Global Operative Assessment Of Laparoscopic Skills Score Research Articles

Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study

BackgroundThe learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees.MethodsThis randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores.ResultsThe participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001).ConclusionsStructured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.

Keep it simple: a crosshair on the screen during proctored laparoscopic surgeries.

Inside the operating room, experts use verbal instructions to guide surgical novices through laparoscopic procedures. In this study, we evaluated the use of a crosshair attached to the video monitor, as a hands-free pointing tool to simplify instructions during operation. Ten surgical novices performed two elective laparoscopic cholecystectomies within a week of each other, randomized such that one was performed with and the other without using the crosshair. Directly after operation, questionnaires were completed by the novices and the consultant surgeons. Measures including the comprehensibility of instructions, subjective feeling of safety during preparation, time delays due to different instruction options, and disruptive influence while instructors used the crosshair. Differences in operative performance were evaluated based on the global operative assessment of laparoscopic skills (GOALS) scores. When the crosshair was used, surgical novices had a better understanding of which anatomical structure should be shown (p = 0.028). Operating time (p = 0.222) and feeling of confidence during preparation did not differ with versus without crosshair use (p = 0.081). All participants stated that the crosshair did not negatively affect the field of vision. In terms of the median GOALS score, the operative performance was improved when the crosshair was used compared with verbal instructions only (median 15, IQR (11; 21) vs. median 12, IQR (5; 19), p < 0.001). The crosshair is a simple, inexpensive, and widely available method to improve communication between instructors and novices in everyday training.

Crowd-sourced and expert video assessment in minimally invasive esophagectomy.

Video-based assessment by experts may structurally measure surgical performance using procedure-specific competency assessment tools (CATs). A CAT for minimally invasive esophagectomy (MIE-CAT) was developed and validated previously. However, surgeon's time is scarce and video assessment is time-consuming and labor intensive. This study investigated non-procedure-specific assessment of MIE video clips by MIE experts and crowdsourcing, collective surgical performance evaluation by anonymous and untrained laypeople, to assist procedure-specific expert review. Two surgical performance scoring frameworks were used to assess eight MIE videos. First, global performance was assessed with the non-procedure-specific Global Operative Assessment of Laparoscopic Skills (GOALS) of 64 procedural phase-based video clips < 10min. Each clip was assessed by two MIE experts and > 30 crowd workers. Second, the same experts assessed procedure-specific performance with the MIE-CAT of the corresponding full-length video. Reliability and convergent validity of GOALS for MIE were investigated using hypothesis testing with correlations (experience, blood loss, operative time, and MIE-CAT). Less than 75% of hypothesized correlations between GOALS scores and experience of the surgical team (r < 0.3), blood loss (r = -0.82 to 0.02), operative time (r = -0.42 to 0.07), and the MIE-CAT scores (r = -0.04 to 0.76) were met for both crowd workers and experts. Interestingly, experts' GOALS and MIE-CAT scores correlated strongly (r = 0.40 to 0.79), while crowd workers' GOALS and experts' MIE-CAT scores correlations were weak (r = -0.04 to 0.49). Expert and crowd worker GOALS scores correlated poorly (ICC ≤ 0.42). GOALS assessments by crowd workers lacked convergent validity and showedpoor reliability. It is likely that MIE is technically too difficult to assess for laypeople. Convergent validity of GOALS assessments by experts could also not be established. GOALS might not be comprehensive enough to assess detailed MIE performance. However, expert's GOALS and MIE-CAT scores strongly correlated indicating video clip (instead of full-length video) assessments could be useful to shorten assessment time.

