Fundamentals Of Laparoscopic Surgery Tasks Research Articles

Brain-behavior analysis of transcranial direct current stimulation effects on a complex surgical motor task.

Transcranial Direct Current Stimulation (tDCS) has demonstrated its potential in enhancing surgical training and performance compared to sham tDCS. However, optimizing its efficacy requires the selection of appropriate brain targets informed by neuroimaging and mechanistic understanding. Previous studies have established the feasibility of using portable brain imaging, combining functional near-infrared spectroscopy (fNIRS) with tDCS during Fundamentals of Laparoscopic Surgery (FLS) tasks. This allows concurrent monitoring of cortical activations. Building on these foundations, our study aimed to explore the multi-modal imaging of the brain response using fNIRS and electroencephalogram (EEG) to tDCS targeting the right cerebellar (CER) and left ventrolateral prefrontal cortex (PFC) during a challenging FLS suturing with intracorporeal knot tying task. Involving twelve novices with a medical/premedical background (age: 22-28 years, two males, 10 females with one female with left-hand dominance), our investigation sought mechanistic insights into tDCS effects on brain areas related to error-based learning, a fundamental skill acquisition mechanism. The results revealed that right CER tDCS applied to the posterior lobe elicited a statistically significant (q < 0.05) brain response in bilateral prefrontal areas at the onset of the FLS task, surpassing the response seen with sham tDCS. Additionally, right CER tDCS led to a significant (p < 0.05) improvement in FLS scores compared to sham tDCS. Conversely, the left PFC tDCS did not yield a statistically significant brain response or improvement in FLS performance. In conclusion, right CER tDCS demonstrated the activation of bilateral prefrontal brain areas, providing valuable mechanistic insights into the effects of CER tDCS on FLS peformance. These insights motivate future investigations into the effects of CER tDCS on error-related perception-action coupling through directed functional connectivity studies.

Modification of Fundamentals of Laparoscopic Surgery Manual Tasks Simulation Curriculum With the Addition of the Vaginal Cuff Closure Training

Fundamentals of Laparoscopic Surgery (FLS) is a multiple-choice test and a manual skills exam using simulation that Obstetrics and Gynecology (OBGYN) residents must pass to qualify for board certification. There is insufficient validity evidence supporting the use of FLS as a high-stakes exam. This study examines the correlation between OBGYN residents' performance on the FLS manual tasks and simulated vaginal cuff closure. We compared residents' performance on FLS tasks with simulated vaginal cuff suturing on a model. During the first coached simulation session, after completion of training on the standard 5 FLS tasks, residents were coached on vaginal cuff closure using a simulated model placed inside the standard FLS box trainer. At a subsequent session, their performance was scored using the Global Operative Assessment of Laparoscopic Skills Scale (GOALS) and a second task-specific metric, and these scores were compared to their official FLS score. Twenty-nine residents completed the vaginal cuff simulation training between June 2019 and November 2021. Nineteen of the 29 were able to complete the cuff closure with the mean time to completion being 14.5 minutes. We found no correlation between official manual skills FLS scores and vaginal cuff GOALS scores (rho = -0.02, p = 0.90) or cuff closure assessment tool score (rho = -0.015, p = 0.048). There was also no correlation between time to completion for any FLS task and vaginal cuff closure OSAT scores. All residents reported that they found the cuff to be a useful addition to the FLS curriculum. Our study demonstrated that trainee performance on a simulated vaginal cuff closure model did not correlate with official FLS manual tasks skills. This finding adds to the body of evidence disputing the use of FLS as a high-stakes exam to assess laparoscopic skills in gynecology in the relationship with other variables category.

