Box Trainer Research Articles

Surgeon Assessment of a Novel Multi-Resolution Foveated Laparoscope.

We developed a multi-resolution foveated laparoscope (MRFL) to improve situational awareness in laparoscopic surgery. We assessed surgeon objective task performance and subjective attitudes with MRFL when used for box trainer tasks and porcine surgery. The MRFL simultaneously obtains a wide-angle view and a magnified view. The 2 images are displayed simultaneously. 6 urologists and 2 general surgeons performed box trainer and porcine surgery tasks with the MRFL and a standard laparoscope. Task time, use of display options, and subjective assessments were obtained. Subjectively, surgeons rated situational awareness, depth perception, and instrument interference as comparable between the prototype MRFL and laparoscope for trainer tasks. For porcine surgery, the MRFL was rated as having less interference than the standard laparoscope. The image quality of the MRFL was rated interior to the standard laparoscope. Participants found the different viewing modes useful for different roles and reported that they would likely use the MRFL for conventional laparoscopic and robotic surgery. Objectively, box trainer task time was comparable for 2 of 3 tasks with the remaining task shorter for the standard laparoscope. Porcine nephrectomy and oophorectomy were feasible with the prototype MRFL, although nephrectomy task time was significantly longer than traditional laparoscopy. The MRFL demonstrated feasibility for performing complex surgery. Surgeons had favorable attitudes toward its features and likelihood to use the device if available. Users utilized different view types for different tasks. Longer MRFL task times were attributed to poorer image quality of the prototype.

Democratizing Flexible Endoscopy Training: Noninferiority Randomized Trial Comparing a Box-Trainer vs a Virtual Reality Simulator to Prepare for the Fundamental of Endoscopic Surgery Exam.

A considerable number of surgical residents fail the mandated endoscopy exam despite having completed the required clinical cases. Low-cost endoscopy box trainers (BTs) could democratize training; however, their effectiveness has never been compared with higher-cost virtual reality simulators (VRSs). In this randomized noninferiority trial, endoscopy novices trained either on the VRS used in the Fundamental of Endoscopic Surgery manual skills (FESms) exam or a validated BT-the Basic Endoscopic Skills Training (BEST) box. Trainees were tested at fixed timepoints on the FESms and on standardized ex vivo models. The primary endpoint was FESms improvement at 1 week. Secondary endpoints were FESms improvement at 2 weeks, FESms pass rates, ex vivo tests performance, and trainees' feedback. Seventy-seven trainees completed the study. VRS and BT trainees showed comparable FESms improvements (25.16 ± 14.29 vs 25.58 ± 11.75 FESms points, respectively; p = 0.89), FESms pass rates (76.32% vs 61.54%, respectively; p = 0.16) and total ex vivo tasks completion times (365.76 ± 237.56 vs 322.68 ± 186.04 seconds, respectively; p = 0.55) after 1 week. Performances were comparable also after 2 weeks of training, but FESms pass rates increased significantly only in the first week. Trainees were significantly more satisfied with the BT platform (3.97 ± 1.20 vs 4.81 ± 0.40 points on a 5-point Likert scale for the VRS and the BT, respectively; p < 0.001). Simulation-based training is an effective means to develop competency in endoscopy, especially at the beginning of the learning curve. Low-cost BTs like the BEST box compare well with high-tech VRSs and could help democratize endoscopy training.

Watching surgical tapes: video playback as an educational tool for improving resident laparoscopic performance

