeal technique was the preferred (89%) method of knot tying among surgical residents. The time for completion of laparoscopic suturing was significantly (P < 0.05) shorter with the Endo Stitch (114 +/- 64 s) than with the conventional instrument (206 +/- 107 s) or the Suture Assistant (151 +/- 70 s). Residents preferred the use of the Endo Stitch in all three categories for suturing, knot tying, and handling. CONCLUSION: The Endo Stitch enhanced laparoscopic skills and was the preferred instrument for laparoscopic knot tying and suturing among surgical residents.     

The knit stitch

Intracorporeal suturing is essential to advanced laparoscopy and is a rate-limiting step in many procedures. We have outlined an improved method of intracorporeal knot tying which is easier to learn, faster, and more consistently performed than current methods. Conventional intracorporeal knot-tying technique was compared to the knit-stitch method by ten volunteer surgeons. Each participant tied ten conventional-style knots in a video trainer. Surgeons were then taught the knit-stitch method and tied an additional ten knots. Knot-tying times were recorded and compared. Participants were asked to choose the method they preferred. The knit-stitch method was demonstrated to be faster than the conventional method for all participants, regardless of level of training or laparoscopic expertise (mean 63±19 vs 97±48 s; P<0.001). The difference was most marked in participants with the least laparoscopic suturing experience. The knit-stitch was preferred by 90% of the surgeons. Reasons cited for this preference were ease of learning, conservation of instrument motion, better utilization of the nondominant hand, and ability to work with shorter suture.Knit stitching is a faster, more consistent method of intracorporeal suturing. It is preferred because of its simplicity, efficiency, and potential to further reduce tissue trauma during the course of laparoscopic suturing.     

Robotic surgery: identifying the learning curve through objective measurement of skill

Background: The incorporation of new devices into surgical practice often requires that surgeons acquire and master new skills. We studied the learning curve for intracorporeal knot tying in robotic surgery. Methods: We developed an objective scoring system to evaluate knot tying and tested eight attending surgeons during 3 weeks of training on a surgical robot. Each performed intracorporeal knot tying tasks both before and after robotic skills training. These performances were compared to their laparoscopic knots and analyzed to determine and define skill improvement. Results: Baseline laparoscopic knot completion took 140 sec (range, 47–432), with a mean composite score of 77 (100 possible), whereas robotic knot tying took 390 sec, with a mean composite score of 40. After initial robotic training, times decreased by 65% to 139 sec and scores increased to 71. With more training, completion times and composite scores were improved and errors were reduced. Conclusion: Like any new technology, surgical robotics requires dedicated training to achieve mastery. Initially, even experienced laparoscopists may register an inferior performance. However, after adequate training, surgeons can exceed their laparoscopic performance, completing intracorporeal knots better and faster using robotics. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and 10th World Congress of Endoscopic Surgery, New York, NY, USA, 13–15 March 2003     

The reliability of multiple objective measures of surgery and the role of human performance

BACKGROUND: There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings. METHODS: Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics. RESULTS: On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94. CONCLUSION: The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged.     

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.     

Pediatric robotic surgery: lessons from a clinical experience

PURPOSE: Robotic surgery may improve minimally invasive surgery at high magnification by tremor filtration, motion-scaling, and improved dexterity with the provision of a wrist at the end of the robotic instrument. MATERIALS AND METHODS: We chose the Zeus Microwrist robotic surgical system as more applicable to small children than the competing da Vinci surgical system. We attempted 57 surgical procedures and completed 54. RESULTS: Completed procedures included Nissen fundoplication (n = 25), cholecystectomy (n = 18), Heller myotomy (n = 2), splenectomy (n = 2), Morgagni hernia repair (n = 2), and single cases of complex pyloroplasty in the chest, bowel resection, left Bochdalek congenital diaphragmatic hernia repair, esophageal atresia and tracheoesophageal fistula repair, and choledochal cyst excision. There were no complications related to the use of the robot. The mean time for the surgeon at the console using the robot was 117 +/- 39 minutes for Nissen fundoplication, and the total operating room time was 250 +/- 60 minutes. Surgeons found dissection, suturing, and knot tying easier than with conventional laparoscopy. None of the surgeons thought the lack of touch feedback (haptics) was crucial. CONCLUSION: Robotic surgery offers increased dexterity to the pediatric minimally invasive surgeon, but procedures require more time, and there is no defined patient benefit. The fact that robotic surgery digitalizes minimally invasive surgery creates exciting possibilities for training surgeons, planning operations, and performing surgery at great distances from the operator.     