Assessment of Surgical Tasks Using Neuroimaging Dataset (ASTaUND)

Functional near-infrared spectroscopy (fNIRS) is a neuroimaging tool for studying brain activity in mobile subjects. Open-access fNIRS datasets are limited to simple and/or motion-restricted tasks. Here, we report a fNIRS dataset acquired on mobile subjects performing Fundamentals of Laparoscopic Surgery (FLS) tasks in a laboratory environment. Demonstrating competency in the FLS tasks is a prerequisite for board certification in general surgery in the United States. The ASTaUND data set was acquired over four different studies. We provide the relevant information about the hardware, FLS task execution protocols, and subject demographics to facilitate the use of this open-access data set. We also provide the concurrent FLS scores, a quantitative metric for surgical skill assessment developed by the FLS committee. This data set is expected to support the growing field of assessing surgical skills via neuroimaging data and provide an example of data processing pipeline for use in realistic, non-restrictive environments.

Performance and learning rate prediction models development in FLS and RAS surgical tasks using electroencephalogram and eye gaze data and machine learning

ObjectiveThis study explored the use of electroencephalogram (EEG) and eye gaze features, experience-related features, and machine learning to evaluate performance and learning rates in fundamentals of laparoscopic surgery (FLS) and robotic-assisted surgery (RAS).MethodsEEG and eye-tracking data were collected from 25 participants performing three FLS and 22 participants performing two RAS tasks. Generalized linear mixed models, using L1-penalized estimation, were developed to objectify performance evaluation using EEG and eye gaze features, and linear models were developed to objectify learning rate evaluation using these features and performance scores at the first attempt. Experience metrics were added to evaluate their role in learning robotic surgery. The differences in performance across experience levels were tested using analysis of variance.ResultsEEG and eye gaze features and experience-related features were important for evaluating performance in FLS and RAS tasks with reasonable results. Residents outperformed faculty in FLS peg transfer (p value = 0.04), while faculty and residents both excelled over pre-medical students in the FLS pattern cut (p value = 0.01 and p value < 0.001, respectively). Fellows outperformed pre-medical students in FLS suturing (p value = 0.01). In RAS tasks, both faculty and fellows surpassed pre-medical students (p values for the RAS pattern cut were 0.001 for faculty and 0.003 for fellows, while for RAS tissue dissection, the p value was less than 0.001 for both groups), with residents also showing superior skills in tissue dissection (p value  = 0.03).ConclusionFindings could be used to develop training interventions for improving surgical skills and have implications for understanding motor learning and designing interventions to enhance learning outcomes.Graphical abstract

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

Role of video self-assessment in laparoscopic simulation training: a randomized pilot trial

Residency programs have implemented simulation training to compensate for reduced operating room exposure. Video recording is an educational tool that can be utilized for coaching, telepresence, and self-assessment during simulation training. Data is limited on the utility of video recording and self-assessment for laparoscopic training in Ob/Gyn residency programs.. This study aimed to determine the role of video self-assessment as an educational tool in laparoscopic simulation training and to establish the feasibility of our study design for a larger randomized controlled trial. This was a prospective pilot study with a parallel, randomized, trial design that occurred in the Department of Obstetrics and Gynecology at the Mount Sinai Hospital. Subject participation took place in a surgical simulation training room. A total of 23 subjects were recruited (7 medical students, 15 residents, 1 fellow) voluntarily. All participants completed the study. All the subjects completed a pretest survey. The surgical simulation room contained a single Fundamentals of Laparoscopic Surgery box trainer and video-recording station. For session #1, each participant performed 2 Fundamentals of Laparoscopic Surgery tasks (A, peg transfer; B, intracorporeal knot tie). Participants were video recorded during session #1 and were randomized to either receive or not receive their video recording. The video group (n=13) and control group (n=10) repeated the Fundamentals of Laparoscopic Surgery tasks 7 to 10 days later (session #2). The primary outcome was percentage change in completion time between sessions. Secondary outcomes were percentage change in peg and needle drops between sessions. The participant characteristics (video vs control) were as follows: average training level (6.15 vs 4.90 years), self-assessment (1=poor, 10=excellent) of surgical skill (4.8 vs 3.7), and laparoscopic skill (4.4 vs 3.5). Training level was inversely correlated with completion time for tasks A and B (r, -0.79 and -0.87; P<.0001). Less experienced trainees required the maximum time allotted for each task in session #1 (A, 3; B, 13). Regarding the primary outcome, the video group improved less than the control group (A, 16.7% vs 28.3%; B, 14.4% vs 17.3%). After controlling for training level (residents only), the video group improved more in the primary outcome (A, 17% vs 7.4%; B, 20.9% vs 16.5%) and secondary outcomes (A, 0.0% vs -194.1%; B, 41.3% vs 37.6%). Video self-assessment has a potential role in simulation training for obstetrics-gynecology residents. With key improvements, the feasibility of our study design was demonstrated in preparation for a future definitive trial.

Virtual fundamentals of laparoscopic surgery (FLS) boot-camp using telesimulation: an educational solution during the COVID-19 pandemic.

The Fundamentals of Laparoscopic Surgery (FLS) is an internationally recognized educational and certification program designed to teach the knowledge and skills required for basic laparoscopic surgery. Previously, our institution has organized an FLS boot-camp to teach PGY1 residents the FLS manual skills. During the COVID-19 pandemic, in-person sessions were not possible. The purpose of this study was to utilize telesimulation as an education solution for teaching FLS technical skills to PGY1 residents during the COVID-19 pandemic. A virtual FLS program was established. A complete, easily portable FLS kit was distributed to participantsand instructors to set up an FLS box and connect remotely using telesimulation. The program was delivered by three senior residents using the Zoom™ platform. Participants were split into groups of 3-4 individuals, each receiving three 1-h sessions. Sessions were structured with initial demonstration of tasks followed by individual coaching of participants in 'break-out' rooms. The official FLS exam was administered in-person on the 4th week. Pre- and post-course surveys were administered to participants gauging self-reported proficiency with FLS tasks and overall course feedback. Anonymized FLS exam results were collected. A total of 14 residents participated, and 11 responded to the survey. Participants reported that their overall FLS skills proficiency significantly improved on a 5-point likert scale from 1.5 ± 0.5 pre-course to 4.0 ± 0.5 post-course (mean ± SD). Participants unanimously stated that having the FLS box at home was valuable and enabled them to practice more. On the FLS exam, 13 of 14 participants passed the manual skills component. We developed a telesimulation hands-on FLS course as an alternative to in-person training. The course was practical and effective and was preferred to traditional methods by participants. With ever-expanding technological solutions, virtual telesimulation education is an attractive and underutilized tool, not only in the setting of COVID-19, but also more broadly across current educational programs.

Performance in the Fundamentals of Laparoscopic Surgery: Does it reflect global rating scales in the Objective Structured Assessment of Technical Skills in porcine laparoscopic surgery?

ObjectiveTo correlate the utility of the Fundamentals of Laparoscopic Surgery (FLS) manual skills program with the Objective Structured Assessment of Technical Skills (OSATS) global rating scale in evaluating operative performance. MethodsThe Asian Urological Surgery Training and Educational Group (AUSTEG) Laparoscopic Upper Tract Surgery Course implemented and validated the FLS program for its usage in laparoscopic surgical training. Delegates’ basic laparoscopic skills were assessed using three different training models (peg transfer, precision cutting, and intra-corporeal suturing). They also performed live porcine laparoscopic surgery at the same workshop. Live surgery skills were assessed by blinded faculty using the OSATS rating scale. ResultsFrom March 2016 to March 2019, a total of 81 certified urologists participated in the course, with a median of 5 years of post-residency experience. Although differences in task time did not reach statistical significance, those with more surgical experience were visibly faster at completing the peg transfer and intra-corporeal suturing FLS tasks. However, they took longer to complete the precision cutting task than participants with less experience. Overall OSATS scores correlated weakly with all three FLS tasks (peg transfer time: r=−0.331, r2=0.110; precision cutting time: r=−0.240, r2=0.058; suturing with intra-corporeal knot time: r=−0.451, r2=0.203). ConclusionFLS task parameters did not correlate strongly with OSATS globing rating scale performance. Although the FLS task models demonstrated strong validity, it is important to assimilate the inconsistencies when benchmarking technical proficiency against real-life operative competence, as evaluated by FLS and OSATS, respectively.

8895 Fundamentals of Laparoscopic Surgery for Senior Medical Students Entering Surgical Residency

<h3>Study Objective</h3> The Fundamentals of Laparoscopic Surgery (FLS) is mandatory for OBSTETRICS AND GYNECOLOGY residency. We aimed to evaluate the usefulness of FLS for fourth year medical students to gain confidence and to determine quantitative improvement in FLS tasks and exam. <h3>Design</h3> On the first and last day of the course, students completed a Likert scale (1-10) self-assessment rating confidence in knowledge of laparoscopy, confidence in technical laparoscopic skills, and satisfaction with laparoscopic training during medical school. Students also completed the FLS written assessment. For two weeks, students had didactics and practiced the five practical tasks on FLS trainers: peg transfer, circle cutting, endoloop, extracorporeal and intracorporeal knot tying. Pre and post practice times were recorded. Students were evaluated by OBSTETRICS AND GYNECOLOGY faculty mentors with a pre and post validated global assessment tool per FLS task. <h3>Setting</h3> Fourth year medical school elective in an academic setting. <h3>Patients or Participants</h3> Sixteen fourth year medical students enrolled in the two-week FLS elective course over two years (2021-2022). <h3>Interventions</h3> Participants received daily didactic lessons taught by OBSTETRICS AND GYNECOLOGY faculty, as well as guided practice sessions utilizing laparoscopic task trainers. All interventions were measured pre and post didactic sessions. <h3>Measurements and Main Results</h3> Overall, students felt more confident in their combined laparoscopic knowledge, skills, and training assessment following the course (2.3 (1.7) vs. 6.1 (2.0), p<0.001). Students showed improvement on the written exam (.62 (.10) vs. .87 (.06), p<0.001). The mean time to complete all five of the FLS tasks decreased (seconds, 247 (135) vs. 143 (102), p<0.001). Finally, the average combined faculty global rating assessment of the students' performance improved (2.3 (0.4) vs. 3.9 (0.3), p<0.001). Feedback from students was universally positive. <h3>Conclusion</h3> Implementing the FLS curriculum for fourth year medical students increases confidence in laparoscopic knowledge and performance of technical skills prior to entering a surgical residency.

The evaluation of the correlation between origami crane training and Fundamentals of Laparoscopic Surgery (FLS)

ObjectiveHow does making origami cranes under a dry box affect Fundamentals of Laparoscopic Surgery (FLS) scores in medical students? DesignFour medical students from Asahikawa Medical University (tertiary hospital) participated. They made origami cranes under a dry box (origami crane training) five days per week for four weeks. The time required to make each origami crane (origami crane time) and degree of completion were evaluated. FLS scores were measured before training and on days 5, 10, 15, and 20. We examined the relationship between “origami crane training” and FLS scores. ResultsAt the beginning of the experiment, none of the participants could complete the origami crane, but they were able to complete it in 31 ± 7 min on day 20. The Total FLS score was 164 ± 48 before the start of training, and 1107 ± 112 on day 20. The average scores of the students closely approached the Proficiency Level for the FLS tasks of peg transfer, loop ligation and extracorporeal ligation (103→228, 61→137, 0→259). The change over time in the average of the increase in Total FLS Score (difference from the first time and each week’s score) improved significantly in four weeks (P < 0.01). ConclusionsOrigami crane training improved the medical students' FLS scores. We thought that origami crane training mainly enhanced hand-eye coordination and bi-hand coordination.

Error related fNIRS-EEG microstate analysis during a complex surgical motor task.

Fundamentals of Laparoscopic Surgery (FLS) is a standard education and training module with a set of basic surgical skills. During surgical skill acquisition, novices need to learn from errors due to perturbations in their performance which is one of the basic principles of motor skill acquisition. This study on thirteen healthy novice medical students and nine expert surgeons aimed to capture the brain state during error epochs using multimodal brain imaging by combining functional near-infrared spectroscopy (fNIRS) and electroencephalography (EEG). We performed error-related microstate analysis in the latent space that was found using regularized temporally embedded Canonical Correlation Analysis from fNIRS-EEG recordings during the performance of FLS "suturing and intracorporeal knot-tying" task - the most difficult among the five psychomotor FLS tasks. We found from two-way analysis of variance (ANDVA) with factors, skill level (expert, novice), and microstate type (1-6) that the proportion of the total time spent in microstates in the error epochs was significantly affected by the skill level ( ), microstate type ( ), and the interaction between the skill level and the microstate type ( ). Therefore, our study highlighted the relevance of portable brain imaging to capture error behavior when comparing the skill level during a complex surgical task. Clinical Relevance-This establishes the brain-behavior relationship for monitoring complex surgical motor task errors that differentiated experts from novices.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial.

Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6weeks later. Outcomes included previously validated FLS scores and hand-motion analyses. All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445. Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Merged virtual reality teaching of the fundamentals of laparoscopic surgery: a randomized controlled trial.

BackgroundThe COVID-19 pandemic challenges our ability to provide surgical education, as our ability to gather and train together has been restricted due to safety concerns. However, the importance of quality surgical education has remained. High-fidelity simulation platforms have been developed that merge virtual reality video streams to allow for remote instruction and collaboration. This study sought to validate the use of a merged virtual reality (MVR) platform for the instruction and assessment of the fundamentals of laparoscopic surgery (FLS) skills.MethodsThis was a prospective randomized controlled non-inferiority study. Thirty participants were randomized between three groups: The standard group received in-person instruction and expert feedback, the experimental group received identical training via the MVR platform, and the control group practiced on their own, but received no feedback. All participants were pre-tested for baseline performance at the beginning of the study. Change in performance was evaluated immediately after training and one month later for retention. Ordinary one-way analysis of variance was used to evaluate the effects of time, group, and time-on-group.ResultsThe pre-test confirmed baseline homogeneity between the groups. MVR was non-inferior to standard in-person training for total FLS times on either the post-test (p = 0.632) or the retention test (p = 0.829). Performance was also identical between MVR and standard training groups for each of the individual FLS tasks. Each group improved significantly in nearly all tasks after practice; however, the standard and MVR training groups both improved significantly more than controls for the ligating loop, extracorporeal suturing, intracorporeal suturing, and total FLS task training but did not reach statistical significance for peg transfer and pattern cut tasks.ConclusionThis randomized, controlled trial has demonstrated the use of an MVR platform as non-inferior to in-person instruction for the FLS program, forming the foundation for future work on remote instruction and collaboration.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-021-08939-4.

Implementing FLS Training Protocol for Minimally Invasive GYN Surgery Training

Study Objective The number of minimally invasive surgeries required for residents has increased alongside the requirement of passing the Fundamentals of Laparoscopic Surgery (FLS) program for board certification in Obstetrics and Gynecology (OBGYN) programs. Simulation training has been proposed as a method to increase the proficiency of training surgeons; however, no gynecologic simulation models have been validated. We hypothesized that 24-hour access to the FLS trainer would improve the residents’ times to complete the standardized FLS tasks and improve first time pass rates, and that increased training time would increase resident confidence. Design We performed an observational prospective study. Each resident was timed on the FLS tasks and surveyed to assess confidence each quarter. We compared first time pass rates of the FLS exam for residents who took the exam prior to having access to the trainer to the first-time pass rates of the residents who did have access to the trainer. Setting N/A. Patients or Participants 20 residents were enrolled. During the study period, 1 resident left the program. Interventions N/A. Measurements and Main Results There was no statistical significance between first time pass rates for the FLS exam. Paired t-test was used and found no significant differences in timed task completion or survey question. Conclusion Voluntary simulation-based training was not an effective way to improve gynecologic surgical skills during this study. We suspect this to be a result of lack of defined structure, limited free time, and challenges due to the COVID 19 pandemic. There were low compliance rates of the residents using the FLS trainer and no significant improvement in the time required to finish the standardized FLS tasks, first time pass rates on the FLS exam, or resident confidence levels measured by survey results. More research is needed to evaluate barriers to simulation training to improve minimally invasive surgical skills The number of minimally invasive surgeries required for residents has increased alongside the requirement of passing the Fundamentals of Laparoscopic Surgery (FLS) program for board certification in Obstetrics and Gynecology (OBGYN) programs. Simulation training has been proposed as a method to increase the proficiency of training surgeons; however, no gynecologic simulation models have been validated. We hypothesized that 24-hour access to the FLS trainer would improve the residents’ times to complete the standardized FLS tasks and improve first time pass rates, and that increased training time would increase resident confidence. We performed an observational prospective study. Each resident was timed on the FLS tasks and surveyed to assess confidence each quarter. We compared first time pass rates of the FLS exam for residents who took the exam prior to having access to the trainer to the first-time pass rates of the residents who did have access to the trainer. N/A. 20 residents were enrolled. During the study period, 1 resident left the program. N/A. There was no statistical significance between first time pass rates for the FLS exam. Paired t-test was used and found no significant differences in timed task completion or survey question. Voluntary simulation-based training was not an effective way to improve gynecologic surgical skills during this study. We suspect this to be a result of lack of defined structure, limited free time, and challenges due to the COVID 19 pandemic. There were low compliance rates of the residents using the FLS trainer and no significant improvement in the time required to finish the standardized FLS tasks, first time pass rates on the FLS exam, or resident confidence levels measured by survey results. More research is needed to evaluate barriers to simulation training to improve minimally invasive surgical skills

Evaluation and usability study of low-cost laparoscopic box trainer “Lap-Pack”: a 2-stage multicenter cohort study

Introduction: Laparoscopic training is restricted in low resource settings due to limited access to specialist training equipment and financial constraints. This study aimed to evaluate simulation skills and usability of an original low-cost laparoscopic trainer, the “Lap-Pack,” developed at the University of Leeds, UK. Methods: Stage I evaluation was conducted in Kolkata (India) between March, 12 and 14, 2019. Laparoscopic simulation training was based on the 5 domains of fundamentals of laparoscopic surgery (FLS), which assessed skill acquisition across 7 rural surgeons from North-East India. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) criteria was used to statistically analyze trainee performance between pretraining and posttraining sessions. Also, Lap-Pack was qualitatively compared with a commercial box trainer, Inovus Pyxus HD (IPHD). Stage II involved a multi-center usability study in 2 centers of India and the United Kingdom (2019). Seventy-eight participants performed 2 FLS tasks using Lap-Pack and provided scores on a 25-point questionnaire, including a preestablished Face-Validity Criteria and 4 evaluation categories—Usability, Camera, View, and, Material. Results: In stage I, the total posttraining MISTELS score for Lap-Pack was higher, that is 773.37 (SD: 183.67) than pretraining score, that is 351.2 (SD: 471.5). The posttraining scores showed laparoscopic skill acquisition with statistically significant (P&lt;0.05) difference for precision cutting, intracorporeal and extracorporeal knot. In stage II, Lap-Pack scored highly in Face-Validity with a combined mean score of 4.81 [95% confidence interval (CI): 4.52–5.09, P&lt;0.05] out of a possible 6. It scored highest (scale: 1=low to 7=high) in Usability 6.14 (95% CI: 6.05–6.22, P&lt;0.05) and Camera 6.14 (95% CI: 6.01–6.27, P&lt;0.05). The “Lightweight” (6.46, 95% CI: 6.32–6.60, P&lt;0.05) and “Portability” (6.35, 95% CI: 6.18–6.51, P&lt;0.05) features of Lap-Pack were appreciated. Conclusion: The Lap-Pack is a suitable low fidelity simulator for laparoscopic training in a low-resource setting.

Correcting the Fundamentals of Laparoscopic Surgery “Illusion of Validity” in Laparoscopic Vaginal Cuff Suturing

The "illusion of validity" is a cognitive bias in which the ability to interpret and predict surgical performance accurately is overestimated. To address this bias, we assessed participants comparing fundamentals of laparoscopic surgery (FLS) and non-FLS tasks with cadaveric vaginal cuff suturing to determine the most representative simulation task for laparoscopic vaginal cuff suturing. Validity (Messick framework) study comparing FLS and non-FLS tasks with cadaveric vaginal cuff suturing. Simulation center cadaver laboratory. Obstetrics and gynecology residents (n=21), minimally invasive gynecologic surgery fellows (n=3), gynecologic surgical subspecialists (n=4), general obstetrician/gynecologists (n=10). Tasks included a simulated vaginal cuff (ipsilateral port placement), needle passage through a metal eyelet loop (contralateral and ipsilateral), and intracorporeal knot tying (contralateral and ipsilateral). Simulation task times were compared with the placement of the first cadaveric vaginal cuff suture time, as well as the in-person and blinded Global Operative Assessment of Laparoscopic Skills (GOALS) score ("relations to other variables" validity evidence). Statistical analyses included Spearman's test of correlation (continuous and ordinal variables) or Wilcoxon rank sum test (categoric variables). There was a stronger association with cadaver cuff suturing time for simulated vaginal cuff suturing time (r=0.73, p <.001) compared with FLS intracorporeal contralateral suturing time (r=0.54, p <.001). Additional measures associated with cadaveric performance included subspecialty training (median: 82 vs 185 seconds, p=.002), number of total laparoscopic hysterectomies (r=-0.53, p <.001), number of laparoscopic cuff closures (r=-0.61, p <.001), number of simulated laparoscopic suturing experiences (r=-0.51, p <.001), and eyelet contralateral time (r=0.52, p <.001). Strong agreement between the in-person and blinded GOALS (intraclass correlation coefficient=0.80) supports response process evidence. Correlations of cadaver cuff time with in-person (Spearman's r=-0.84, p <.001) and blinded GOALS (r=-0.76, p <.001) supports relations to other variables evidence CONCLUSION: The weaker correlation between FLS suturing and cadaver cuff suturing compared with a simulated vaginal cuff model may lead to an "illusion of validity" for assessment in gynecology. Since gynecology specific validity evidence has not been well established for FLS, we recommend prioritizing the use of a simulated vaginal cuff suturing assessment in addition to FLS.

Modification of Fundamentals of Laparoscopic Surgery Manual Skills Curriculum with Addition of a Vaginal Cuff Closure Task.

Study Objective Obstetrics and gynecology (OBGYN) residents are required to pass a Fundamentals of Laparoscopic Surgery (FLS) exam to qualify for written boards. FLS exam validity evidence has been questioned recently and concerns have been raised with its applicability to gynecologic surgical training. We present preliminary data from a pilot study which aims to correlate performance on FLS manual skills to a vaginal cuff closure model in a simulated setting. Design Prospective descriptive study Setting OBGYN residency program at a large urban academic medical center. Patients or Participants OBGYN residents in post-graduate year three. Interventions In addition to the standard five FLS tasks, participants are introduced to a previously studied vaginal cuff closure model during a teaching session. Before taking FLS exam, they are evaluated on a cuff closure using the modified Global Operative Assessment of Laparoscopic Skills (GOALS) and a task-specific checklist. After assessment, residents filled out a usability survey. Measurements and Main Results Seven residents participated between July and December 2019. The mean time to completion of the cuff closure was 14.6 minutes (SD= 2.2 minutes) and range of 12.5 to 18.5 minutes. In our sample size of 7, we did not detect a correlation between official composite FLS and vaginal cuff scores as measured with GOALS (rho = 0.1070, p = 0.819) or the checklist (rho = 0.359, p = 0.429). All residents found the cuff to be a useful addition to curriculum and preferred to replace an FLS task with the cuff model. We plan to continue enrollment of 11 residents per year for four years, to reach a sample size of 44. Conclusion In this preliminary analysis of a pilot study, we did not find a correlation between performance on a vaginal cuff task trainer and FLS manual skills. Residents preferred cuff closure to FLS tasks.