In this single masked, randomized controlled study, we evaluate if watching video recordings of oneself performing Fundamentals of Laparoscopic Skills (FLS) exercises results in an improvement on the 30-point Global Operative Assessment of Laparoscopic Skills (GOALS) assessment among Obstetrics & Gynecology (Ob/Gyn) residents. Participants were randomized to verbal feedback only (control) or verbal feedback and watching their video recording (intervention). Each participant completed the five FLS exercises using a laparoscopic box trainer while being timed, video recorded and receiving real-time feedback from an Ob/Gyn faculty member. Baseline GOALS assessment was completed by participants and faculty evaluator. Participants randomized to the intervention were allowed to watch their video recording and the faculty evaluator was masked to this randomization. All participants then repeated the FLS exercises while being timed and this was again scored using the GOALS assessment. In addition, all participants completed a pre- and post-test survey to gauge their laparoscopic comfort level. Two-sample t-test was used to assess within-group differences in overall GOALS scores and exercise times while Wilcox Rank Sum test was used for within-group comparisons of survey responses. Between-group analysis for change in GOALS scores, exercise times and survey responses was performed using the Mann-Whitney test. Differences in variables across Post Graduate Year (PGY) levels were evaluated using ANOVA and Kruskal-Wallis tests. Twenty-three Ob/Gyn residents in the 2020-2021 academic year completed the study; 12 were randomized to the intervention and 11 received verbal feedback only. Relative to baseline, there were significant within-group improvements in the faculty (p<0.01) and self-reported GOALS scores (p<0.01). Between the groups, the intervention group improved by 3.2 points more than the control group based on masked faculty evaluation (95% CI 1.4 to 5.0 points, p<0.01). This between-group difference was not significant in resident self-scores. Overall time improved for all participants (15:54 ± 0.21 minutes pre and 13:13 ± 0.14 minutes post) but this difference was not significant between groups. Higher PGY residents reported significantly more comfort performing laparoscopic tasks, earned higher GOALS score (faculty and self-scores), and completed the first set of exercises in less time. A significant interaction between PGY and intervention was detected using 2-way ANOVA with between-group improvement in GOALS score most strongly associated with PGY4 residents (p<0.01). This suggests that while all learners objectively benefit from watching recordings of themselves performing surgical tasks, advanced learners may benefit the most when video recordings are used as an educational tool.

Effectiveness of the world’s first 1-Day online hands-on laparoscopic suturing training during COVID-19 pandemic

We aimed to investigate the effectiveness of an online laparoscopic suturing training course conducted via an online meeting program. The mean needle loading, stitching, and knot-tying times were 77.3 s, 63.0 s, and 140.3 s, respectively on the initial test. Total laparoscopic suture time before the course was 273.8 s. After the course, time measures across all parameters decreased significantly (p < .001). The mean needle loading, suture passing, and knot tying times were 25.0 s, 31.0 s, and 34.6 s on the final test. The total intracorporeal suture time after the course was 90.0 s. The Objective and Structured Assessment of Technical Skills Scores significantly increased from 16.8 at the initial test to 25.4 at the final test (p < .001). IMPACT STATEMENT What is already known on this subject? Training models like box trainers and virtual reality simulators have frequently been shown to significantly improve laparoscopic skills. What the results of this study add? A 1-day online laparoscopic suturing course significantly reduces the intracorporeal suturing time. What the implications are of these findings for clinical practice and/or further research? Basis the results, online laparoscopic suturing training might become the new norm for training over conventional training given the benefits of cost and time savings.

Quantitative influence and performance analysis of virtual reality laparoscopic surgical training system

BackgroundVirtual reality (VR) surgery training has become a trend in clinical education. Many research papers validate the effectiveness of VR-based surgical simulators in training medical students. However, most existing articles employ subjective methods to study the residents’ surgical skills improvement. Few of them investigate how to improve the surgery skills on specific dimensions substantially.MethodsOur paper resorts to physiological approaches to objectively study the quantitative influence and performance analysis of VR laparoscopic surgical training system for medical students. Fifty-one participants were recruited from a pool of medical students. They conducted four pre and post experiments in the training box. They were trained on VR-based laparoscopic surgery simulators (VRLS) in the middle of pre and post experiments. Their operation and physiological data (heart rate and electroencephalogram) are recorded during the pre and post experiments. The physiological data is used to compute cognitive load and flow experience quantitatively. Senior surgeons graded their performance using newly designed hybrid standards for fundamental tasks and Global operative assessment of laparoscopic skills (GOALS) standards for colon resection tasks. Finally, the participants were required to fill the questionnaires about their cognitive load and flow experience.ResultsAfter training on VRLS, the time of the experimental group to complete the same task could drop sharply (p < 0.01). The performance scores are enhanced significantly (p < 0.01). The performance and cognitive load computed from EEG are negatively correlated (p < 0.05).ConclusionThe results show that the VRLS could highly improve medical students' performance and enable the participants to obtain flow experience with a lower cognitive load. Participants' performance is negatively correlated with cognitive load through quantitative physiological analysis. This might provide a new way of assessing skill acquirement.

Unprecedented Training: Experience of Residents During the COVID-19 Pandemic

Unprecedented Training: Experience of Residents During the COVID-19 Pandemic

Smart laparoscopic grasper integrated with fiber Bragg grating based tactile sensor for real-time force feedback.

