Fundamentals Of Laparoscopic Surgery Simulator Research Articles

Automatic performance evaluation of the intracorporeal suture exercise.

This work uses deep learning algorithms to provide automated feedback on the suture with intracorporeal knot exercise in the fundamentals of laparoscopic surgery simulator. Different metrics were designed to provide informative feedback to the user on how to complete the task more efficiently. The automation of the feedback will allow students to practice at any time without the supervision of experts. Five residents and five senior surgeons participated in the study. Object detection, image classification, and semantic segmentation deep learning algorithms were used to collect statistics on the practitioner's performance. Three task-specific metrics were defined. The metrics refer to the way the practitioner holds the needle before the insertion to the Penrose drain, and the amount of movement of the Penrose drain during the needle's insertion. Good agreement between the human labeling and the different algorithms' performance and metric values was achieved. The difference between the scores of the senior surgeons and the surgical residents was statistically significant for one of the metrics. We developed a system that provides performance metrics of the intracorporeal suture exercise. These metrics can help surgical residents practice independently and receive informative feedback on how they entered the needle into the Penrose.

Validation of the VBLaST pattern cutting task: a learning curve study.

Mastery of laparoscopic skills is essential in surgical practice and requires considerable time and effort to achieve. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PC©) is a virtual simulator that was developed as a computerized version of the pattern cutting (PC) task in the Fundamentals of Laparoscopic Surgery (FLS) system. To establish convergent validity for the VBLaST-PC©, we assessed trainees' learning curves using the cumulative summation (CUSUM) method and compared them with those on the FLS. Twenty-four medical students were randomly assigned to an FLS training group, a VBLaST training group, or a control group. Fifteen training sessions, 30min in duration per session per day, were conducted over 3weeks. All subjects completed pretest, posttest, and retention test (2weeks after posttest) on both the FLS and VBLaST© simulators. Performance data, including time, error, FLS score, learning rate, learning plateau, and CUSUM score, were analyzed. The learning curve for all trained subjects demonstrated increasing performance and a performance plateau. CUSUM analyses showed that five of the seven subjects reached the intermediate proficiency level but none reached the expert proficiency level after 150 practice trials. Performance was significantly improved after simulation training, but only in the assigned simulator. No significant decay of skills after 2weeks of disuse was observed. Control subjects did not show any learning on the FLS simulator, but improved continually in the VBLaST simulator. Although VBLaST©- and FLS-trained subjects demonstrated similar learning rates and plateaus, the majority of subjects required more than 150 trials to achieve proficiency. Trained subjects demonstrated improved performance in only the assigned simulator, indicating specificity of training. The virtual simulator may provide better opportunities for learning, especially with limited training exposure.

Factors associated with simulator-assessed laparoscopic surgical skills of veterinary students.

OBJECTIVE To determine whether simulator-assessed laparoscopic skills of veterinary students were associated with training level and prior experience performing nonlaparoscopic veterinary surgery and other activities requiring hand-eye coordination and manual dexterity. DESIGN Experiment. SAMPLE 145 students without any prior laparoscopic surgical or fundamentals of laparoscopic surgery (FLS) simulator experience in years 1 (n = 39), 2 (34), 3 (39), and 4 (33) at a veterinary college. PROCEDURES A questionnaire was used to collect data from participants regarding experience performing veterinary surgery, playing video games, and participating in other activities. Participants performed a peg transfer, pattern cutting, and ligature loop-placement task on an FLS simulator, and FLS scores were assigned by an observer. Scores were compared among academic years, and correlations between amounts of veterinary surgical experience and FLS scores were assessed. A general linear model was used to identify predictors of FLS scores. RESULTS Participants were predominantly female (75%), right-hand dominant (92%), and between 20 and 29 years of age (98%). No significant differences were identified among academic years in FLS scores for individual tasks or total FLS score. Scores were not significantly associated with prior surgical or video game experience. Participants reporting no handicraft experience had significantly lower total FLS scores and FLS scores for task 2 than did participants reporting a lot of handicraft experience. CONCLUSIONS AND CLINICAL RELEVANCE Prior veterinary surgical and video game experience had no influence on FLS scores in this group of veterinary students, suggesting that proficiency of veterinary students in FLS may require specific training.