Automated robot‐assisted surgical skill evaluation: Predictive analytics approach

Background

Surgical skill assessment has predominantly been a subjective task. Recently, technological advances such as robot‐assisted surgery have created great opportunities for objective surgical evaluation. In this paper, we introduce a predictive framework for objective skill assessment based on movement trajectory data. Our aim is to build a classification framework to automatically evaluate the performance of surgeons with different levels of expertise.

Methods

Eight global movement features are extracted from movement trajectory data captured by a da Vinci robot for surgeons with two levels of expertise – novice and expert. Three classification methods – k‐nearest neighbours, logistic regression and support vector machines – are applied.

Results

The result shows that the proposed framework can classify surgeons' expertise as novice or expert with an accuracy of 82.3% for knot tying and 89.9% for a suturing task.

Conclusion

This study demonstrates and evaluates the ability of machine learning methods to automatically classify expert and novice surgeons using global movement features.     

Construct validity for the LAPSIM laparoscopic surgical simulator

Background The skills required for laparoscopic surgery are amenable to simulator-based training. Several computerized devices are now available. We hypothesized that the LAPSIM simulator can be shown to distinguish novice from experienced laparoscopic surgeons, thus establishing construct validity.Methods We tested residents of all levels and attending laparoscopic surgeons. The subjects were tested on eight software modules. Pass/fail (P/F), time (T), maximum level achieved (MLA), tissue damage (TD), motion, and error scores were compared using the t-test and analysis of variance.Results A total of 54 subjects were tested. The most significant difference was found when we compared the most (seven attending surgeons) and least experienced (10 interns) subjects. Grasping showed significance at P/F and MLA (p < 0.03). Clip applying was significant for P/F, MLA, motion, and errors (p < 0.02). Laparoscopic suturing was significant for P/F, MLA, T, TD, as was knot error (p < 0.05). This finding held for novice, intermediate, and expert subjects (p < 0.05) and for suturing time between attending surgeons and residents (postgraduate year [PGY] 1-4) (p < 0.05).Conclusions LAPSIM has construct validity to distinguish between expert and novice laparoscopists. Suture simulation can be used to discriminate between individuals at different levels of residency and expert surgeons.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, CO, USA, April 1–3, 2004     

Performance of basic manipulation and intracorporeal suturing tasks in a robotic surgical system: single- versus dual-monitor views

Background  Technical advances in the application of laparoscopic and robotic surgical systems have improved platform usability. The authors hypothesized that using two monitors instead of one would lead to faster performance with fewer errors. Methods  All tasks were performed using a surgical robot in a training box. One of the monitors was a standard camera with two preset zoom levels (zoomed in and zoomed out, single-monitor condition). The second monitor provided a static panoramic view of the whole surgical field. The standard camera was static at the zoomed-in level for the dual-monitor condition of the study. The study had two groups of participants: 4 surgeons proficient in both robotic and advanced laparoscopic skills and 10 lay persons (nonsurgeons) who were given adequate time to train and familiarize themselves with the equipment. Running a 50-cm rope was the basic task. Advanced tasks included running a suture through predetermined points and intracorporeal knot tying with 3–0 silk. Trial completion times and errors, categorized into three groups (orientation, precision, and task), were recorded. Results  The trial completion times for all the tasks, basic and advanced, in the two groups were not significantly different. Fewer orientation errors occurred in the nonsurgeon group during knot tying (p = 0.03) and in both groups during suturing (p = 0.0002) in the dual-monitor arm of the study. Differences in precision and task error were not significant. Conclusions  Using two camera views helps both surgeons and lay persons perform complex tasks with fewer errors. These results may be due to better awareness of the surgical field with regard to the location of the instruments, leading to better field orientation. This display setup has potential for use in complex minimally invasive surgeries such as esophagectomy and gastric bypass. This technique also would be applicable to open microsurgery. Presented at the 2008 SAGES meeting.     

A new technique for intracorporeal knot tying in laparoscopic surgery

INTRODUCTION: Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is a difficult process with a long learning curve. Intracorporeal suturing is essential to advanced laparoscopy and is a rate-limiting step in many procedures. Many different instruments and methods have been described for laparoscopic suturing and knot tying. We have developed a new technique for laparoscopic knot tying. TECHNIQUE: The long end of the suture is held with a left-hand instrument, and the instrument is rotated for 360 degrees in a clockwise direction to make a forward-direction loop. The end of the loop is grasped with the right-hand instrument, and the other end of the suture is grasped with the left-hand instrument. The suture end, held by the left hand, is pulled though the loop and tied, thus making a half-knot of a square knot. The second half-knot is made by using the right-hand instrument with the same technique. DISCUSSION: Laparoscopic suturing and knotting is difficult to perform, especially when the angle between the working instruments is narrow and working space is limited. In all these situations, knot tying using this technique makes knotting more simple and easy to perform, especially for those who have limited experience in intracorporeal suturing and knot tying. No special instrument is required to perform knot tying with this technique.     

Surgical skills training restructured for the 21st century

BackgroundFew if any medical schools have a comprehensive surgical skills program taking medical students from learning basic knot tying and surgical skills to performing these skills at a level adequate for function during a primary care, surgical, or subspecialty residency. We have designed and continue to refine a program, which consists of five workshops focused on basic surgical skills, which are applicable to all medical and surgical disciplines.Materials and methodsDuring the first workshop students learn how to tie both one- and two-handed surgical knots. The second workshop involves teaching students differences in suture type and use, instrument handling, and suturing techniques. The third workshop is used to address problems and refine techniques previously learned in the first two sessions. The fourth workshop comprises a final examination to evaluate suture and knot tying skills. The fifth session is a voluntary knot tying and suturing competition with awards for speed, finesse, aesthetics, and the watertightness of a vascular surgical repair. Surgical faculty and house staff are present at each workshop to provide direction and constructive criticism.ResultsFifty-seven third-year medical students have completed the surgical skills curriculum. Statistical analysis demonstrates significant improvement in both knot tying and suturing (P < 0.05) for these students. Forty-four percent of students have successfully sewn a watertight anastomosis.ConclusionWe hypothesize that this curriculum will produce medical students with basic surgical skills, appreciation of surgical technique, and the confidence to perform basic surgical skills at completion of the curriculum.     

Performance differences in laparoscopic surgical skills between true high-definition and three-chip CCD video systems

Background Laparoscopic surgery requires surgeons to rely on visual clues for discrimination among differing tissues and for depth of field on a two-dimensional screen. High definition (HD) provides a superior image. If there is a measurable advantage with HD television (TV), the increase in the cost of the technology would be justified. Methods A digital three-chip CCD camera with a standard monitor (SD system) and a true HD camera (1,080 pixels) with a 16:9-ratio HD monitor (HD system) were compared in clinical and laboratory settings. Three experiments were performed: (1) subjective visual evaluation of the HD and SD systems during actual surgical cases, (2) subjective visual evaluation in a controlled laboratory surgical setting with simultaneous parallel recording, and (3) three laparoscopic surgical task evaluations in a laboratory setting, namely, task A (metric analysis of participants on the surgical simulator), task B (simple eye–hand coordination performance), and task C (knot tying). Results All 53 participants subjectively evaluated HD as superior to SD in the laboratory setting and during actual surgery. In task B, there was no significant difference between SD and HD (dominant hand: p = 0.19; nondominant hand: p = 0.07). In task C, the knot-tying time was significantly less when performed with HD (mean, 173 ± 84 s vs 214 ± 107 s; p = 0.003). Most importantly, subjects with less skill (more documented time required in the basic module on a surgical simulator) improved significantly in the knot-tying task with the HD system (R = 0.631; p = 0.005). Conclusion All the participants preferred HD to SD. High definition significantly improved laparoscopic knot tying, which requires precise depth perception, proving that HD is more than just a pretty picture.     

Technical performance: Relation between surgical dexterity and technical knowledge

Technical performance consists of surgical knowledge, judgment, and dexterity. Although assessment of surgical dexterity is now possible, assessing technical knowledge and its relation to dexterity has not been elucidated. Surgeons of varying experience were recruited to the skills laboratory to undertake three assessments: simple surgical dexterity (at 14 stations scored by motion analysis), an operating room equipment examination, and a novel error analysis. The scores were correlated, and p < 0.05 was deemed to be significant. Thirty surgeons were recruited; and construct validity was exhibited in all areas. Correlations were shown to exist between the two knowledge examinations (Spearmans rho = 0.39). Correlations existed between all dexterity task parameters and the equipment examination, whereas they existed for only 15 of the 28 parameters of the error examination and were always weaker. The stronger correlations between dexterity and instrument and operating room (OR) equipment reflect greater surgical experience and time spent in the OR. The weaker correlations between the error analysis and dexterity suggest that these skills are learned at different times. The identification of common surgical errors should be more formally taught to ensure greater uniformity.     