Minimally invasive surgery, such as laparoscopic surgery, has developed rapidly due to its small wound, less bleeding and quick recovery. However, a lack of force feedback, which leads to tissue damage, is still unsolved. Many sensors have been used to offer force feedback but still limited by their large size, low security and high complexity. Based on the advantages of small size, high sensitivity and immunity to electromagnetic interferences, we propose a tactile sensor integrated with fiber Bragg gratings (FBGs) at the tip of laparoscopic grasper to offer real-time force feedback in the laparoscopic surgery. The tactile sensor shows a force sensitivity of 0.076 nm/N with a repeatable accuracy of 0.118 N. A bench test is conducted in a laparoscopic training box to verify its feasibility. Test results illustrate that gripping force exerted on the laparoscopic grasper in terms of peak and standard deviation values reduce significantly for the novice subjects with force feedback compared to those without force feedback. The proposed sensor integrated at the tip of the laparoscopic grasper demonstrates a better control of the gripping force among the novice surgeons and indicates that the smart grasper can help surgeons achieve precise gripping force to reduce unnecessary tissue trauma.

Semisupervised Training of a Brain MRI Tumor Detection Model Using Mined Annotations.

Background Artificial intelligence (AI) applications for cancer imaging conceptually begin with automated tumor detection, which can provide the foundation for downstream AI tasks. However, supervised training requires many image annotations, and performing dedicated post hoc image labeling is burdensome and costly. Purpose To investigate whether clinically generated image annotations can be data mined from the picture archiving and communication system (PACS), automatically curated, and used for semisupervised training of a brain MRI tumor detection model. Materials and Methods In this retrospective study, the cancer center PACS was mined for brain MRI scans acquired between January 2012 and December 2017 and included all annotated axial T1 postcontrast images. Line annotations were converted to boxes, excluding boxes shorter than 1 cm or longer than 7 cm. The resulting boxes were used for supervised training of object detection models using RetinaNet and Mask region-based convolutional neural network (R-CNN) architectures. The best-performing model trained from the mined data set was used to detect unannotated tumors on training images themselves (self-labeling), automatically correcting many of the missing labels. After self-labeling, new models were trained using this expanded data set. Models were scored for precision, recall, and F1 using a held-out test data set comprising 754 manually labeled images from 100 patients (403 intra-axial and 56 extra-axial enhancing tumors). Model F1 scores were compared using bootstrap resampling. Results The PACS query extracted 31 150 line annotations, yielding 11 880 boxes that met inclusion criteria. This mined data set was used to train models, yielding F1 scores of 0.886 for RetinaNet and 0.908 for Mask R-CNN. Self-labeling added 18 562 training boxes, improving model F1 scores to 0.935 (P < .001) and 0.954 (P < .001), respectively. Conclusion The application of semisupervised learning to mined image annotations significantly improved tumor detection performance, achieving an excellent F1 score of 0.954. This development pipeline can be extended for other imaging modalities, repurposing unused data silos to potentially enable automated tumor detection across radiologic modalities. © RSNA, 2022 Online supplemental material is available for this article.

Automation of an automobile internal combustion engine bench calibration tests

Introduction(problemstatement and relevance).The article presents the work on the automation of an internal combustion engine (ICE) calibration tests results on a motor stand. The relevance of the article is due to the high labor intensity of such tests, the complexity of documentation and decisionmaking based on the results of the work.Purposeof the study. This work is part of a comprehensive methodology, the purpose of which is to reduce the duration of tests and improve the calibration results quality of the vehicle’s power plant. The entire methodology description as a whole is also given in the publication.Methodology and research methods.The achievement of this goal is ensured with the help of special systems – INCA-FLOW (test automation) and ASCMO (processing results and optimization), produced by Bosch/ETAS. The approbation of the technique was carried out on a motor stand in the MADI training box in relation to the problem of forming an ignition timing map.Scientific novelty and results.As a result of the methodology application, a 4.8 times reduction in the motor tests duration takes place if 2 people work in manual mode at the test bench without interruption.At the same time, the variance of the adequacy ofSadof the torque empirical modelMkturned out to be, on average, 1.5 times less if the model was built according to the automated tests results. The obtained data indicated an improvement in the quality of measurements in the transition to automated test methods.From a scientific point of view, the most original part of the work is the application of the “Gaussian process” method to build empirical models. This method provides more accurate results than, for example, the traditional method of least squares.Thepracticalsignificanceof the work lies in the ability to considerably reduce routine actions on a motor stand, and the additional time spent on developing and testing a test scenario (program) is compensated for by the fact that scenario models can be used in the future for other similar tests. The proposed methodology makes it possible to cover a significant part of the internal combustion engine calibration tests. For example, you can apply it if you possess the preliminary information about the test object (basing on which you can draw up an experiment plan) and the engine is to be prepared either for a car road tests or tests under special conditions.

