Fundamentals Of Laparoscopic Surgery Research Articles

Implementation, satisfaction, and attitudes towards fundamentals of laparoscopic surgery (FLS) for obstetrics and gynecology (OB/GYN) residencies in the united states

Implementation, satisfaction, and attitudes towards fundamentals of laparoscopic surgery (FLS) for obstetrics and gynecology (OB/GYN) residencies in the united states

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.

A Summative Assessment of the Pattern-Cutting Task in Laparoscopic Box Trainer using Color Tracking and Fuzzy Logic

In Minimally Invasive Surgery (MIS), surgeons should acquire many skills before carrying out a real operation. The Fundamentals of Laparoscopic Surgery (FLS) tasks are currently used as an assessment tool for laparoscopic skills. However, the current training methods still require the presence of an expert surgeon to assess the surgical dexterity of the trainee. This process is time-consuming and may lead to subjective assessment. This research aims to extend the application of image processing and analysis methods to detect and track the tips of the laparoscopic instruments and to localize the circle center to calculate the distance between the scissors' tips and the circle's center in each processed frame. The data obtained will feed the fuzzy system to assess the trainer’s performance with a processing speed of 4 frames per second. The proposed system can provide a final text report that lists an error counter value and the fuzzy assessment at each time slot of 0.29 s on average. Additionally, a BMP image that summarizes the tips of the scissors within the predefined circles during the test is created. Finally, a Canny edge detector is applied to detect whether any circle line was cut during the test. This work enables a summative assessment of the precision-cutting task without altering the original setup of the FLS box trainer. Additionally, this can expedite the development of surgery skills and assess the trainees’ performance using a single-input-single-output fuzzy logic system. The output of the fuzzy logic assessment is the performance evaluation for the surgeon, and it is quantified in percentages.

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.

Automatic assessment of performance in the FLS trainer using computer vision.

Fundamentals of Laparoscopic Surgery (FLS) box trainer is a well-accepted method for training and evaluating laparoscopic skills. It mandates an observer that will measure and evaluate the trainee's performance. Measuring performance in the Peg Transfer task includes time and penalty for dropping pegs. This study aimed to assess whether computer vision (CV) may be used to automatically measure performance in the FLS box trainer. Four groups of metrics were defined and measured automatically using CV. Validity was assessed by dividing participants to 3 groups of experience levels. Twenty-seven participants were recorded performing the Peg Transfer task 2-4 times, amounting to 72 videos. Frames were sampled from the videos and labeled to create an image dataset. Using these images, we trained a deep neural network (YOLOv4) to detect the different objects in the video. We developed an evaluation system that tracks the transfer of the triangles and produces a feedback report with the metrics being the main criteria. The metric groups were Time, Grasper Movement Speed, Path Efficiency, and Grasper Coordination. The performance was compared based on their last video (3 participants were excluded due to technical issues). The ANOVA tests show that for all metrics except one, the variance in performance can be explained by the experience level of participants. Senior surgeons and residents significantly outperform students and interns on almost every metric. Senior surgeons usually outperform residents, but the gap is not always significant. The statistical analysis shows that the metrics can differentiate between the experts and novices performing the task in several aspects. Thus, they may provide a more detailed performance analysis than is currently used. Moreover, these metrics calculation is automatic and relies solely on the video camera of the FLS trainer. As a result, they allow independent training and assessment.

Preparing for and passing the fundamentals of laparoscopic surgery (FLS) exam improves general surgery resident operative performance and autonomy.