Video Playback as an Educational Tool for Improving Resident Laparoscopic Performance: A Randomized Controlled Trial

Study ObjectiveIn this single-masked randomized controlled study, we evaluate whether watching video recordings of oneself performing Fundamentals of Laparoscopic Skills (FLS) exercises results in an improvement on the 30-point Global Operative Assessment of Laparoscopic Skills (GOALS) assessment among Obstetrics and Gynecology (Ob/Gyn) residents. DesignTwenty-three Ob/Gyn residents in the 2020–2021 academic year completed the FLS exercises while being timed, video recorded, and receiving real-time feedback from an Ob/Gyn faculty member. Baseline GOALS assessment was completed by participants and faculty. After the intervention, all participants then repeated the FLS exercises while being timed and were again scored using the GOALS assessment. Each participant completed the study in a single session. In addition, all participants completed a pre- and post-test survey. SettingUniversity of Louisville Laparoscopic Skills Labortaory. ParticipantsUniversity of Louisville Ob/Gyn residents in the 2020–2021 academic year. InterventionTwelve participants were randomized to the intervention and were allowed to watch their video recording in addition to receiving verbal feedback whereas the remaining 11 received verbal feedback only. Measurements and Main ResultsThere were significant improvements in faculty (p <.01) and self-reported GOALS scores (p <.01) when comparing both the intervention and control group with baseline scores. The intervention group improved by 3.2 points more than that of the control group based on masked faculty evaluation (95% confidence interval, 1.4–5.0 points; p <.01). The difference was not significant in resident self-scores. Overall time improved for all participants (15:54 ± 0.21 minutes before and 13:13 ± 0.14 minutes after), but this difference was not significant between the 2 groups. Higher postgraduate year (PGY) residents reported significantly more comfort performing laparoscopic tasks, earned higher GOALS score (faculty and self-scores), and completed the first set of exercises in less time. A significant interaction between PGY and intervention was detected with improvement in GOALS score most strongly associated with PGY4 residents (p <.01). ConclusionAlthough all learners objectively benefit from watching recordings of themselves performing surgical tasks, advanced learners may benefit the most when video recordings are used as an educational tool.

282. VALIDITY AND RELIABILITY OF CROWD-SOURCED AND EXPERT VIDEO ASSESSMENT IN MINIMALLY INVASIVE ESOPHAGECTOMY USING GLOBAL RATING SCALES

Abstract Minimally Invasive Esophagectomy (MIE) is a complex and technically demanding procedure and implementation is associated with a substantial learning curve. Suboptimal surgical performance in complex minimally invasive procedures has convincingly been related to less favorable patient outcomes. Structured video-based assessment by other surgeons can objectively evaluate surgical performance, but requires a surgeon’s scarce time. This study investigated whether crowdsourcing, collective surgical performance evaluation by anonymous and untrained laypeople, could be a valid alternative for MIE. Two video assessments types were conducted via the C-SATS platform with eight MIE operative videos. First, videos were cut into eight procedural phase-based video clips of maximum ten minutes. These 64 video clips were assessed with the validated Global Operative Assessment of Laparoscopic Skills (GOALS)‘s four domains (depth perception, bimanual dexterity, efficiency and tissue handling) using a 1-5 Likert scale. Each video clip was assessed by a pair of two MIE experts and &amp;gt; 30 crowd workers, recruited via Amazon Mechanical Turk. Second, the same expert pairs assessed the corresponding complete video with the procedure-specific MIE competency assessment tool (MIE-CAT). Experts assessed 128 clips and sixteen complete videos in 3.5 months. Crowd workers assessed 1984 clips in &amp;lt; two days. Expert scores showed a wider range (expert GOALS score range 7.50-19.50 versus 12.84-15.63 for crowds). When comparing experts and crowd workers scores, a poor correlation was found on all domains and total GOALS scores (ICC ≤ 0.42). When correlating GOALS scores with MIE-CAT scores a strong, positive correlation between experts’ scores was found (r¬s = 0.76, p = 0.03) while between crowd’s GOALS and expert’s MIE-CAT scores a small correlation was found (r¬s = 0.23, p = 0.58) (Figure 1). Despite rapid results from crowd workers, a poor agreement between crowd and experts’ GOALS scores was observed. MIE might be technically too difficult to assess for laypeople. Furthermore, GOALS might not be extensive enough to assess MIE performance in detail, while the procedure-specific MIE-CAT might be more comprehensive. However, the correlation between the experts’ MIE-CAT and GOALS scores indicates video clip assessments (instead of full length video assessments) could be helpful to shorten assessment time.

The impact of virtual reality simulation training on operative performance in laparoscopic cholecystectomy: meta-analysis of randomized clinical trials.