Initial Experience of the Training Centre of Minimally Invasive Surgery at Ahli Arab Hospital in Gaza

Background: Minimally Invasive Surgery (MIS) training outside operation room is still done by simulation in different training centers worldwide. Strong validity of such a training was evidenced using either the physical simulator (trainer box) or a biological model or a virtual reality (VR) or an animal model. Currently MIS is rapidly spreading worldwide in different surgical centers depending on the fact that MIS training is an essential prerequisite for any surgeon even with a vast experience in open surgery. A well-structured proficiency-based curriculum is essential to provide training for individuals who need to acquire MIS skills. Aim: To prove the efficiency and accuracy of training laparoscopic skills on combination of physical simulator as the dry module to be scored by a modified McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) scoring system and on laparoscopic simulator as the wet module (Full Turkey model) using the Global Operative Assessment of Laparoscopic Surgery (GOALS) scoring items. Methods: One hundred and thirty-nine surgeons of different surgical specialties, age and experience levels (during the period from July 2018 to July 2019) were subjected to this curriculum-based training. All trainees received the basic cognitive knowledge in groups of fifteen to eighteen. In the hands on training each group is divided into three subgroups to fit the available six fundamental laparoscopic surgery (FLS) training boxes. Trainees are monitored by at two mentored per trainer in the different FLS skills and tasks. A modified (MISTELS) was used to score the five Fundamental Laparoscopic Surgery (FLS) skills and tasks that are the standard of the Society of American Gastroenterology Endoscopic Surgery (SAGES). Modifications entail the scoring time to be in minutes rather than in seconds. Some extra-activities were added to the first three skills/tasks. A score sheet was designed for each task considering both the scoring time and penalties. In Wet lab, not only the five tasks were repeated but also a complementary skill such as Veress needle insertion, port insertion and camera manipulation together with dissection e.g. intracorporeally in cholecystectomy were provided through a full Turkey model on a laparoscopic simulator. Trainees’ performance was measured with integration of cognitive knowledge post-testing, score in the modified MISTEL in dry lab and by the Global Operative Assessment of Laparoscopic Surgery (GOALS) scoring in wet laboratory. The mean of total score of the trainee before training was 35.28 while after training was 82.59 but Cronbach’s Alpha value in the pre and post testing scored 0.778 and 0.799 respectively Results: Majority of trainees showed improvement in all measured domains in different stations. In cognitive knowledge the mean score difference between the pre and post testing was 50.1and 72.14 respectively. This is statistically significant as shown in the student T-test value of 19.13. This indicates that the trainees are having some knowledge but definitely refined and improved on post testing. In Dry Lab there is a dramatic improvement in the post testing compared to pretests where there was a clear statistical significance of a P value of 0.01 in all the five skills and tasks between the pre and post test of each. In wet Lab the Global Operative Assessment of Laparoscopic Surgery (GOALS) scoring system Which is used to assess skill of surgeons in clinical settings in OR is used to simulate clinical sessions on a Full Turkey Model on laparoscopic simulator set. GOALS scoring in Full Turkey model proves its feasibility and efficiency in most trainees where Mean score was 84.1, The Median 84.0, and the Std = 5.38. Construct validity of this triad methodology of cognitive knowledge, dry lab and wet lab of full Turkey model is evident among different trainees of different groups with no florid significance of different surgeons in relation scores achieved and age group proving validity of this type of training. There is no statistical differences between age group and the final score of overall training the mean average of the trainees ages less than 35 years old was 81.2% followed by the trainees above 45 years old 79.7% with very simple difference in mean with trainees aged between 35 years old to 45 years old 79.6%. Conclusion: MIS training integrating a triad of training modules of MIS cognitive knowledge, traditional physical box trainer and a biological wet lab on a full Turkey model is fairly feasible and effective in the acquisition of fundamental laparoscopic skills and tasks. Global Operative Assessment of Laparoscopic Skills (GOALS) can be a valid tool to assess trainees outside operation room.

Quantification of electrosurgery-related critical events during laparoscopic cholecystectomy – a prospective experimental study among surgical novices

Uncontrolled movement of instruments in laparoscopic surgery can lead to inadvertent tissue damage, particularly when the dissecting or electrosurgical instrument is located outside the field of view of the laparoscopic camera. The incidence and relevance of such events are currently unknown. The present work aims to identify and quantify potentially dangerous situations using the example of laparoscopic cholecystectomy (LC). Twenty-four final year medical students were prompted to each perform four consecutive LC attempts on a well-established box trainer in a surgical training environment following a standardized protocol in a porcine model. The following situation was defined as a critical event (CE): the dissecting instrument was inadvertently located outside the laparoscopic camera’s field of view. Simultaneous activation of the electrosurgical unit was defined as a highly critical event (hCE). Primary endpoint was the incidence of CEs. While performing 96 LCs, 2895 CEs were observed. Of these, 1059 (36.6%) were hCEs. The median number of CEs per LC was 20.5 (range: 1–125; IQR: 33) and the median number of hCEs per LC was 8.0 (range: 0–54, IQR: 10). Mean total operation time was 34.7 min (range: 15.6–62.5 min, IQR: 14.3 min). Our study demonstrates the significance of CEs as a potential risk factor for collateral damage during LC. Further studies are needed to investigate the occurrence of CE in clinical practice, not just for laparoscopic cholecystectomy but also for other procedures. Systematic training of future surgeons as well as technical solutions address this safety issue.

Effect of Early Intervention through Light Box Training on Developmental Level in Children With Autistic Features

Effect of Early Intervention through Light Box Training on Developmental Level in Children With Autistic Features

197 Maintaining Surgical Skills Through Small-Group Simulation During COVID-19 [Quality Improvement Project

The COVID-19 Pandemic has had a significant disruption to the provision of Surgical Training. Core and Improving Surgical Trainees (CSTs and ISTs) are noted to be a group profoundly affected due to the impact of the pandemic in reducing operative time, cancelled elective procedures and redeployment to other specialities We aimed to evaluate the benefit of Small Group Surgical Simulation teaching for CSTs and ISTs recently deployed in the Norfolk and Norwich University Hospital.Physical simulation models were designed with the use of animal tissue and/or surgical simulators (such as laparoscopic box trainers) to simulate surgical procedures appropriate for the grade of trainees.We designed a monthly Surgical Simulation Programme, which took place in the Surgical Skills Laboratory. Topics were selected from those suitable for Simulation from the Intercollegiate Surgical Curriculum Programme (ISCP) Core Surgical Curriculum Participants felt that the COVID pandemic affected opportunities to perform/assist or observe the surgical skills. Participant comments on COVID affecting opportunities included ‘Reduced opportunities due to cancelled lists’, ‘Fewer elective cases so less opportunity ‘ and ‘Affected in the Peak of COVID but it is improving. Following the session, 100% of participants found the sessions to be effective in improving confidence in performing the surgical skill and 87% found the sessions to be extremely effective. Participants found the teaching sessions to be useful due to the opportunities of ‘Close supervision and direct feedback’, ‘Set of tasks’, ‘Practise with animal models’, ‘Having the tutor there to assist and help us’ and ‘[Discussing] theory prior to learning the procedure’.Surgical simulation provides opportunities for early-year trainees to learn and perform surgical skills during the COVID-19 pandemic. Small-group surgical simulation allows CSTs and ISTs to develop and practise skills under supervision of tutors, with trainees finding real-time feedback useful. In a post-COVID era, a surgical simulation teaching programme could provide an effective training opportunity to shorten the steep learning curve of core surgical training.

Real-Time 3D Tracking of Laparoscopy Training Instruments for Assessment and Feedback.

Assessment of minimally invasive surgical skills is a non-trivial task, usually requiring the presence and time of expert observers, including subjectivity and requiring special and expensive equipment and software. Although there are virtual simulators that provide self-assessment features, they are limited as the trainee loses the immediate feedback from realistic physical interaction. The physical training boxes, on the other hand, preserve the immediate physical feedback, but lack the automated self-assessment facilities. This study develops an algorithm for real-time tracking of laparoscopy instruments in the video cues of a standard physical laparoscopy training box with a single fisheye camera. The developed visual tracking algorithm recovers the 3D positions of the laparoscopic instrument tips, to which simple colored tapes (markers) are attached. With such system, the extracted instrument trajectories can be digitally processed, and automated self-assessment feedback can be provided. In this way, both the physical interaction feedback would be preserved and the need for the observance of an expert would be overcome. Real-time instrument tracking with a suitable assessment criterion would constitute a significant step towards provision of real-time (immediate) feedback to correct trainee actions and show them how the action should be performed. This study is a step towards achieving this with a low cost, automated, and widely applicable laparoscopy training and assessment system using a standard physical training box equipped with a fisheye camera.

Learning and application of intracorporal slipping knot techniques in minimally invasive surgery

AbstractAimIntracorporal knot tying (ICKT) and suturing in minimally invasive surgery (MIS) are key skills for advanced procedures. The best choice for an intracorporal slipping knot tying technique had not been defined. The aim of this study was to compare two intracorporal slipping knot techniques: the classical C‐loop technique (Variant I) and the square‐to‐slip technique without changing leadership hand (Variant II).MethodsA laparoscopic box trainer including laparoscope was used for ICKT. A total of 120 slipping knots were evaluated in two groups with different levels of surgical education. The first group (n = 5) consisted of senior surgical physicians proficient in laparoscopic surgery. The second group (n = 10) comprised medical students without any prior experience in laparoscopic surgery. The medical student group received a 1‐hour hands‐on training session. Participants were assessed using the Global Rating Scale of the Objective Structured Assessment of Technical Skills, procedural implementation, knot quality, and task time.ResultsIn the medical student group, performance in all parameters was greater for Variant I compared with Variant II (P &lt; .005). Contrary to the students group, senior physicians demonstrated significantly faster task time in Variant II compared with Variant I (P = .001). No significant differences were observed in the remaining parameters.ConclusionFor novices, the intracorporal slipping knot is easier to learn with the C‐loop technique (Variant I) than with the square‐to‐slip technique (Variant II). For surgeons experienced in MIS, the square‐to‐slip technique without changing leadership hand (Variant II) was superior to the slipping knot in the C‐loop technique (Variant I) only by time savings. The knot quality, as the most important variable, showed equally good results between both ICKT techniques.

Postural Differences between Expert Laparoscopic and Naïve Surgeons: Implications for Ergonomic Assessment in Surgical Education

<h3>Study Objective</h3> Poor ergonomics can contribute to musculoskeletal disorders and chronic pain for many surgeons which threatens career longevity. This proof-of-concept study sought to quantify upper body postural differences in expert laparoscopic surgeons and naïve surgeons using 3D motion capture during a standardized simulated surgical task. <h3>Design</h3> Observational case-control. <h3>Setting</h3> Motion capture laboratory; Surgical simulation setting. <h3>Patients or Participants</h3> Expert laparoscopic surgeons (n=6) and naïve surgeons (n=9). <h3>Interventions</h3> All participants watched an instructional video prior to data collection and completed the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task three times. The box trainer's height and distance were adjusted to the participants' preference. A 3D motion capture system recorded trajectories of retroreflective markers placed on the participants at various anatomical landmarks. <h3>Measurements and Main Results</h3> Outcome variables of neck, shoulder, elbow, wrist, and trunk angles were computed using a 3D kinematic model. The mean (X) and variance (2 standard deviations from the mean (2SD)) were extracted for each trial and then averaged across trials. Independent T-tests evaluated significant between group differences in body positions in all three planes of motion at the p<0.05 level. Compared to experts, naïve surgeons exhibited significantly greater variation in lateral neck (2SD=5.43±2.35° vs. 3.91±1.72°, p=0.029) and sagittal trunk motion (2SD=3.84±2.57° vs. 1.91±0.91°, p=0.018). Naïve surgeons also performed the task with their elbows significantly more flexed than the expert surgeons (Dominant Arm=96.9±9.2° vs. 82.9±2.1°, p=0.002; Non-Dominant Arm=94.7±8.9° vs. 86.2±8.4°, p=0.043). <h3>Conclusion</h3> Musculoskeletal injury risk factors among laparoscopic surgeons include awkward body posture, static muscle loading, and long operating times. This study demonstrates postural differences of the neck, trunk, and arms between expert and naïve surgeons. Incorporating ergonomic awareness and knowledge into surgical education may help to reduce surgeons' risk of developing cumulative musculoskeletal disorders and enhance surgeon career longevity.