The American Board of Surgery made the Fundamentals of Laparoscopic Surgery (FLS) exam a prerequisite for board certification in 2009. Some residency programs have questioned the need for a continued FLS testing mandate given limited evidence that supports the impact of FLS on intraoperative skills. The Society for Improving Medical Professional Learning (SIMPL) app is a tool to evaluate resident intraoperative performance. We hypothesized that general surgery resident operative performance would improve immediately after preparing for the FLS exam. The national public FLS data registry was matched with SIMPL resident evaluations from 2015 to 2021 and de-identified. SIMPL evaluations are scored in three categories: supervision required (Zwisch scale 1-4, 1 = show and tell and 4 = supervision only), performance (scale 1-5, 1 = exceptional and 5 = unprepared), and case complexity (scale 1-3, 1 = easiest and 3 = hardest). Statistical analyses compared pre and post-FLS exam resident average operative evaluation scores. There were a total of 76 general surgery residents, and 573 resident SIMPL evaluations included in this study. Residents required more supervision in laparoscopic cases performed before compared to after the FLS exam (2.84 vs. 3.03, respectively, p = 0.007). Residents performance scores improved from cases before compared to after the FLS exam (2.70 vs. 2.43, respectively, p = 0.001). Case complexity did not differ before versus after the FLS exam (2.13 vs. 2.18, respectively, p = 0.202). PGY level significantly predicted evaluation scores with a moderate correlation. A sub analysis grouped by PGY level revealed a significant improvement after the FLS exam in supervision among PGY-2 residents (2.33 vs. 2.58, respectively, p = 0.04) and performance among PGY-4 residents (2.67 vs 2.04, respectively, p < 0.001). Preparation for, and passing, the FLS exam improves resident intraoperative laparoscopic performance and independence. We recommend taking the exam in the first two years of residency to enhance the laparoscopic experience for the remainder of training.

Does practice make perfect? Laparoscopic training mainly improves motion efficiency: a prospective trial

Training improves skills in minimally invasive surgery. This study aimed to investigate the learning curves of complex motion parameters for both hands during a standardized training course using a novel measurement tool. An additional focus was placed on the parameters representing surgical safety and precision. Fifty-six laparoscopic novices participated in a training course on the basic skills of minimally invasive surgery based on a modified Fundamentals of Laparoscopic Surgery (FLS) curriculum. Before, twice during, and once after the practical lessons, all participants had to perform four laparoscopic tasks (peg transfer, precision cut, balloon resection, and laparoscopic suture and knot), which were recorded and analyzed using an instrument motion analysis system. Participants significantly improved the time per task for all four tasks (all p < 0.001). The individual instrument path length decreased significantly for the dominant and non-dominant hands in all four tasks. Similarly, both hands became significantly faster in all tasks, with the exception of the non-dominant hand in the precision cut task. In terms of relative idle time, only in the peg transfer task did both hands improve significantly, while in the precision cut task, only the dominant hand performed better. In contrast, the motion volume of both hands combined was reduced in only one task (precision cut, p = 0.01), whereas no significant improvement in the relative time of instruments being out of view was observed. FLS-based skills training increases motion efficiency primarily by increasing speed and reducing idle time and path length. Parameters relevant for surgical safety and precision (motion volume and relative time of instruments being out of view) are minimally affected by short-term training. Consequently, surgical training should also focus on safety and precision-related parameters, and assessment of these parameters should be incorporated into basic skill training accordingly.

Changes in functional neuroimaging measures as novices gain proficiency on the fundamentals of laparoscopic surgery suturing task.

As trainees practice fundamental surgical skills, they typically rely on performance measures such as time and errors, which are limited in their sensitivity. The goal of our study was to evaluate the use of portable neuroimaging measures to map the neural processes associated with learning basic surgical skills. Twenty-one subjects completed 15 sessions of training on the fundamentals of laparoscopic surgery (FLS) suture with intracorporeal knot-tying task in a box trainer. Functional near infrared spectroscopy data were recorded using an optode montage that covered the prefrontal and sensorimotor brain areas throughout the task. Average oxy-hemoglobin (HbO) changes were determined for repetitions performed during the first week of training compared with the third week of training. Statistical differences between the time periods were evaluated using a general linear model of the HbO changes. Average performance scores across task repetitions increased significantly from the first day to the last day of training ( ). During the first day of training, there was significant lateral prefrontal cortex (PFC) activation. On the final day, significant activation was observed in the PFC, as well as the sensorimotor areas. When comparing the two periods, significant differences in activation ( ) were found for the right medial PFC and the right inferior parietal gyrus. While gaining proficiency, trainees activated the perception-action cycle to build a perceptual model and then apply the model to improve task execution. Learners engaged the sensorimotor areas more substantially as they developed skill on the FLS suturing task. These findings are consistent with findings for the FLS pattern cutting task and contribute to the development of objective metrics for skill evaluation.