BackgroundSimulation training can improve the learning curve of surgical trainees. This research aimed to systematically review randomized clinical trials (RCT) evaluating the performance of junior surgical trainees following virtual reality training (VRT) and other training methods in laparoscopic cholecystectomy.MethodsMEDLINE (PubMed), Embase (Ovid SP), Web of Science, Scopus and LILACS were searched for trials randomizing participants to VRT or no additional training (NAT) or simulation training (ST). Outcomes of interest were the reported performance using global rating scores (GRS), the Objective Structured Assessment of Technical Skill (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS), error counts and time to completion of task during laparoscopic cholecystectomy on either porcine models or humans. Study quality was assessed using the Cochrane Risk of Bias Tool. PROSPERO ID: CRD42020208499.ResultsA total of 351 titles/abstracts were screened and 96 full texts were reviewed. Eighteen RCT were included and 15 manuscripts had data available for meta-analysis. Thirteen studies compared VRT and NAT, and 4 studies compared VRT and ST. One study compared VRT with NAT and ST and reported GRS only. Meta-analysis showed OSATS score (mean difference (MD) 6.22, 95%CI 3.81 to 8.36, P < 0.001) and time to completion of task (MD −8.35 min, 95%CI 13.10 to 3.60, P = <0.001) significantly improved after VRT compared with NAT. No significant difference was found in GOALS score. No significant differences were found between VRT and ST groups. Intraoperative errors were reported as reduced in VRT groups compared with NAT but were not suitable for meta-analysis.ConclusionMeta-analysis suggests that performance measured by OSATS and time to completion of task is improved with VRT compared with NAT for junior trainee in laparoscopic cholecystectomy. However, conclusions are limited by methodological heterogeneity and more research is needed to quantify the potential benefit to surgical training.

Establishing validity evidence for device-assisted advanced laparoscopic suturing tasks using simulation.

Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. Twenty-seven participants (13 ES, 14 NS, median age 34years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061). In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Pilot Evaluation of a Novel, Low-Cost, Simulation Model for Training and Assessment of Laparoscopic Intracorporeal Continuous Suturing.

Background: Laparoscopic intracorporeal continuous suturing is being employed in a growing number of minimally invasive procedures. However, there is a lack of adequate bench models for gaining proficiency in this complex task. The purpose of this study was to assess a novel simulation model for running suture. Methods: Participants were grouped as novice (LSN) or expert (LSE) at laparoscopic suturing based on prior experience and training level. A novel low-cost bench model was developed to simulate laparoscopic intracorporeal continuous closure of a defect. The primary outcome measured was time taken to complete the task. Videos were scored by independent raters for Global Operative Assessment of Laparoscopic Skills (GOALS). Results: Sixteen subjects (7 LSE and 9 LSN) participated in this study. LSE completed the task significantly faster than LSN (430 ± 107 vs 637 ± 164seconds, P ≤ .05). LSN scored higher on accuracy penalties than LSE (Median 30 vs 0, P ≤ .05). Mean GOALS score was significantly different between the 2 groups (LSE 20.64 ± 2.64 vs LSN 14.28 ± 1.94, P < .001) with good inter-rater reliability (ICC ≥ .823). An aggregate score using the formula: Performance Score = 1200-time(sec)-(accuracy penalties x 10) was significantly different between groups with a mean score of 741 ± 141 for LSE vs 285 ± 167 for LSN (P < .001). Conclusion A novel bench model for laparoscopic continuous suturing was able to significantly discriminate between laparoscopic experts and novices. This low-cost model may be useful for both training and assessment of laparoscopic continuous suturing proficiency.

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

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

Subjective vs. objective assessment of simulation performance on laparoscopic cholecystectomy: are we evaluating the right things?

Simulation using virtual reality (VR) simulators is an important tool in surgical training. VR laparoscopic simulators can provide immediate objective performance assessment without observer evaluation. This study aims to explore the correlation between subjective observer evaluation and VR laparoscopic simulator performance metrics in a laparoscopic cholecystectomy (LC) simulation module. A LC simulation module using a VR laparoscopic simulator was completed by PGY2-3 general surgery residents at a single institution. Simulation performance was recorded and evaluated by a trained evaluator using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) form, the Objective Structured Assessment of Technical Skills (OSATS) form, and a LC-specific simulation assessment form (LC-SIM). Objective performance metrics were also obtained from the simulator system. Performance before the curriculum (pre-test) and after the curriculum (post-test) were compared. Fourteen residents were included in the study. There were significant improvements from pre-test to post-test on each component of GOALS, OSATS, and LC-SIM scores (all p values < 0.05). In terms of objective simulator metrics, significant improvements were noted in time to extract gallbladder (481 ± 221 vs 909 ± 366min, p = 0.019), total number of movements (475 ± 264 vs 839 ± 324min, p = 0.012), and total path length (955 ± 475 vs 1775 ± 632cm, p = 0.012) from pre-test to post-test. While number of movements and total path lengths of both hands decreased, speed of right instrument also decreased from 4.1 + 2.7 to 3.0 ± 0.7cm/sec (p = 0.007). Average speed of left instrument was associated with respect for tissue (r = 0.60, p < 0.05) and depth perception (r = 0.68, p < 0.05) on post-test evaluations. Our study demonstrated significant improvement in technical skills based on subjective evaluator assessment as well as objective simulator metrics after simulation. The few correlations identified between the subjective evaluator and the objective simulator assessments suggest the two evaluation modalities were measuring different aspects of the technical skills and should both be considered in the evaluation process.

Development of a performance rubric for transanal endoscopic rectal purse-string sutures.

Placing a transanal endoscopic rectal purse-string suture (taEPS) is the crucial first component of transanal total mesorectal excision (taTME). However, no structured training is available to improve the procedure-specific skills for taEPS. The aim of this study was to create a performance rubric to improve taEPS skills and provide preliminary evidence for its validity. A performance rubric was created based on technical considerations for taEPS, identified by consulting with taTME surgical and performance assessment experts. Ten independent, blinded raters assessed 10 videotaped taEPS procedures of consecutive taTME cases, at National Cancer Center Hospital East (NCCHE), Chiba, Japan, in January 2018-March 2019 using the rubric and the Global Operative Assessment of Laparoscopic Skills (GOALS). Internal consistency and inter-rater reliabilities were calculated. Videotaped taEPS procedures were timed and assessed by the rubric. Correlation between rubric scores and suturing times were analyzed. The rubric consists of four items: loading the needle (LN), atraumatic needle passage (AP), planned suture path (PS), and overall performance (OA). Videotaped performances were graded on a 3-point Likert scale; scores were calculated as sums of the points. Cronbach's α for internal consistency was 0.713. Inter-rater reliabilities were LN: 0.73, AP: 0.76, PS: 0.71, and OA: 0.70. Rubric and GOALS scores were strongly correlated (r = 0.964, p < 0.001). In 112 consecutive taEPS performances, rubric scores were strongly correlated with suturing time (r = - 0.69, p < 0.001). Surgeons' experience with taTME was associated with rubric scores and suturing time. This study provides preliminary validation for the taEPS skill performance rubric. The rubric's structured training may facilitate skill acquisition by providing trainees with critical clinical considerations.

Evaluation of YouTube laparoscopic hysterectomy videos as educational materials during the COVID-19 era using the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) and LAP-VEGaS video assessment tool

With increasing numbers of laparoscopic hysterectomies, surgical trainees are compelled to learn more about endoscopy. Owing to coronavirus disease-related social distancing requirements, online education has gained prominence. Here, we aimed to investigate the laparoscopic hysterectomy video quality on YouTube using the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS). YouTube was searched on June 7, 2020 using ‘laparoscopic hysterectomy’. Three examiners evaluated videos using Global Operative Assessment of Laparoscopic Skills (GOALS). Subsequently, videos were assessed for their conformity to the LAP-VEGaS and LAP-VEGaS Video Assessment Tool. Interobserver reliability was estimated using intraclass coefficients and Cronbach’s alpha. Cochran’s Q test was used to determine correlations among quantitative data. The median GOALS score was 21.50. The observers’ GOALS scores were significantly correlated. The results showed low conformity to the LAP-VEGaS. YouTube is the most used platform among trainees. The low YouTube video educational quality highlights the necessity for peer review, as trainees increasingly seek such resources during the pandemic. IMPACT STATEMENT What is already known on this subject? YouTube is the most commonly used online resource for educational material among surgical trainees. Online videos usually do not undergo a peer-review process. The LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) may be used to assess the educational quality of surgical videos. What do the results of this study add? To our knowledge, this is the first study on the quality of laparoscopic hysterectomy videos available on YouTube and the first study to evaluate YouTube laparoscopic surgery videos using the LAP-VEGaS Video Assessment Tool (VAT). Our study revealed the low educational quality of YouTube laparoscopic hysterectomy videos. The LAP-VEGaS VAT seems to be a valid and practical tool for assessing online laparoscopic hysterectomy videos. What are the implications of these findings for clinical practice and/or further research? Medical communities, especially tertiary care or academic centres, may upload educational peer-reviewed videos for trainees seeking this type of resource, especially during the coronavirus disease pandemic, as surgical education alternatives are limited.

Training on a virtual reality laparoscopic simulator improves performance of live laparoscopic surgery.

IntroductionTo determine whether training laparoscopic nephrectomy (LN) with a virtual reality (VR) simulator improves the performance of porcine LN.MethodsTwelve urological residents were assigned to two groups: a training and a non‐training group. All participants performed baseline assessments of LN skills and time on the LapPASS® simulator. The training group received preoperative LapPASS® training. Both groups then performed LN using a porcine model. The operations were videotaped and evaluated using the Global Operative Assessment of Laparoscopic Skills (GOALS) system. After porcine LN, the training group performed a final LN with the LapPASS® simulator.ResultsThere was no significant difference in the operation time required for porcine LN. There were no significant differences in the total A (autonomy), B (bimanual dexterity), D (depth perception), or T (tissue handling) GOALS scores. However, the total E (efficiency) score in the training group was higher than that in the non‐training group (P = .030). The final LN score with LapPASS® was significantly higher than the baseline (P = .004).ConclusionsThe results of this study demonstrated that VR LN training improved performance in an actual operation. VR‐based procedural simulation could become a vital part of the laparoscopic training program for residents.

Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) - Observational feasibility study

BackgroundBenefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India. MethodsA 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated. ResultsSeven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers. ConclusionStructured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.

Characterization of technical skill progress in a standardized rabbit model for training in laparoscopic duodenal atresia repair

BackgroundLaboratory skills training is an essential step before conducting minimally invasive surgery in clinical practice. Our main aim was to develop an animal model for training in clinically highly challenging laparoscopic duodenal atresia repair that could be useful in establishing a minimum number of repetitions to indicate safe performance of similar interventions on humans.Materials and methodsA rabbit model of laparoscopic duodenum atresia surgery involving a diamond-shaped duodeno-duodenostomy was designed. This approach was tested in two groups of surgeons: in a beginner group without any previous clinical laparoscopic experience (but having undergone previous standardized dry-lab training, n = 8) and in an advanced group comprising pediatric surgery fellows with previous clinical experience of laparoscopy (n = 7). Each participant performed eight interventions. Surgical time, expert assessment using the Global Operative Assessment of Laparoscopic Skills (GOALS) score, anastomosis quality (leakage) and results from participant feedback questionnaires were analyzed.ResultsParticipants in both groups successfully completed all eight surgeries. The surgical time gradually improved in both groups, but it was typically shorter in the advanced group than in the beginner group. The leakage rate was significantly lower in the advanced group in the first two interventions, and it reached its optimal level after five operations in both groups. The GOALS and participant feedback scores showed gradual increases, evident even after the fifth surgery.ConclusionsOur data confirm the feasibility of this advanced pediatric laparoscopic model. Surgical time, anastomosis quality, GOALS score and self-assessment parameters adequately quantify technical improvement among the participants. Anastomosis quality reaches its optimal value after the fifth operation even in novice, but uniformly trained surgeons. A minimum number of wet-lab operations can be determined before surgery can be safely conducted in a clinical setting, where the development of further non-technical skills is also required.

Comparing Proficiency of Laparoscopic Vaginal Cuff Suturing in Naïve Learners after Training with Two Different Laparoscopic Simulators

Study Objective To determine if a gynecology-specific laparoscopic simulation trainer better prepares learners to perform a gynecologic surgical task than the current standard laparoscopic simulation trainer. Design Randomized controlled trial incorporating block randomization and a masked design. Setting Participants were trained and tested during a four-hour session in the Northwestern Center for Advanced Surgical Education simulation lab. Patients or Participants 45 surgically naive premedical and preclinical medical students were recruited from June-November 2019. Interventions Participants were randomized into two laparoscopic simulator groups – Essentials in Minimally Invasive Gynecology (EMIG) or Fundamentals of Laparoscopic Surgery (FLS) – then underwent training on relevant simulation tasks for 2.5 hours. Measurements and Main Results Participants completed a video-recorded pre-test and post-test on a laparoscopic vaginal cuff suturing model. Videos were then masked to simulator group and test phase (pre-/post-test). High-volume minimally invasive gynecologic surgeons graded the videos using a modified version of the Global Operative Assessment of Laparoscopic Skills (GOALS) tool. Composite GOALS scores were compared using two sample t-tests with unequal variances. The mean difference between post- and pre-composite GOALS scores was 6.50 for EMIG and 4.07 for FLS, p=0.34. Differences in individual GOALS domains were compared using Wilcoxon Rank-Sum tests. The mean EMIG post-pre difference was greater for six of eight individual GOALS domains, though all p-values > 0.05. A post-hoc power analysis revealed n=127 per simulation group was needed to obtain p-value=0.05. Conclusion Neither EMIG nor FLS was associated with better performance on the vaginal cuff suturing task with regard to statistical significance. However, when examining the raw data, EMIG-randomized participants had a larger mean difference between post- and pre-test GOALS scores across multiple domains. These results suggest that EMIG may better prepare surgically naive learners to complete a laparoscopic vaginal cuff suturing task; however, larger studies are needed to demonstrate this conclusively.

Fine Motor Skills Task Experience and Laparoscopic Vaginal Cuff Suturing Performance after Training with Two Laparoscopic Simulators

Study Objective To determine if prior video gaming or fine motor skills task experience was associated with improved performance on a vaginal cuff suturing task following training with two laparoscopic simulators. Design Randomized controlled trial incorporating block randomization and a masked design. Setting Participants were trained and tested during a four-hour session in the Northwestern Center for Advanced Surgical Education simulation lab. Patients or Participants 45 surgically naive premedical and preclinical medical students were recruited from June-November 2019. Interventions Participants were randomized into two laparoscopic simulator groups – Essentials in Minimally Invasive Gynecology or Fundamentals of Laparoscopic Surgery – then underwent training on relevant simulation tasks for 2.5 hours. Measurements and Main Results Demographic information was collected for all participants, including fine motor skills task and video gaming experience. Participants completed a video-recorded pre-test and post-test on a laparoscopic vaginal cuff suturing model. Videos were masked then graded using a modified version of the Global Operative Assessment of Laparoscopic Skills (GOALS) tool by high-volume minimally invasive gynecologic surgeons. Two sample t-tests with unequal variances were employed to compare GOALS scores. Significant differences were noted in baseline pre-test composite GOALS scores for participants with prior experience playing instruments (diff=2.7, p=0.007), sewing (diff=2.3, p=0.03) and completing artistic tasks (diff=3.05, p=0.01). However, the mean difference between post- and pre-test composite GOALS scores was not different for participants with prior video gaming or fine motor skills task experience. Conclusion Participants with prior fine motor skills task experience performed better at baseline on the pre-test vaginal cuff model. However, after training, these same participants did not perform better when compared to those without prior fine motor task skill experience, regardless of simulation group. These results suggest that prior fine motor skills task experience may not predispose surgically naive learners to improved performance with certain laparoscopic simulation tasks.

Comparing Participant-Reported Confidence during Laparoscopic Vaginal Cuff Suturing after Training with Two Laparoscopic Simulators

Study Objective To determine if participants’ self-reported confidence level with performing a laparoscopic gynecologic surgical task was higher after training with a gynecology-specific laparoscopic trainer. Design Randomized controlled trial incorporating block randomization and a masked design. Setting Participants were trained and tested during a four-hour session in the Northwestern Center for Advanced Surgical Education simulation lab. Patients or Participants 45 surgically naive premedical and preclinical medical students were recruited from June-November 2019. Interventions Participants were randomized into two laparoscopic simulator groups – Essentials in Minimally Invasive Gynecology (EMIG) or Fundamentals of Laparoscopic Surgery (FLS) – then underwent training on relevant simulation tasks for 2.5 hours (including peg transfer and intracorporeal knot tying). Measurements and Main Results Participants completed a video-recorded pre-test and post-test on a laparoscopic vaginal cuff suturing model. Videos were masked then graded using a modified version of the Global Operative Assessment of Laparoscopic Skills (GOALS) tool by high-volume minimally invasive gynecologic surgeons. Participants were not aware of their GOALS scores. All participants completed a survey at the conclusion of the session, rating their confidence level during each laparoscopic simulation task on a 5-point Likert scale. Confidence scores were compared using two sample t-tests with unequal variances. No statistically significant differences in confidence levels were noted between EMIG and FLS participants: peg transfer (diff=0.03, p=0.88), intracorporeal knot tying (diff=0.15, p=0.55) and vaginal cuff suturing (diff=0.41, p=0.11). Conclusion Neither EMIG participants nor FLS participants had higher self-rated confidence scores for the simulator tasks or the vaginal cuff suturing task with regard to statistical significance. However, when examining the raw data, confidence scores for all three tasks were higher for EMIG participants than FLS participants. These results suggest that EMIG-randomized participants may have felt better prepared to complete a laparoscopic gynecologic surgical task; however, larger studies are needed to demonstrate this conclusively.

Analysis of the Educational Value of YouTube Laparoscopic Appendectomy Videos.

PurposeTo evaluate the educational value of laparoscopic appendectomy (LA) videos on YouTube for surgical trainees.MethodsThe search term “Laparoscopic appendectomy” was used on YouTube. The top 100 videos sorted by the number of views were evaluated. Each YouTube account was analyzed, and only videos uploaded by medical physicians were included in this study. Video quality was evaluated using an arbitrary appendectomy scoring system. Video characteristics and Global Operative Assessment of Laparoscopic Skills (GOALS) scores were analyzed regarding video quality and upload source.ResultsThe video quality of 14 (25.0%) videos was graded as good, 36 (64.3%) moderate, and 6 (10.7%) of poor quality. Video characteristic analysis showed no differences in video quality according to the upload source (p=0.573). Video quality and upload source were not related to video length, total views, days online, number of likes, number of dislikes, number of comments, or GOALS score. Among the factors analyzed, only appendicitis severity was found to be associated with video grade (p=0.049).ConclusionThe quality of LA YouTube videos varied. Categories considered as viewer feedback were not associated with video grade or upload source. Responsible video uploading by academic institutions, and appropriate censorship by YouTube seems necessary. Further research with objective data on actual application to surgical trainees is necessary.

Validity Assessment of the Laparoscopic Radical Nephrectomy Module of the LapVision® Virtual Reality Simulator

Background: Virtual reality (VR) simulators allow trainees to perform repeated practice, and provide objective dexterity metrics regarding their performance, which means that VR-based surgical training is becoming a vital part in initial learning of basic laparoscopic surgical skills. However, its educational role of learning advanced procedures remains undetermined. We evaluated the validity of the laparoscopic radicalnephrectomy module of the LapVision® virtual reality simulator. Methods: Urologists, medical students, and junior resident voluntarily participated in the present study and they performed a laparoscopic left radical nephrectomy module. For construct validation, dexterity metrics calculated in the simulator, and mean score of Global Operative Assessment of Laparoscopic Skills (GOALS) evaluated by two experts’ video review were compared according to the certification of Japanese Endoscopic Surgical Skill Qualification (ESSQ) or previous surgical experience. Results: Ten experts (>50 laparoscopic surgeries), 9 intermediates (11-49), and 14 novices (0-10) voluntarily joined the present study. Regarding the construct validity, there was a significant difference in the total number of errors, blood loss, and GOALS score among the groups for both the ESSQ status and previous surgical experience. Conclusions: The present study demonstrated good construct validity for the LapVision® nephrectomy module. Furthermore, global skill assessment could be possible by experts’ reviews, which means the usefulness of VR procedural module for skill assessment tool. VR-based procedural simulation has marked potential to become a vital part of integrated laparoscopic training programs.