Training In Laparoscopic Surgery Research Articles

Laparoscopic training in colorectal surgery: can we do it safely?

ObjectiveLaparoscopic approach should be offered for most patients requiring colectomy, as it is a safe procedure, associated with shorter hospitalization, better cosmetic results, and does not affect negatively the oncological outcomes of patients with colon cancer. However, there is no consistent data on the safety of laparoscopic surgery training during residency. Therefore, the aim of this study was to assess whether or not the resident par- ticipation in laparoscopic colectomy affected the postoperative outcomes. MethodsThe database of the American College of Surgeons National Surgical Quality Im- provement Program (ACS-NSQIP) was searched for patients undergoing laparoscopic col- ectomies between 2005 and 2007. We excluded patients with no data regarding whether or not there was a resident participation in the operation. The study population was divided into 2 groups (resident and nonresident), according to residents participation in the surgi- cal procedure. Perioperative variables and postoperative complications were compared be- tween groups. A multivariate analysis was performed to evaluate the association between postoperative complications and resident participation in the operation. ResultsThe search yielded 5,912 patients with a median age of 63 years. Of these, 3,112 (53%) were female and 3.887 (66%) had a resident involved in their operation. The resident group had a significantly longer mean operative time (163 ± 64min vs 138 ± 58min, p < 0.0001). Other variables did not differ significantly between groups. Moreover, multivari- ate analysis showed no association between resident participation and the occurrence of postoperative complications. ConclusionLaparoscopic training during residency may be safely performed without threatening the patient's integrity.

Virtual Reality Does Not Meet Expectations in a Pilot Study on Multimodal Laparoscopic Surgery Training

The purpose of the present study was to determine the value of virtual reality (VR) training for a multimodality training program of basic laparoscopic surgery. Participants in a two-day multimodality training for laparoscopic surgery used box trainers, live animal training, and cadaveric training on the pulsating organ perfusion (POP) trainer in a structured and standardized training program. The participants were divided into two groups. The VR group (n = 13) also practiced with VR training during the program, whereas the control group (n = 14) did not use VR training. The training modalities were assessed using questionnaires with a five-point Likert scale after the program. Concerning VR training, members of the control group assessed their expectations, whereas the VR group assessed the actual experience of using it. Skills performance was evaluated with five standardized test tasks in a live porcine model before (pre-test) and after (post-test) the training program. Laparoscopic skills were measured by task completion time and a general performance score for each task. Baseline tests were compared with laparoscopic experience of all participants for construct validity of the skills test. The expected benefit from VR training of the control group was higher than the experienced benefit of the VR group. Box and POP training received better ratings from the VR group than from the control group for some purposes. Both groups improved their skill parameters significantly from pre-training to post-training tests [score +17 % (P < 0.01), time -29 % (P < 0.01)]. No significant difference was found between the two groups for laparoscopic skills improvement except for the score in the instrument coordination task. Construct validity of the skills test was significant for both time and score. At its current level of performance, VR training does not meet expectations. No additional benefit was observed from VR training in our multimodality training program.

Ethical Issues and Training in Laparoscopic Surgery

Ethical Issues and Training in Laparoscopic Surgery

Ethical Issues and Training in Laparoscopic Surgery

Teaching operative laparoscopic skills by taking into account the basic principles of medical ethics in a recognized teaching hospital like the World Laparoscopic Hospital in India under the supervision of experienced laparoscopic surgeons is of paramount importance to surgical training.

Feasibility of single-incision laparoscopic surgery for appendicitis in abnormal anatomical locations: A single surgeon′s initial experience

