Laparoscopic Surgical Skills Research Articles

Gasless laparoscopically assisted myomectomy using a wound retraction system

The purpose of this study was to elucidate the feasibility of gasless laparoscopically assisted myomectomy (LAM) using a wound retraction system. This method treats symptomatic uterine myomas by combining laparoscopy with a mini-laparotomy to enucleate myoma nodules and to close the uterine myometrium. This study includes 275 patients who underwent gasless LAM. For patients with fewer than three myoma nodules, the location of the largest nodule was classified as anterior, fundal, or posterior. The operative outcomes, intraoperative and postoperative courses, and complications were examined. All operations were performed satisfactorily, and no conversions to laparotomy were required. None of the patients developed serious complications. The mean blood loss and operating time were 190.3 mL and 152.2 minutes, respectively. The mean myoma size was 8.9 cm, and the mean number of myomas per patient was 2.8. The average postoperative hospital stay was 5.7 days. There were no significant differences in resected myoma size, blood loss, and surgical duration with respect to the location of the largest nodule. Gasless LAM with a wound retractor is feasible and allows surgeons to perform myomectomy safely and cost-effectively, without requiring advanced laparoscopic surgical skills and while maintaining minimum invasiveness.

The Endoscopic Surgical Skill Qualification System for gastric surgery in Japan

Laparoscopic surgery has been increasing in popularity in recent years. In 2004, the Japan Society for Endoscopic Surgery developed its Endoscopic Surgical Skill Qualification System (ESSQS) to assess surgeons. To earn the ESSQS accreditation, applicants must submit an unedited operative video in which they perform either a distal gastrectomy or pylorus-preserving gastrectomy with lymph node dissection for gastric cancer. The videos are assessed by two separate judges based on detailed criteria for common and procedure-specific technical-grade slips. Common criteria from all fields of gastrointestinal and general surgery are used to evaluate the basic laparoscopic surgical skills and autonomy of the operator. The target organ determines the procedure-specific criteria are set to assess whether or not adequate oncological clearance has been achieved. Between 2004 and 2009, 154 (44.6%) out of 345 applicant surgeons assessed under the ESSQS for gastric surgery have been accredited. Interrater agreement was acceptable and ranged between 0.21 and 0.59. The ESSQS system may facilitate improvement in surgical technique and the standardization of laparoscopic surgery in Japan.

Skill qualifications in pediatric minimally invasive surgery

In 2006, The Japanese Society of Pediatric Endoscopic Surgeons devised a plan to develop a pediatric endoscopic surgical skill qualification (ESSQ) system. This system is controlled by The Japan Society for Endoscopic Surgery. The standard requirement for skills qualification is the ability of each applicant to complete common types of laparoscopic surgery. The main goal of the system is to decrease complications of laparoscopic surgery by evaluating the surgical skills of each applicant and subsequently certify surgeons with adequate skills to perform laparoscopic operations safely. A committee of pediatric ESSQ created a checklist to assess the applicant's laparoscopic surgical skills. Skills are assessed in a double-blinded fashion by evaluating an unedited video recording of a fundoplication for pediatric gastroesophageal reflux disease. The initial pediatric ESSQ system was started in 2008. In 2008 and 2009, respectively, 9 out of 17 (53%) and 6 out of 12 (50%) applicants were certified as expert pediatric laparoscopic surgeons. Our ultimate goal is to provide safe and appropriate pediatric minimally invasive procedures and to avoid severe complications. To prove the predictive validity of this system, a survey of the outcomes of operations performed by certified pediatric surgeons is required.

Knowledge elicitation for performance assessment in a computerized surgical training system

Effective training is the key to minimizing the dangers of minimally invasive surgery (MIS). At present, the assessment of laparoscopic skills relies on the expertise of senior surgeons. The judgment is typically based on and expressed in ordinal variables that can take values such as low, medium, high or other comparable terms. This limited assessment, along with the lack of expert surgeons’ metacognitive awareness of how the judgment process takes place, results in imprecise rules for the evaluation of laparoscopic surgical skills. In this work, we present the knowledge elicitation process to model the performance metrics and the rules involved in the assessment of minimally invasive surgical skills. We have implemented a scoring system for the evaluation of laparoscopic skills based on five performance metrics capable of distinguishing between four proficiency levels while providing a quantitative score. Our assessment model is based on fuzzy logic, so that it is easier to mimic the judgment that is already performed by experienced surgeons. The presented framework was empirically validated using the performance data of 38 subjects belonging to five groups: non-medical students, medical students with no previous laparoscopic training, medical students with some training, residents, and expert surgeons.

Deconstructing laparoscopic competence in a virtual reality simulation environment

Virtual reality (VR) simulators play a substantial role in modern medical education and have generated several performance parameters that are not always standardized and open to clear and easy interpretation. Consequently, our study objective was to investigate how these parameters contribute to the enhancement of key competencies in laparoscopic surgical skills. We recruited 20 residents and 8 experienced surgeons to participate in this study. The residents were trained on 5 basic tasks (4 of them at two difficulty levels) using a commercially available VR simulator. Study participants also performed an additional 3 complex tasks before and after training for assessment purposes. The experienced surgeons served as controls and so only performed the assessment tasks. Performance parameters were grouped to reflect errors in dexterity, safety, and technical skill. These errors, as well as the parameters of time and instrument velocity, were analyzed during training and assessment. Performance for training tasks demonstrated notable learning curves for most of the parameters that were measured (ie, plateaus varied between the second and seventh VR training session). Velocity was influenced least by the training (3 of the 5 tasks), while time and dexterity were influenced most (all 5 tasks and for both difficulty levels). In the assessment tasks, technical skill was improved (P < .05) for some study participants, but this improvement was not demonstrated in all of the complex procedures tested (eg, bowel suturing). There was a significant improvement in safety (all 3 tasks; P < .05), and time to completion and dexterity (both of them in 2 tasks; P < .05). Experienced surgeons scored at a greater level than VR-trained residents in terms of time (all tasks; P < .05), safety and technical skill (bowel suturing; P < .05), as well as dexterity (adhesiolysis and bowel suturing; P < .05). VR simulation training contributed markedly to the enhancement of key surgical competencies of residents. The proposed mapping of the simulator parameters may help program directors and trainees evaluate important competency domains during VR-based surgical training.

Robotic sacrocolpopexy: An observational experience at mayoclinic, USA

Although there are many studies the ongoing debate on the management of posthysterectomy vault prolapse whether it should be abdominal, vaginal, or laparoscopic still continues. However there is no clear consensus. Though the incidence of vaginal vault prolapse is said to range from 0.2 to 45%, the choice of the optimal treatment depends on the surgeon's experience, suitability for surgery, age, symptoms, quality of life impairment, and prolapse grade. Abdominal sacrocopopexy (ASCP) with mesh interposition is the traditional surgical procedure for treating pelvic organ prolapse and has been shown to have one of the highest long-term success rates for vaginal vault prolapse. The laparoscopic approach offers reduced morbidity, shorter hospitalization, and decreased post operative pain. The disadvantages of the laparoscopic approach include longer operating time and need for advanced laparoscopic surgical skills including suturing. Robot-assisted laparoscopic procedure allows the performance of complex laparoscopic maneuvers with less difficulty, and thereby simplifies the complex procedure. The aim is to describe and demonstrate the use and benefit of robot-assisted laparoscopic sacrocolpopexy in the treatment of posthysterectomy vaginal vault prolapse in obese patients along with mid-urethral sling application.

Laparoscopic adrenalectomy by general surgeons familiar with laparoscopic surgical skills: Experiences of a single center

Laparoscopic adrenalectomy (LA) is still considered an advanced procedure requiring a high level of skills with potentially lethal pitfalls. We report our clinical outcomes of 50 cases of LA, and discuss whether a general surgeon is suitable to perform LA, and the effect of mentor-initiated training on improving outcomes. Patients' age and sex, size of tumor, preoperative diagnosis, procedure details, intra- and postoperative complications, operation time, final histological diagnosis, and length of stay of 50 consecutive cases of LA were collected through a review of hospital charts. These cases were divided into two equal consecutive groups. The first 25 cases were named Group A, and the latter 25 cases were named Group B, and two groups were compared. Median operation time in Group B (110 min) was significantly shorter than that in Group A (125 min) (P=0.021). Mean postoperative hospital stay in Group B (7.0 ± 2.8 days) was significantly shorter than that in Group A (10.9 ± 8.8 days) (P=0.019). Only one case (Group B) of 50 LA (2%) required a conversion to open adrenalectomy because of failure to control bleeding during dissection. Under mentor-initiated training, general surgeons with experience of more than 50 cases of laparoscopic cholecystectomies can attain favorable clinical outcomes in LA.

Multi-Institutional Analysis of Robotic Partial Nephrectomy for Hilar Versus Nonhilar Lesions in 446 Consecutive Cases

BackgroundMinimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. ObjectiveWe compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. Design, setting, and participantsWe retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. MeasurementsPatient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. Results and limitationsForty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2cm vs 2.6cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3±7.4min vs 19.6±10.0min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons’ prior robotic experience. ConclusionsThe data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.

Core skills in laparoscopic surgery

Core skills in laparoscopic surgery is a three day course for junior surgical trainees (core trainees years 1-2 and specialty trainees years 3-5) who are interested in improving their laparoscopic surgical skills. It covers the theoretical basis of general laparoscopic surgery, alongside a considerable amount of time spent on laparoscopic trainers. I took this course during my second year of core surgical training. Laparoscopic surgery is increasingly becoming the standard approach for a wide range of surgical procedures. Despite this, it can be difficult to gain sufficient experience in laparoscopic surgery, and often junior surgical trainees are left “holding the camera.” I had already had some experience of laparoscopic surgery from a basic surgical skills course and from my own surgical experience. Despite this, laparoscopic surgery remained a daunting prospect, and I wanted to improve my skills as well as my …

Correlation of Fine Motor Skills Testing with Laparoscopic Surgical Skills in Obstetrics and Gynecology Residents

Correlation of Fine Motor Skills Testing with Laparoscopic Surgical Skills in Obstetrics and Gynecology Residents

The current state of Australian laparoscopic surgical skills training

The current state of Australian laparoscopic surgical skills training

A Laparoscopic Surgical Skills Assessment Tool for Veterinarians

Our aim in this study was to validate a test of laparoscopic surgical performance by determining the relation of scores from an objective structured assessment of technical skills performed in a canine abdominal model to experience and basic laparoscopic skills. The number of years the participants had performed rigid video-endoscopic procedures (VEP), using triangulation skills, correlated positively with both evaluators' total surgical performance scores for all three evaluation methods: global rating scale, visual analog scale (VAS) rating of overall performance, and operative component rating scale (OCRS). Experience of VEP without triangulation skills (i.e., flexible endoscopy, otoscopy) or video game experience did not correlate with surgical performance. A highly validated basic laparoscopic skills assessment (McGill University inanimate system for training and evaluation of laparoscopic skills, or MISTELS) score was strongly correlated with the VAS score for surgical performance and OCRS scores. Inter-rater reliability was high for the VAS and OCRS evaluation methods, and scores from the detailed OCRS method did not differ between evaluators. In conclusion, the surgical performance test correlated with VEP triangulation experience and basic laparoscopic skills. This type of test needs to be evaluated in a larger sample population including higher numbers of veterinary laparoscopic surgeons for further validation.

How do young residents practice laparoscopic surgical skills?

How do young residents practice laparoscopic surgical skills?

How Do Young Residents Practice Laparoscopic Surgical Skills?

To investigate whether a training system using a dry box is feasible for training young urologists. Despite laparoscopic surgery being widely indicated for several urological diseases, a laparoscopic training system for young urologists has not been fully established yet. However, the learning curve for laparoscopic surgery has not yet been ascertained. We continued to test 11 sixth-year residents (postgraduate year: PGY6) and third-year residents (PGY3) in our department in terms of surgical skills using a dry box. We gave them several tasks (cutting and suturing) and let them practice until task completion. We continued to test all participants by these tasks for 16 weeks. At the beginning of the present study, the PGY6 residents achieved significantly better scores than the PGY3 residents. However, the difference between the 2 groups became insignificant over time. Furthermore, statistical analysis revealed that a practice time of 100 minutes per week was the only significant factor affecting the last test score. For the final test, the mean practice time for all participants was 79.1 minutes per week. These results suggest that laparoscopic surgical skills can definitely be polished by adequate voluntary practice.

Tip/Trick 1

OBJECTIVES: To determine the effect of self-directed skill practice with weekly verbal feedback sessions for learning basic open and laparoscopic surgical skills in first year Obstetrics and Gynecology (OBGYN) residents. MATERIALS AND METHODS: First year OBGYN residents entering in July 2009 received a study guide consisting of five learning modules: instrument identification, suturing, knot tying, basic laparoscopic skills, and advanced laparoscopic skills. Each module contained 1) a learning map with prerequisite knowledge and skills, unit contents, and criterion-referenced learning objectives that trainees were expected to meet by the end of the training period, and 2) principles of technique, common errors, and prevention strategies. Each resident was given a take-home skills training box that included: suturing and knot tying boards, a portable laparoscopy training box, and videos. In addition to home training, residents attended 4 weekly practice sessions for 60 min/session. Assessments occurred at baseline and 6 weeks after starting the curriculum in knowledge of surgical instruments and skill performing open suturing, knot tying, and Fundamentals of Laparoscopic Surgery (FLS) tasks including peg transfer, cutting, intracorporeal, and extracorporeal knot tying. These tasks are mandatory skills for graduating general surgery residents. The primary outcome was resident performance using global rating scale (GRS) scores and FLS expert-derived cutoff time criteria. RESULTS: All 7 first year residents participated. Median non-supervised practice time was 125 (98–158) minutes per week. Basic instrument identification improved from 6 (18%) to 29 (85%) instruments (P < .001). Residents' performance significantly improved from baseline to posttest in 10/13 skills including: simple interrupted [GRS score = 1 (0–1) to 4 (2–4) P < .01] simple running [1 (1–2) to 3 (1–4) P < .03], and simple subcuticular suture [1 (0–2) to 3 (2–4) P < .03]; instrument handling while suturing [1 (0–2) to 3 (3–4) P < .03]; one-handed square knot at depth [0 (0–2) to 3 (0–4) P < .03]; laparoscopic peg transfer [192s (±52) to 70s (±40) P = .003]; cutting [233s (±64) to 103s (±25) P = .006]; intracorporeal suturing [300s to 166s (±70) P = .005] and extracorporeal suturing [300s to 153s (±46) P < .001]. All residents reached competence cutoff scores in suturing and instrument handling while 71% reached competence in knot tying and efficiency of movement. Two first year residents were able to successfully perform laparoscopic peg transfer and intracorporeal suturing within cutoff times while 3 were able to successfully perform laparoscopic cutting and extracorporeal suturing within cutoff times. On average, trainees reported being 60% (50–100) better than before they started the curriculum. The majority (86%) of residents reported they would recommend continuing the curriculum for learning surgical skills in their residency, while 7/7 (100%) recommended this curriculum to future incoming first year residents. CONCLUSION: Self-directed skill practice with weekly feedback sessions improves formal basic and advanced surgical skill learning in first year residents.

Mental rotation: Cross-task training and generalization.

It is well established that performance on standard mental rotation tasks improves with training (Peters et al., 1995), but thus far there is little consensus regarding the degree of transfer to other tasks which also involve mental rotation. In Experiment 1, we assessed the effect of mental rotation training on participants' Mental Rotation Test (MRT) scores. Twenty-eight participants were randomly assigned to one of three groups: a "One-Day Training," "Spaced Training," or "No Training" group. Participants who received training achieved higher scores on the MRT, an advantage that was still evident after 1 week. Distribution of training did not affect performance. Experiment 2 assessed generalization of mental rotation training to a more complex mental rotation task, laparoscopic surgery. Laparoscopic surgical skills were assessed using Fundamentals of Laparoscopic Surgery (FLS) tasks. Thirty-four participants were randomly assigned to a "Full Mental Rotation Training, MRT and FLS," "MRT and FLS," or "FLS-only" group. MRT results from Experiment 1 were replicated and mental rotation training was found to elicit higher scores on the MRT. Further, mental rotation training was found to generalize to certain laparoscopic surgical tasks. Participants who obtained mental rotation training performed significantly better on mental-rotation dependent surgical tasks than participants who did not receive training. Therefore, surgical training programs can use simple computer or paper-based mental rotation training instead of more expensive materials to enhance certain aspects of surgical performance of trainees.

Validation of laparoscopic surgical skills training outside the operating room: a long road

Surgical skills training outside the operating room is beneficial. The best methods have yet to be identified. The authors aimed to document the predictive validity of simulation training in three different studies. Study 1 was a prospective, randomized, multicenter trial comparing performance in the operating room after training on a laparoscopic simulator and after no training. The Global Operative Assessment of Laparoscopic Skills (GOALS) was used to evaluate operative performance. Study 2 retrospectively reviewed the operative performance of junior residents before and after implementation of a laparoscopic skills training curriculum. Operative time was the variable used to determine resident improvement. Study 3 was a prospective, randomized trial evaluating intern operative performance of laparoscopic cholecystectomy in a porcine model before and after training on a simulator. Operative performance was assessed using GOALS. All three studies failed to demonstrate predictive validity. With GOALS used as the assessment tool, no difference was found between trained and untrained residents in studies 1 and 3. In study 2, the trained group took significantly longer to complete a laparoscopic cholecystectomy than the untrained group. No correlation was found between the three types of training outside the operating room, and no improved operative performance was observed. Possible explanations include too few subjects, training introduced too late in the learning curve, and training criteria that were too easy. Additionally, simulator training focuses on precision, which may actually increase task time. Awareness of these issues can improve the design of future studies.

The First Laparoscopic Resection of Extra-Adrenal Pheochromocytoma Using the da Vinci®Robotic System

Laparoscopic surgery for pheochromocytoma is difficult because of the potential release of catecholamines, which may lead to severe intraoperative hemodynamic changes. In particular, extra-adrenal pheochromocytoma imposes special demands on the laparoscopic surgical skills of the operator because of changes in anatomic disposition. In this paper, we report a case of extra-adrenal pheochromocytoma, located in the vulnerable anatomic structures, taking place in tiny areas that were difficult to access and that was resected by using the da Vinci robotic system. We found that the da Vinci robotic system gave us improved visual quality to surrounding structures. After our initial experience, we suggest the robot-assisted laparoscopic resection for extra-adrenal pheochromocytoma.

Laparoscopic Surgical Skills Assessment: Can Simulators Replace Experts?

Global Rating Scales (GRS) quantify and structure subjective expert assessment of skill. Hybrid simulators measure performance during physical laparoscopic tasks through instrument motion analysis. We assessed whether motion analysis metrics were as accurate as structured expert opinion by using GRS. A random sample of 10 consultant laparoscopic surgeons, 10 senior trainees, and 10 novice students were assessed on a Sharp Dissection task. Coded video footage was reviewed by two blinded assessors and scored using a Likert Scale. Correlation with metrics was tested using Spearman's rho. Inter-rater reliability was measured using intraclass correlation coefficient (ICC). Strongest GRS-Metric correlations were found for Time/Motion/Progress with Time (Spearman's rho 0.88; p < 0.05) and Instrument Handling with Path Length (Spearman's rho 0.8; p < 0.05). Smoothness correlated with Respect for Tissue in Rater 1 (rho 0.68) but not Rater 2 (rho 0.18). Mean GRS showed stronger inter-rater agreement than individual scale components (ICC 0.68). Correlation coefficients with actual experience group were 0.58-0.74 for mean GRS score and 0.67-0.78 for metrics (Spearman's rho, p < 0.05). Metrics correlate well with GRS assessment, supporting concurrent validity. Metrics predict experience level as accurately as global rating and are construct valid. Hybrid simulators could provide resource-efficient feedback, freeing trainers to concentrate on teaching.

A Clinical Analysis of about 2,000 Cases for the Laparoscopic Cholecystectomy: Single Center Experiences - A Change in the Indication for Laparoscopic Cholecystectomy according to Period

Purpose: Laparoscopic cholecystectomy has become the standard modality of acute and chronic gallbladder disease. This study was performed to evaluate a change in the indication for laparoscopic cholecystectomy according to period by analyzing our experiences. Methods: We retrospectively analyzed 2,096 cases of laparoscopic cholecystectomy that were treated at the Department of Surgery, Dong-A University. They were divided into 3 groups from October 1992 to December 1996 (Group 1), from January 1997 to December 2001 (Group 2) and from January 2002 to March 2007 (Group 3). Results: The mean age was 50.14±13.89 years and the male-to-female ratio was 1：1.23. Previous abdominal surgery was noted in 12.24% from Group 1, 14.96% from Group 2 and 21.48% from Group 3. Chronic cholecystitis was the most common pathologic diagnosis in all cases. However, while the incidence of acute cholecystitis and gallbladder empyema in Group 1 was 3.36% and 0%, that of Group 2 was 12.52% and 3.88% and that of Group 3 was 31.79% and 7.59%, which was increased. The mean operation time of each group was 101.00±51.00, 69.86±40.55, 78.01±45.55 minutes (P＜0.05). The conversion rate of each group was nine cases (6.04%), 21 cases (3.02%), and 51 cases (4.07%). The surgical complication rate was 7.38%, 3.88% and 4.71%, respectively. The length of hospital stay was 6.08±3.65, 3.16±2.99 and 2.91±3.34 days, which was significantly decreased (P＜0.05). Conclusion: As surgical experience increased and laparoscopic surgical skills developed, the indication for laparoscopic cholecystectomy changed. The results of this study showed that laparoscopic cholecystectomy was feasible for the treatment of complicated gallbladder lesion.