You Have a Message! Social Networking as a Motivator for FLS Training

Despite evidence supporting the value of the Fundamentals of Laparoscopic Surgery (FLS) curriculum, surgical educators still find it challenging to motivate residents to practice. Wiggio is an online networking and collaboration tool that allows learners to track performance, see what their peers are doing, and send and receive updates. The purpose of this study was to assess whether using Wiggio increases practice and improves performance of the FLS manual skills. After baseline FLS testing, residents were randomized into control (C) and Wiggio (W) groups. The practice events, time spent practicing, and best scores were recorded. Residents in the W group interacted with each other via the Wiggio website. The website moderator sent motivational messages, calendar reminders, and FLS-related articles. The best times and progress graphs for each resident were also posted online. After 4 weeks, all residents underwent final FLS testing and filled out a questionnaire. The study was performed in a tertiary care center, at the Steinberg-Bernstein Centre for Minimally Invasive Surgery at the Montreal General Hospital. Postgraduate year-1 and postgraduate year-2 general surgery residents with no or minimal FLS simulator experience were included. Of the 15 eligible residents, 14 participated, with 7 residents in each group. The FLS scores were similar at baseline (C = 56.9 [±14.2], W = 57. 6 [±14.7]; p = 0.93). During the study period, twice as many residents in the W group practiced compared with those in the C group (4 vs 2); W-group residents reported more practice events than the C-group residents did (14 vs 4) and spent more time practicing in the laboratory (1035 vs 480 minutes). These results did not reach statistical significance. During practice sessions, proficiency scores were achieved for 40% of the tasks in the W group compared with 8.6% in the C group; however, this difference was also not significant. There was no difference in the FLS scores in both groups at the end of the study. The moderator spent an average of 6.5 minutes per day sending messages and managing the Wiggio website. Participation in Wiggio seems to increase practice events and time spent training on FLS. Social networking may play a role in surgical education and learner motivation; however, the optimal use of Web 2.0 tools in resident education is not yet fully understood.

Hypnosis-induced mental training improves performance on the Fundamentals of Laparoscopic Surgery (FLS) simulator.

Mental training (MT) is used extensively by musicians and athletes to improve their performance. Recently, it has been suggested as a training method for surgical trainees. We assessed the influence of MT, induced by hypnosis, on the performance of simulated tasks on a laparoscopic simulator, as compared to a non-specific relaxing intervention. 11 surgeons completed a proficiency-based training program on the Fundamentals of Laparoscopic Surgery (FLS) simulator, until they reached performance plateau of the peg transfer task. Thereafter, they received a single music session, as a relaxing intervention, followed by repeating of the peg transfer task. Then they went through a hypnosis session guided by an experienced psychologist, with suggestions of smooth flow of pegs from one position on the board to another, and re-performed the task. Plateau performance was 51.1 ± 6.9 s. After the music session performance improved by 6.3% to 47.9 ± 5.4 s (p = 0.86). After the MT session performance further improved by 15.3% to 40.1 ± 5.8 s (p = 0.009), which was a 21.6% improvement from baseline (p < 0.001). Subject's satisfaction from their performance, without knowledge of the task scores, was 6.0 ± 2.9 on 0-10 VAS after the music and reached as high as 8.5 ± 1.7 after the hypnotic session (p = 0.01). Hypnosis-induced MT significantly improves performance on the FLS simulator, which cannot be attributed to its relaxing qualities alone. This study contributes evidence to the effectiveness of MT in surgical skills acquisition and suggests that hypnotic techniques should be used in mental preparation processes. There is a need to further study these effects on operating room performance.

Virtual reality versus box laparoscopic simulators in trainee selection and aptitude testing.

The purpose of this study was to compare the validity of high-fidelity and low-fidelity simulators in a selection center environment, using measures of construct and concurrent validity. A total of 46 novice and expert participants were tested on both the low-fidelity Fundamentals of Laparoscopic Surgery (FLS) box trainer and the high fidelity, Lapsim, virtual reality laparoscopic simulator. Outcome scores and performance metrics where recorded. Experts performed better than novices on the FLS (median 71% vs. 51%; P<0.0001) but not the Lapsim (59.1% vs. 57.1%; P = 0.41). No correlation was found between overall Lapsim metrics and FLS outcome scores (correlation = -0.024; P = 0.874). Although most novice participants performed within a narrow window on the FLS simulator, a few high-performing and low-performing outliers where identified. In a selection center scenario, testing with low-fidelity platforms appears to demonstrate greater validity. Outliers can be identified using low-fidelity simulators.

The effects of acute aerobic exercise on the acquisition and retention of laparoscopic skills.