Comparison and analysis of laparoscopic intracorporeal suturing devices: preliminary results

BACKGROUND AND PURPOSE: One of the most challenging aspects of laparoscopic surgery is intracorporeal suturing and knot tying. A loss of depth perception and tactile sense and visual obstruction make placing accurate and well-tied knots a difficult and time-consuming task. Two devices conceived to ease the task of suturing and knotting while presumably speeding performance are the Suture Assist (SA; Ethicon Endo-Surgery) and EndoStitch (ES; US Surgical/Tyco). We set out to objectively assess suture placement accuracy and knot speed and strength of these two suturing devices and conventional laparoscopic suturing (CS). MATERIALS AND METHODS: To date, six surgeons with laparoscopic experience were trained on the three suturing techniques. A pelvic trainer was set up with a freshly marked and incised swine renal pelvis and ureter. Each surgeon placed four sutures of 2-0 polyester suture with each technique (repeated on three separate occasions) with five half-hitches for a total of 216 knots. Time, strength, and accuracy were measured for each suture/knot placement. The knot distance was then measured from the marked target using calipers and carefully dissected from the tissue. Each knot was individually tested on a Monsanto Model 10 tensiometer, whereby slippage, strength, and breakage points were determined. RESULTS: The mean times (min:sec) and accuracy (millimeters) were as following: CS 5:08 and 0.457, ES 2:45 and 0.660, and SA 2:40 and 0.508. The difference in time was found to be statistically significant (P < 0.001), while the difference in accuracy was not. Only 182 of 216 knots were able to be included for analysis because of either a small knot lumen or device failure. Device failures necessitating intervention were encountered only with the SA, which had a misfire rate of 9.7% (7 of 72). The mean knot strength was measured at 41.1 N for CS, 57.3 N for SA, and 28.0 for ES. Knot break percentage (breakage) was calculated as 50.8% for CS, 20.7% for ES, and 95% for SA. CONCLUSION: Preliminary results show that each of the laparoscopic suturing devices has distinct advantages over conventional intracorporeal suturing and tying. Decreased times and comparable, if not greater, knot strengths may translate into improved laparoscopic suturing/tying performance for laparoscopic intracorporeal suturing devices.     

Accelerated skills preparation and assessment for senior medical students entering surgical internship

BACKGROUND: Skills training plays an increasing role in residency training. Few medical schools have skills courses for senior students entering surgical residency. METHODS: A skills course for 4(th)-year medical students matched in a surgical specialty was conducted in 2006 and 2007 during 7 weekly 3-hour sessions. Topics included suturing, knot tying, procedural skills (eg, chest tube insertion), laparoscopic skills, use of energy devices, and on-call management problems. Materials for outside practice were provided. Pre- and postcourse assessment of suturing skills was performed; laparoscopic skills were assessed postcourse using the Society of American Gastrointestinal and Endoscopic Surgeons' Fundamentals of Laparoscopic Surgery program. Students' perceived preparedness for internship was assessed by survey (1 to 5 Likert scale). Data are mean +/- SD and statistical analyses were performed. RESULTS: Thirty-one 4(th)-year students were enrolled. Pre- versus postcourse surveys of 45 domains related to acute patient management and technical and procedural skills indicated an improved perception of preparedness for internship overall (mean pre versus post) for 28 questions (p < 0.05). Students rated course relevance as "highly useful" (4.8 +/- 0.5) and their ability to complete skills as "markedly improved" (4.5 +/- 0.6). Suturing and knot-tying skills showed substantial time improvement pre- versus postcourse for 4 of 5 tasks: simple interrupted suturing (283 +/- 73 versus 243 +/- 52 seconds), subcuticular suturing (385 +/- 132 versus 274 +/- 80 seconds), 1-handed knot tying (73 +/- 33 versus 58 +/- 22 seconds), and tying in a restricted space (54 +/- 18 versus 44 +/- 16 seconds) (p < 0.02). Only 2-handed knot tying did not change substantially (65 +/- 24 versus 59 +/- 24 seconds). Of 13 students who took the Fundamentals of Laparoscopic Surgery skills test, 5 passed all 5 components and 3 passed 4 of 5 components. CONCLUSIONS: Skills instruction for senior students entering surgical internship results in a higher perception of preparedness and improved skills performance. Medical schools should consider integrating skills courses into the 4(th)-year curriculum to better prepare students for surgical residency.