BACKGROUND:Single-incision laparoscopic surgery is considered as a more technically demanding procedure than the standard laparoscopic surgery. Based on an initial and early experience, single-incision laparoscopic appendectomy (LA) was found to be technically advantageous for dealing with appendicitis in unusual anatomical locations. This study aims to highlight the technical advantages of single-incision laparoscopic surgery in dealing with the abnormally located appendixes and furthermore report a case of acute appendicitis occurring in a sub-gastric position, which is probably the first such case to be reported in English literature.MATERIALS AND METHODS:A retrospective analysis of the first 10 cases of single-incision LA which were performed by a single surgeon is presented here.RESULTS:There were seven females and three males. The mean age of the patients was 30.6 (range 18–52) years, mean BMI was 22.7 (range 17–28) kg/m2 and the mean operative time was 85.5 (range 45–150) min. The mean postoperative stay was 3.6 (range 1–7) days. The commonest position of the appendix was retro-caecal (50%) followed by pelvic (30%). In three cases the appendix was found to be in abnormal locations namely sub-hepatic, sub-gastric and deep pelvic or para-vesical or para-rectal. All these cases could be managed with this technique without any conversionsCONCLUSION:Single-incision laparoscopic surgery appears to be a feasible and safe technique for dealing with appendicitis in rare anatomical locations. Appendectomy may be a suitable procedure for the initial training in single-incision laparoscopic surgery.

Surgery for deep infiltrating endometriosis Technique and rationale

The surgical treatment of deep infiltrating endometriosis is challenging and complex. Currently, the gold standard for patient care is the referral to tertiary centers with a multidisciplinary team including gynecologists, colorectal surgeon and urologist with adequate training in advanced laparoscopic surgery. The surgical technique is essential to adequately manage the disease and to minimize the risk of complications; however, the technique is rarely taught and described in details. This paper reviews our current technique and all the tricks to allow the reproduction and even the improvement of this technique by other surgeons.

Training in classic and laparoscopic surgery – needs and remedies

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The Investigation of Laparoscopic Instrument Movement Control and Learning Effect

Laparoscopic surgery avoids large incisions for intra-abdominal operations as required in conventional open surgery. Whereas the patient benefits from laparoscopic techniques, the surgeon encounters new difficulties that were not present during open surgery procedures. However, limited literature has been published in the essential movement characteristics such as magnification, amplitude, and angle. For this reason, the present study aims to investigate the essential movement characteristics of instrument manipulation via Fitts' task and to develop an instrument movement time predicting model. Ten right-handed subjects made discrete Fitts' pointing tasks using a laparoscopic trainer. The experimental results showed that there were significant differences between the three factors in movement time and in throughput. However, no significant differences were observed in the improvement rate for movement time and throughput between these three factors. As expected, the movement time was rather variable and affected markedly by direction to target. The conventional Fitts' law model was extended by incorporating a directional parameter into the model. The extended model was shown to better fit the data than the conventional model. These findings pointed to a design direction for the laparoscopic surgery training program, and the predictive model can be used to establish standards in the training procedure.

Have we learned from lessons of the past? A systematic review of training for single incision laparoscopic surgery

Single incision laparoscopic surgery (SILS) represents the next step in laparoscopic surgery in further reducing the invasiveness of surgical procedures with cosmetic advantages. Recalling the increased rates of major complications at the advent of laparoscopic cholecystectomy 20 years ago, however, it is clear that appropriate training is required before adopting a new technique. This study aims to review the current evidence for training and skills acquisition for SILS. A comprehensive database search of PubMED, MEDLINE, EMBASE and Google Scholar was carried out. Studies considered for inclusion were those addressing SILS learning curves, skills acquisition, or training. 21 studies were included in the final analysis. Ten clinical case series with analysis of SILS learning curve demonstrated a significant learning curve for conventional multiport laparoscopic (LAP)-trained surgeons over the course of initial SILS cases, with several studies reporting increased risk of conversion and complication rates. Five laboratory-based studies demonstrated differences in SILS skills acquisition compared with LAP. Six studies describing SILS-specific training curricula were analysed, but none included a robust validation of the curriculum. Clinical case series and laboratory-based skills acquisition studies demonstrate the unique requirements of SILS, with skill sets and ergonomic demands which cannot be directly adapted from existing LAP experience. Some studies have already reported higher complication rates in initial SILS cases. To avoid repeating the mistakes of the past, the implementation of an evidence- and competency-based SILS curriculum is necessary to ensure appropriate training of future SILS surgeons.

Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?

Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel. Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ(2) analysis. The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73% compliance), 83 completed the baseline skills assessment, and 27 (33%) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (n = 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (p < 0.0001). One surgeon (1.3%) failed the skills certification, and nine (11.8%) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34% compliance). All achieved proficiency at skills, and 60% passed the cognitive exam. This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33% and a certification failure rate of 13% suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.