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.

Automating Surgical Peg Transfer: Calibration With Deep Learning Can Exceed Speed, Accuracy, and Consistency of Humans

Peg transfer is a well-known surgical training task in the Fundamentals of Laparoscopic Surgery (FLS). While human surgeons teleoperate robots such as the da Vinci to perform this task with high speed and accuracy, it is challenging to automate. This paper presents a novel system and control method using a da Vinci Research Kit (dVRK) surgical robot and a Zivid depth sensor, and a human subjects study comparing performance on three variants of the peg-transfer task: unilateral, bilateral without handovers, and bilateral with handovers. The system combines 3D printing, depth sensing, and deep learning for calibration with a new analytic inverse kinematics model and time-minimized motion controller. In a controlled study of 3384 peg transfer trials performed by the system, an expert surgical resident, and 9 volunteers, results suggest that the system achieves accuracy on par with the experienced surgical resident and is significantly faster and more consistent than the surgical resident and volunteers. The system also exhibits the highest consistency and lowest collision rate. To our knowledge, this is the first autonomous system to achieve “superhuman” performance on a standardized surgical task. All data is available at <uri xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">https://sites.google.com/view/surgicalpegtransfer</uri> Note to Practitioners—This paper presents a new approach to calibrating cable-driven robots based on a combination of 3D printing, depth sensing, inverse kinematics, convex optimization, and deep learning. The approach is applied to calibrating the da Vinci, commercial surgical-assist robot, to automate a standard “pick and place” task. Experiments suggest that the resulting system matches human surgical expert performance in speed and accuracy and significantly outperforms humans in terms of consistency. All details on the system including CAD models, code, and user study data are available online.

Autonomous sequential surgical skills assessment for the peg transfer task in a laparoscopic box-trainer system with three cameras

AbstractIn laparoscopic surgery, surgeons should develop several manual laparoscopic skills before carrying out real operative procedures using a low-cost box trainer. The Fundamentals of Laparoscopic Surgery (FLS) program was developed as a program to assess fundamental knowledge and surgical skills, required for basic laparoscopic surgery. The peg transfer task is a hands-on exam in the FLS program that assists a trainee to understand the relative minimum amount of grasping force necessary to move the pegs from one place to another place without dropping them. In this paper, an autonomous, sequential assessment algorithm based on deep learning, a multi-object detection method, and, several sequential If-Then conditional statements have been developed to monitor each step of a surgeon’s performance. Images from three different cameras are used to assess whether the surgeon executes the peg transfer task correctly and to display a notification on any errors on the monitor immediately. This algorithm improves the performance of a laparoscopic box-trainer system using top, side, and front cameras and removes the need for any human monitoring during a peg transfer task. The developed algorithm can detect each object and its status during a peg transfer task and notifies the resident about the correct or failed outcome. In addition, this system can correctly determine the peg transfer execution time, and the move, carry, and dropped states for each object by the top, side, and front-mounted cameras. Based on the experimental results, the proposed surgical skill assessment system can identify each object at a high score of fidelity, and the train-validation total loss for the single-shot detector (SSD) ResNet50 v1 was about 0.05. Also, the mean average precision (mAP) and Intersection over Union (IoU) of this detection system were 0.741, and 0.75, respectively. This project is a collaborative research effort between the Department of Electrical and Computer Engineering and the Department of Surgery, at Western Michigan University.

3D Autonomous Surgeon’s Hand Movement Assessment Using a Cascaded Fuzzy Supervisor in Multi-Thread Video Processing

The purpose of the Fundamentals of Laparoscopic Surgery (FLS) training is to develop laparoscopic surgery skills by using simulation experiences. Several advanced training methods based on simulation have been created to enable training in a non-patient environment. Laparoscopic box trainers-cheap, portable devices-have been deployed for a while to offer training opportunities, competence evaluations, and performance reviews. However, the trainees must be under the supervision of medical experts who can evaluate their abilities, which is an expensive and time-consuming operation. Thus, a high level of surgical skill, determined by assessment, is necessary to prevent any intraoperative issues and malfunctions during a real laparoscopic procedure and during human intervention. To guarantee that the use of laparoscopic surgical training methods results in surgical skill improvement, it is necessary to measure and assess surgeons' skills during tests. We used our intelligent box-trainer system (IBTS) as a platform for skill training. The main aim of this study was to monitor the surgeon's hands' movement within a predefined field of interest. To evaluate the surgeons' hands' movement in 3D space, an autonomous evaluation system using two cameras and multi-thread video processing is proposed. This method works by detecting laparoscopic instruments and using a cascaded fuzzy logic assessment system. It is composed of two fuzzy logic systems executing in parallel. The first level assesses the left and right-hand movements simultaneously. Its outputs are cascaded by the final fuzzy logic assessment at the second level. This algorithm is completely autonomous and removes the need for any human monitoring or intervention. The experimental work included nine physicians (surgeons and residents) from the surgery and obstetrics/gynecology (OB/GYN) residency programs at WMU Homer Stryker MD School of Medicine (WMed) with different levels of laparoscopic skills and experience. They were recruited to participate in the peg-transfer task. The participants' performances were assessed, and the videos were recorded throughout the exercises. The results were delivered autonomously about 10 s after the experiments were concluded. In the future, we plan to increase the computing power of the IBTS to achieve real-time performance assessment.

24. The Duke Microsurgery Training Model: Curriculum Creation and Implementation

Background: Given the increased emphasis on patient safety within healthcare systems, the ACGME now supports the use of competency-based education models. In surgery, the Fundamentals of Laparoscopic Surgery and Endoscopic Surgery were created to ensure a basic level of competency among graduating general surgery residents. In plastic surgery, despite the highly technical nature of the field, there are no comparable national programs. Regarding microsurgery, currently only 16% of programs require a skills assessment prior to participation in microsurgery in the operating room. Furthermore, 77% of residents think that a comprehensive, multi-year training curriculum would be beneficial. Therefore, our goal was to create a comprehensive, multi-year curriculum for Duke Plastic Surgery residents to develop microsurgery skills. Methods: The Duke Microsurgery Training Model was created by evaluating currently published curricula for microsurgery training including currently available skills simulations and assessment rubrics. They were then adapted into a proposed multi-year microsurgery curriculum for a 6-year integrated residency program to support the development of microsurgery skills. Results: We developed a 6-year microsurgery curriculum that will be implemented over the course of this year. Based on the curriculum, each class has one dedicated teaching session in the microsurgery lab to work on a pre-defined set of level appropriate skills. Additionally, the PGY 1/2 classes will have a dedicated introduction to microsurgery including the standard instruments and use and the microscope use. The curriculum will be evaluated using standardized survey data and will be iteratively improved based on resident feedback. Further, each resident will be video recorded performing an end-to-end anastomosis at the end of each year. These will be reviewed and graded in a blinded manner using the Stanford Microsurgery and Resident Training Scale (SMaRT). The grades will be released to the residents yearly as part of their comprehensive feedback. Conclusion: Creation and implementation of the Duke Microsurgery Training Model will allow Duke to create a standardized and competency-based training model for the highly technical skill of microsurgical anastomosis. Using this model, we hope to have the junior residents become proficient in microsurgical skills before performing these skills intraoperatively.

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.

The Economy of Motion for Laparoscopic Ball Clamping Surgery: A Feedback Educational Tool

The Ball Clamping module of the Laparoscopic Surgery Training Box involves the transfer of beads across the training board using laparoscopic tools. Fundamentals of Laparoscopic Surgery (FLS) requires practitioners to move their hands at as short a distance as possible to perform the functions in the shortest amount of time. This study introduces a feedback tool that presents to the student, after attempting their exam, the right direction (step by step) of obtaining the optimal pathway for minimizing distance traveled in the Ball Clamping Module of the Laparoscopic Surgery Training Box. The shortest distance tour for the ball clamping task is determined using the Traveling Salesman Model (TSM). A sensitivity analysis is conducted to assess the model's applicability to different types and settings of trainer boxes.•Find the best sequence of points resulting in the shortest distance tour for the ball clamping task.•The effects of adding or removing columns from the box cannot be intuitively predicted.

SuSiPed: An initial step towards a universal, low-cost, 3D-printable platform for pediatric minimal-invasive surgery training

BackgroundTraining platforms such as the Fundamentals of Laparoscopic Surgery have become an integral part of postgraduate adult general surgical education. So far, however, there is no such universal tool for pediatric minimal-invasive surgery (MIS). We therefore designed and validated a novel 3D printable pediatric MIS simulation program. MethodsThe SuSiPed (Surgical Simulation in Pediatrics) curriculum consists of 6 MIS training modules: camera guidance, shell transfer, figure cutting, cyst resection, single interrupted suturing, and slipknot suturing. All modules can be 3D printed, and thus manufactured in a low-cost, sustainable and reproducible fashion. Instructional videos for the participants for each module were created. For validation, a group of medical students and surgical residents were compared to a group of pediatric surgical specialists with experience in MIS. All participants performed the entire SuSiPed curriculum 3 times, measuring time to task completion and technical mistakes. The results of the last attempt were compared using Welch's T-test. ResultsThere were 25 participants in the novice group and 5 in expert group. Times to task completion were lower in the expert group for all modules except camera guidance. Errors were significantly more frequent during slipknot suturing in the novice group, while there were no difference in the other modules. ConclusionOur novel training platform showed good construct validity for 5 out of 6 modules, while scores of camera navigation was not associated with prior experience. The SuSiPed platform is useful for pediatric minimal-invasive surgery training and evaluation, even in low-resource countries where expensive simulators are not affordable. Level of evidenceLevel III, Validation Study.

Ethiopia's first minimally invasive surgery program: A novel approach in global surgical education

ObjectiveComplex lung diseases are among the leading causes of death in Ethiopia. Access to thoracic surgery is limited, and before 2016 no thoracic surgeons were trained in minimally invasive surgery. A global academic partnership was formed between the University of Toronto and Addis Ababa University. We describe implementation of the first minimally invasive surgery training program in sub-Sahara Africa and evaluate its safety. MethodsWe performed a retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at Addis Ababa University from January 2016 to June 2021. Baseline demographic, diagnostic, operative, and postoperative outcomes including length of stay and complications were compared. ResultsIn our bilateral model of surgical education, training is provided in Ethiopia and Canada over 2 years with a focus on capacity building through egalitarian forms of knowledge exchange. Program features included certification in Fundamentals of Laparoscopic Surgery, high-fidelity lobectomy simulation, and hands-on training. Overall, 41 open and 56 minimally invasive surgery cases were included in the final statistical analysis. The average length of stay in the minimally invasive surgery group was 5.2 days versus 11.0 days in the open group (P < .001). The overall complication rate was 18% in the minimally invasive surgery group versus 39% in the open group (P = .020). ConclusionsWe demonstrated the successful initiation of sub-Sahara Africa's first minimally invasive surgery program in thoracic and upper gastrointestinal surgery and characterize its patient safety. We envision the minimally invasive surgery program as a template to continue expanding global partnerships and improving surgical care in other resource-limited settings.