Exercise is beneficial to learning. The purpose of this research was to determine whether an episode of aerobic exercise prior to practice improves the acquisition and retention of laparoscopic skills in the fundamentals of laparoscopic surgery (FLS) simulator. Baseline maximal physical fitness (VO2 max), performance on peg transfer (PT), pattern cut (PC), and intracorporeal suture (ICS) were measured for FLS naïve undergraduates. 2 Weeks later, participants were randomized into exercise (E) and control (C) groups. C did unrelated work for 40 min and then practiced PT and PC for 10 min, and ICS for 15 min. Final scores were recorded. In E, participants ran on a treadmill for 20 min at 60 % of their VO2 max. After a 15 min cool down, they engaged in identical FLS simulator training as group C. Both groups completed the NASA task load index (TLX) to assess workload. Retention was recorded 2 months after the training session. Groups were compared using t tests, χ(2) and Wilcoxon rank tests. p < 0.05 was considered significant. There were 52 participants (22 in C; 30 in E) with high physical fitness at baseline. Demographics between the groups were similar at baseline. There were no differences in VO2 max and scores on the three tasks at baseline (all p values NS). There was no statistical significance between the scores of the C and E groups at the training session and retention, except for higher PT scores in the E group after the training session. In physically fit, surgically naïve students, one bout of aerobic exercise enhanced immediate learning of simple FLS skills but did not have an impact on more complex skills or on retention. The use of exercise in the surgical curriculum, or as a learning tool, warrants further investigation regarding how best to apply it.

Laparoscopic Skills Maintenance: A Randomized Trial of Virtual Reality and Box Trainer Simulators

A number of simulators have been developed to teach surgical trainees the basic skills required to effectively perform laparoscopic surgery; however, consideration needs to be given to how well the skills taught by these simulators are maintained over time. This study compared the maintenance of laparoscopic skills learned using box trainer and virtual reality simulators. Participants were randomly allocated to be trained and assessed using either the Society of American Gastrointestinal Endoscopic Surgeons Fundamentals of Laparoscopic Surgery (FLS) simulator or the Surgical Science virtual reality simulator. Once participants achieved a predetermined level of proficiency, they were assessed 1, 3, and 6 months later. At each assessment, participants were given 2 practice attempts and assessed on their third attempt. The study was conducted through the Simulated Surgical Skills Program that was held at the Royal Australasian College of Surgeons, Adelaide, Australia. Overall, 26 participants (13 per group) completed the training and all follow-up assessments. There were no significant differences between simulation-trained cohorts for age, gender, training level, and the number of surgeries previously performed, observed, or assisted. Scores for the FLS-trained participants did not significantly change over the follow-up period. Scores for LapSim-trained participants significantly deteriorated at the first 2 follow-up points (1 and 3 months) (p < 0.050), but returned to be near initial levels by the final follow-up (6 months). This research showed that basic laparoscopic skills learned using the FLS simulator were maintained more consistently than those learned on the LapSim simulator. However, by the final follow-up, both simulator-trained cohorts had skill levels that were not significantly different to those at proficiency after the initial training period.

New dog, new tricks: trends in performance on the Fundamentals of Laparoscopic Surgery simulator for incoming surgery residents

Exposure to laparoscopic surgery during medical school has increased over recent years. The Fundamentals of Laparoscopic Surgery (FLS) simulator allows for objective assessment of laparoscopic skills. This study aimed to determine whether the fundamental laparoscopic skills of incoming surgery residents have improved. The initial FLS performance of first-year residents between 2003 and 2008 was identified from a prospective database. Linear regression was used to determine the effect of incoming year on performance of the five FLS simulator tasks (peg transfer, pattern cut, endoloop placement, suture with an extracorporeal knot [EC], suture with an intracorporeal knot [IC]) and the total score. Statistical significance was defined as a p value less than 0.05. A total of 63 first-year residents were identified from the database. The total FLS scores improved over time (r=0.39; p=0.001). The scores for peg transfer did not change significantly, but the scores for pattern cutting (r=0.37; p=0.002), endoloop placement (r=0.36; p=0.004), suture with EC (r=0.32; p=0.02), and suture with IC (r=0.26; p=0.03) all improved significantly over the 5years. The baseline fundamental laparoscopic skills of incoming surgery residents appear to have improved over time. This may be due to increased clinical laparoscopic exposure and availability of laparoscopic simulation in medical school.