The Use of 3D Motion Capture for the Quantitative Assessment of Surgical Tool Motion in Expert Laparoscopic and Naïve Surgeons

Study Objective This proof-of-concept study sought to evaluate the efficacy of using quantitative variables derived from 3D motion analysis to differentiate laparoscopic surgical skill level. Design Observational case-control. Setting Simulation-based setting; surgical task completion. Patients or Participants Expert laparoscopic surgeons (n=7) and naïve surgeons (n=10). Interventions Participants were recruited to complete the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task. Measurements and Main Results All participants watched an instructional video prior to data collection and completed the task three times. A 3D motion capture system recorded trajectories of retroreflective markers placed on two Maryland graspers and location of surgical tool tips were computed relative to a box trainer. Variables of interest: completion time, surgical tool translation (sagittal, frontal, coronal planes, surgical tool pathlength, and symmetry ratios (non-dominant vs. dominant tool motion). Independent one-tailed T-tests evaluated significant between group differences at the p<0.05 level. Experts completed the task with significantly shorter (mean±stdev) times (119.4±61.7s) (p=0.007) compared to naïve surgeons (201.9±78.4s). This is complemented by significantly shorter tool pathlengths (dominant=195.1±108.7cm; non-dominant=187.1±103.9cm) (p=0.038,0.004) and more symmetrical grasper use (symmetry ratio=0.95±0.19) (p=0.019) in experts compared to naïve surgeons (dominant=297.6±110.7cm; non-dominant=356.9±118.3cm; symmetry ratio=1.24±0.29). No between group differences in surgical tool tip translations were observed. Conclusion 3D motion variables can be used to quantify between group differences in surgical tool motion. Not only did expert surgeons complete tasks more quickly, they also moved more efficiently and displayed more symmetrical use of their hands compared to naïve surgeons, who had greater movement of their non-dominant hands during the task. Objective, quantitative methods allowing trainees to improve surgical skill outside the OR are critical to ensure the highest possible standard of care is provided to patients. However, current evaluation models lack feedback relating to quality of movement. We believe motion capture can be a valuable adjunct to current skills acquisition models to improve self-directed surgical education and resident technicity. This proof-of-concept study sought to evaluate the efficacy of using quantitative variables derived from 3D motion analysis to differentiate laparoscopic surgical skill level. Observational case-control. Simulation-based setting; surgical task completion. Expert laparoscopic surgeons (n=7) and naïve surgeons (n=10). Participants were recruited to complete the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task. All participants watched an instructional video prior to data collection and completed the task three times. A 3D motion capture system recorded trajectories of retroreflective markers placed on two Maryland graspers and location of surgical tool tips were computed relative to a box trainer. Variables of interest: completion time, surgical tool translation (sagittal, frontal, coronal planes, surgical tool pathlength, and symmetry ratios (non-dominant vs. dominant tool motion). Independent one-tailed T-tests evaluated significant between group differences at the p<0.05 level. Experts completed the task with significantly shorter (mean±stdev) times (119.4±61.7s) (p=0.007) compared to naïve surgeons (201.9±78.4s). This is complemented by significantly shorter tool pathlengths (dominant=195.1±108.7cm; non-dominant=187.1±103.9cm) (p=0.038,0.004) and more symmetrical grasper use (symmetry ratio=0.95±0.19) (p=0.019) in experts compared to naïve surgeons (dominant=297.6±110.7cm; non-dominant=356.9±118.3cm; symmetry ratio=1.24±0.29). No between group differences in surgical tool tip translations were observed. 3D motion variables can be used to quantify between group differences in surgical tool motion. Not only did expert surgeons complete tasks more quickly, they also moved more efficiently and displayed more symmetrical use of their hands compared to naïve surgeons, who had greater movement of their non-dominant hands during the task. Objective, quantitative methods allowing trainees to improve surgical skill outside the OR are critical to ensure the highest possible standard of care is provided to patients. However, current evaluation models lack feedback relating to quality of movement. We believe motion capture can be a valuable adjunct to current skills acquisition models to improve self-directed surgical education and resident technicity.

Cost Effective Simulation Model for Laparoscopic Uretero-Ureterostomy

<h3>Study Objective</h3> The objectives of this video are to review the techniques of uretero-ureterostomy, to develop a low-cost simulation model, and to provide instruction to gynecologists on how to perform this procedure in the absence of a urologist. <h3>Design</h3> A simulation model for ureteral re-anastomosis was created using rubber tubing and a pipe cleaner. The model was placed in a laparoscopic simulation box trainer, and the steps of the procedure are reviewed in sequence. <h3>Setting</h3> Simulation center at an academic tertiary care center. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> The simulation model was developed and explained during the course of the video. <h3>Measurements and Main Results</h3> A piece of rubber tubing is placed in a laparoscopic box simulator, and both ends are secured. A cut is made in the mid-portion of the tube to mimic a ureteral injury. Spatulation is performed to both the proximal and distant parts of the ureter. A pipe cleaner is introduced into both ends of the tube in order to simulate a ureteral stent. Once the stent is secure, we check if the spatulated ends are in position. Interrupted sutures are placed to secure the ureteral ends in the correct anatomical position. Intra-corporeal knot tying is performed to secure the sutures. <h3>Conclusion</h3> Our simulated uretero-ureterostomy model can easily be reproduced to teach residents, fellows, and early career physicians how to repair a ureter laparoscopically. We feel that simulation is essential to teach surgical skills, and ureteral re-anastomosis is a highly technical skill that is very useful for gynecologists who may not always have access to Urology consultation. Using a low-cost model like ours is helpful to practice the steps of the procedure and build confidence for surgeons who may find themselves in an emergent situation where ureteral repair is required.

Remote Fundamentals of Laparoscopic Surgery (FLS) Training in Pre-Clinical Medical Students

<h3>Study Objective</h3> To pilot a remote learning Fundamentals of Laparoscopic Surgery (FLS) elective to pre-clinical medical students. <h3>Design</h3> Due to COVID-19 restrictions, pre-clinical medical students were required to strictly quarantine for two weeks upon arrival to their clinical rotation sites, during which they would engage in an elective of their choice. Medical students enrolled in the Remote Learning FLS Elective received a laparoscopic training box (Task It) with supplies prior to traveling around the continental United States for clinical rotations. Students also received instructions to access publicly available FLS modules and videos to introduce instruments and tasks. Each learner engaged in self-guided practice with coaching available via a live-streaming platform to assist with refining their skills during the course. <h3>Setting</h3> While quarantined in three different locations (Bethesda MD, San Antonio TX, and San Diego CA) learners utilized space in their living quarters to set up the Task II trainer and computer. <h3>Patients or Participants</h3> Three pre-clinical medical students enrolled in a 2-week distance learning FLS elective. <h3>Interventions</h3> Learners participated in a 2-week distance learning elective that utilized self-directed learning and practice, use of available FLS modules and videos, and individual coaching sessions with instructor. <h3>Measurements and Main Results</h3> All learners were true novices with no prior FLS or laparoscopic experience, and minimal to no experience with surgical skills. Learners practiced individually and timed themselves practicing each skill. Each was able to attain facility with object transfer, depth perception. <h3>Conclusion</h3> All learners improved from their baseline skills level. Remote coaching of FLS with true novices is a viable alternative to traditional face to face learning with motivated learners.

ENHANCED PIXEL BASED URBAN AREA CLASSIFICATION OF SATELLITE IMAGES USING CONVOLUTIONAL NEURAL NETWORK

Recent years have witnessed a great development in the use of deep learning in the applied fields in general, including the improvement of remote sensing. Satellite imagery classification has played a prominent role in various development processes. This paper presents a new improvement in automatic urban classification using One Dimension Convolutional Neural Network (1DCNN) architecture. The suggested approach has three enhancement processes. First, select training boxes for different classes and create many pixels with variable class signatures. This makes the training process dependent on the broadband of signature for the classes. Second, modified 1D convolution was used to re-encode pixel values to increase distinguish power. Third, adding a new median filter layer at the end of network architecture to remove pixels like noise to make the resulting map smoother. An image of Greater Cairo is used and the different urban classes are defined within it. The proposed method was compared to other methods based on pixels. The proposed method proved to be numerically and visually superior.