Resident Training in Laparoscopic Colorectal Surgery: Role of the Porcine Model

Laparoscopic colorectal surgery (LCRS) is an effective option for the treatment of various colorectal conditions. However, its implementation in surgical practice is still limited, and there are no clear guidelines for residency training requirements or evaluation of the level of expertise. The aim of this study was to assess the level of practical expertise of senior residents regarding LCRS in an animal porcine model. At the Department of Biosciences of Rome, Tecnopolo of Castel Romano, 50 senior residents underwent training sessions on a porcine model under the direction of attending laparoscopic surgeons. A total of 20 residents underwent box trainer preparation before starting the surgical procedure on the animal model; and a group of 6 repeated the course 3 months after the first session. Overall, 90 % of the residents needed help during the surgical procedures, and only 9 residents (18 %) showed a high level of confidence when performing the surgery. Video-trainer preparation helped residents increase their laparoscopic ability (p = 0.04). Residents who attended two training courses showed significant improvement regarding the duration of the procedures, rate of complications, and the need of a tutor. The study demonstrated that the experience of senior surgical residents in regard to performing LCRS is less than ideal. A national training program should carefully consider the present quality of training in Italy and attempt to develop and integrate alternative methods for teaching laparoscopic surgery, perhaps by having an animal model laboratory.

The effect of simulation in improving students’ performance in laparoscopic surgery: a meta-analysis

There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education. We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. The inclusion criteria were peer-reviewed published randomized clinical trials that compared simulators versus standard apprenticeship surgical training of surgical trainees with little or no prior laparoscopic experience. Of the 551 relevant studies found, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95 % confidence intervals [CI] were calculated for multiple psychometric skill outcome measures. Data were combined by means of both fixed- and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d = 1.98, 95 % CI: 1.20-2.77; P < 0.01), were more careful in handling various body tissue (d = 1.08, 95 % CI: 0.36-1.80; P < 0.01), and had a higher accuracy score in conducting laparoscopic tasks (d = 1.38, 95 % CI: 0.30-2.47; P < 0.05). Simulators have been shown to provide better laparoscopic surgery skills training for trainees than the traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.

Value of fundamentals of laparoscopic surgery training in a fourth-year medical school advanced surgical skills elective

BackgroundFew data are available describing the benefits of initiating fundamentals of laparoscopic surgery (FLS) training during medical school. We hypothesized that an intense 1-month surgical skills elective that included FLS task training for fourth-year medical students (MS4s) would result in performance levels indistinguishable from graduating chief residents (PGY5) who had received clinical skill training and access to self-guided FLS curriculum. MethodsFrom July 2007 through June 2011, 114 MS4s participated in a 1-month advanced surgical skills elective. The curriculum for the elective included cadaver dissections, patient management presentations, and surgical skill training (open surgical skills and basic laparoscopic skills modules performed on FLS trainers and virtual reality laparoscopic simulators). From June 2009 through June 2011, 21 PGY5s graduated who had never received formalized FLS skills training. These residents were tested on FLS by a certified proctor and the results recorded. The performance outcome measure was task completion time. Unpaired Student's t-test was used to compare the performance measures for each group. ResultsAll PGY5s achieved FLS certification on their first attempt and completed enough cases for graduation. The MS4 group showed significantly better performance than the PGY5 group in the peg transfer and circle cut (P < 0.05). No difference was seen in the knot tying tasks between the two groups (P > 0.05) ConclusionsIncorporating FLS training into a 1 month-long medical school surgery elective enabled MS4s to achieve FLS performance similar to, or better than, the performance achieved by PGY5 surgery residents. We support the integration of FLS skills task training as a standard part of the skills training curriculum for medical students.

Does gender predict performance of novices undergoing Fundamentals of Laparoscopic Surgery (FLS) training?