Development and validation of a pediatric laparoscopic surgery simulator

BackgroundAlthough a validated simulator exists for adult laparoscopy, there is no pediatric counterpart. The objective of this study is to develop and validate a pediatric laparoscopic surgery (PLS) simulator. MethodsA PLS simulator was developed. Participants were stratified according to level of expertise and tested on the fundamentals of laparoscopic surgery (FLS) and PLS simulators. A subsequent group was tested exclusively on the PLS simulator. ResultsThe PLS intracorporeal suturing score was lower than its adult counterpart (P = .02). The PLS pattern-cutting score was higher than in the FLS simulator (P < .001). If the latter was eliminated from the calculation, the revised total FLS score was significantly better than the revised PLS score. When all participants were combined, total PLS scores as well as performance on 3 of 5 tasks allowed differentiation between novice, intermediate, and expert. ConclusionsThe PLS simulator was able to discriminate between the novice, intermediate, and expert using the total PLS score and the performance on 3 of the 5 tasks, thus providing evidence for construct validity. The other 2 tasks will require formal modification or a change in the scoring metrics to establish their independent construct validity.

Fundamentals of Laparoscopic Surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial

Background The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the operating room (OR). Methods Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores ≤15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status. Results Sixteen residents completed the study. There were no differences in baseline simulator (49.1 ± 17 vs 39.5 ± 16, P = .27) or OR scores (11.3 ± 2.0 vs 12.0 ± 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 ± 4 vs 60.5 ± 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 ± 2.2 ( P = .04), whereas the trained group improved by 6.1 to 17.4 ± 1.9 ( P = .0005 vs control; P < .0001 vs baseline). Conclusions This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.

Maintaining proficiency after Fundamentals of Laparoscopic Surgery training: A 1-year analysis of skill retention for surgery residents

The purpose of this study was to determine performance retention after initial and ongoing Fundamentals of Laparoscopic Surgery (FLS) skills training. Surgery residents (postgraduate year [PGY] 1-5; n = 91) initially underwent proficiency-based training during a 2-month period for all 5 FLS tasks. Subsequently, available residents (PGY 2-5; n = 44) were enrolled in a follow-up curriculum for Tasks 4 and 5, with retention testing at 6.5 +/- 1.0 months (Retention 1) and 12.5 +/- 1.3 months (Retention 2), followed by mandatory retraining if needed. Forty-two residents participated in the follow-up curriculum. For Task 4, retraining was required for 55% of trainees after Retention 1 and for 40% after Retention 2 testing. For Task 5, retraining was required for 86% of trainees after Retention 1 and for 48% after Retention 2 testing. Compared with posttest performance, skill retention was 86% and 96% for Task 4 and 87% and 96% for Task 5 at Retentions 1 and 2, respectively. A modest decrement in performance was detected at 6.5 months, but a small amount of additional structured practice reinforced skill acquisition and minimized skill loss at 12.5 months. In addition to clinical experience, trainees may benefit from ongoing FLS simulator training to optimally maintain proficiency.

Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries

Several challenges exist with laparoscopic skills training in resource-restricted countries, including long travel distances required by mentors for onsite teaching. Telesimulation (TS) is a novel concept that uses the internet to link simulators between an instructor and a trainee in different locations. The purpose of this study was to determine the effectiveness of telesimulation for teaching the Fundamentals of Laparoscopic Surgery (FLS) to surgeons in Botswana, Africa. A total of 16 surgeons from two centers in Botswana participated in this 8-week study. FLS TS was set up using two simulators, computers, webcams, and Skype software for eight surgeons in the TS group. A standard FLS simulator was available for the eight surgeons in the self-practice (SP) group. Participants in the TS group had one remote training session per week with an FLS proctor at the University of Toronto who provided feedback and demonstrated proper technique. Participants in the SP group had access to the FLS DVD and were instructed to train on FLS at least once per week. FLS post-test scores were obtained in Botswana by a trained FLS proctor at the conclusion of the study. Participants in the TS group had significantly higher post-test FLS scores than those in the SP group (440 +/- 56 vs. 272 +/- 95, p = 0.001). All trainees in the TS group achieved an FLS simulator certification passing score, whereas only 38% in the SP group did so (p = 0.03). Remote telesimulation is an effective method for teaching the Fundamentals of Laparoscopic Surgery in Africa, achieving a 100% FLS skills pass rate. This training platform provides a cost-effective method of teaching in resource-restricted countries and could be used to teach laparoscopic skills anywhere in the world with internet access.

Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course

The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa. A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3. Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 +/- 94 versus 132 +/- 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification. To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.