Basic Laparoscopic Skills Training Is Equally Effective Using 2D Compared to 3D Visualization: A Randomized Controlled Trial.

Reduced depth perception due to two-dimensional (2D) visualization of a three-dimensional (3D) space represents a main challenge in acquiring basic laparoscopic skills (BLS); 3D visualization might increase training efficiency. This study aimed to assess whether BLS training on a standard box trainer using 2D is at least equally effective compared to 3D. Medical students were randomized to training of Fundamentals of Laparoscopic Surgery (FLS) tasks using either 2D or 3D for four weeks. Baseline and post-training tests were performed using the assigned visualization modality. Data of 31 participants were analyzed (n = 16 2D, n = 15 3D). Baseline test scores did not differ significantly between groups; only at the peg transfer task and total scores, the 3D group performed better than the 2D group. All scores improved significantly in both groups, with post training scores not differing significantly between groups. Non-inferiority of 2D compared to 3D was demonstrated for total score improvement and improvement in all individual FLS tasks except for suturing with extracorporeal knot tying. Post training test performance did not change significantly when changing to the unfamiliar modality. In conclusion, BLS training using standard 2D is at least equally effective as with 3D, without significant disadvantages when changing to the other modality.

Muscle fatigue and performance analysis during fundamental laparoscopic surgery tasks

The goal of this study is to detect muscle fatigue and time-to-fatigue in vulnerable muscle groups, before determining whether the former has any effect on surgical performance. In the experiment, surface electromyography (sEMG) was deployed to record the muscle activations of 12 subjects while performing fundamentals of laparoscopic surgery (FLS) tasks for a total of three hours. In all, 16 muscle groups were tested. The resultant data were then reconstructed using recurrence quantification analysis (RQA). In addition, a subjective fatigue assessment was conducted to draw comparisons with the RQA results. The subjects' performance was also investigated via a FLS task performance analysis, the results demonstrating that RQA can detect muscle fatigue in 12 muscle groups as well as their time-to-fatigue. The results also indicated that RQA and subjective fatigue assessment are very closely correlated (p-value < 0.05). However, the performance analysis results showed that the subjects' performance improved over time.

Career Interest and Psychomotor Aptitude Among Medical Students

The primary objective is to assess psychomotor aptitude of medical students interested in pursuing a procedural career. Secondary objectives include exploring the relationship between actual and perceived aptitude, and identifying predictors of superior aptitude. This is a cross-sectional, multisite study in which participants completed a paper survey, four visuospatial aptitude assessments, and a laparoscopic simulation modeled after the Fundamentals of Laparoscopic Surgery (FLS) peg transfer test (used as a proxy for psychomotor aptitude). Johns Hopkins University School of Medicine and Mayo Clinic School of Medicine. All second-year medical students who had not yet initiated clinical rotations were eligible. Sixty-four students participated. Students interested in a procedural career exhibited superior psychomotor aptitude (faster FLS task completion time), and a majority of these students correctly identified themselves as having above-average aptitude compared with peers. However, over one quarter of all students, regardless of career interest, incorrectly over- or under-rated their psychomotor aptitude. Upon completing their preclinical curriculum, a minority of students felt prepared to participate or assist in their surgical clinical rotations. Prior to embarking on their clinical rotations, over one quarter of medical students lack awareness of their psychomotor aptitude and many do not feel prepared to participate in the next phase of their training. Early aptitude testing and introduction to laparoscopic training may assist in career selection, preparedness, and success.