BackgroundThis study was performed to assess the hypothesis that performance levels for Fundamentals of Laparoscopic Surgery (FLS) tasks were not dependent on trainee gender. MethodsInitial and final task completion times for 4 FLS tasks performed by 132 novices (4th-year medical students and 1st-year residents) were collated by task type and compared by gender. ResultsAll novices improved significantly with training (P > .001) on all tasks. Initial performance by men was better than by women but only reached significance for peg transfer and intracorporeal knot tying (P > .05). With training, women's performance became equivalent to that of men but showed a comparable or greater response to training. ConclusionsThe gender-related differences noted in initial FLS task performance disappeared after training. Gender displayed no effect on FLS training outcomes. The use of initial FLS task performance levels, seemingly objective selection criteria, would introduce gender bias into the ranking process.

Has laparoscopic colorectal surgery become more cost-effective over time?

Several studies have confirmed that laparoscopic colorectal surgery (LCS) has superior short-term outcomes when compared to open colorectal surgery. However, the evidence for cost-effectiveness of LCS is less clear. The aim of this study is to explore the cost-effectiveness of LCS over time since it was first developed in 1991. Systematic review of the literature was conducted. Electronic databases (PubMed, ScienceDirect and Google Scholar) were searched for studies from 1991 to 2010 using the keywords "laparoscopic, colorectal surgery cost, economic evaluation". Fifteen economic evaluations met the inclusion criteria. The percentage cost difference between open and laparoscopic surgery varied widely between different studies. The general trend when observing all the included economic evaluations is that there is a moderate negative correlation between progression of time and the size of the cost gap between laparoscopic and open surgery (R-value=-0.44). This correlation is even stronger (R-value=-0.64, P=0.046) if the studies are subdivided by the country where the surgery was carried out in. Western healthcare systems, even though they had a heterogeneous set of results (SD=27%), showed a decline in costs of laparoscopic surgery with time. From the current trends, it is projected that the results of future economic evaluations will unequivocally show that laparoscopic surgery is cheaper than open surgery. The initial higher costs of laparoscopic surgery training may be worth the savings made in the long term if it is practised in settings where postoperative care is expensive.

Training in laparoscopic colorectal surgery: a new educational model using specially embalmed human anatomical specimen

BackgroundWith an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training “before the job” on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed.MethodsThe new embalming method Anubifix™ combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model.ResultsEleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills.ConclusionThe new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of “training before the job.”

Value of Fundamentals of Laparoscopic Surgery (FLS) Training in a Fourth-Year Medical School Advanced Surgical Skills Elective

Value of Fundamentals of Laparoscopic Surgery (FLS) Training in a Fourth-Year Medical School Advanced Surgical Skills Elective

Training in laparoscopic surgery: From the lab to the or

Training in laparoscopic surgery: From the lab to the or

Effect of haptic feedback in laparoscopic surgery skill acquisition

The benefits of haptic feedback in laparoscopic surgery training simulators is a topic of debate in the literature. It is hypothesized that novice surgeons may not benefit from the haptic information, especially during the initial phase of learning a new task. Therefore, provision of haptic feedback to novice trainees in the early stage of training may be distracting and detrimental to learning. A controlled experiment was conducted to examine the effect of haptic feedback on the learning curve of a complex laparoscopic suturing and knot-tying task. The ProMIS and the MIST-VR surgical simulators were used to represent conditions with and without haptic feedback, respectively. A total of 20 novice subjects (10 per simulator) were trained to perform suturing and knot-tying and practiced the tasks in 18 sessions of 1 h each. At the end of the 3-week training period, the subjects performed equally fast but more consistently with haptics (ProMIS) than without haptics (MIST-VR). The subjects showed a slightly higher learning rate and reached the first plateau of the learning curve earlier with haptic feedback. In general, learning with haptic feedback was significantly better than learning without it for a laparoscopic suturing and knot-tying task, but only during the first 5 h of training. Haptic feedback may not be warranted in laparoscopic surgical trainers. The benefits of a shorter time to the first performance plateau and more consistent initial performance should be balanced with the cost of implementing haptic feedback in surgical simulators.

Training and learning robotic surgery, time for a more structured approach: a systematic review

Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons. To review the literature on training and learning strategies for robotic assisted laparoscopic surgery. A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed. We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism. Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation. We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme. Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes.