Laparoscopic Surgical Training Research Articles

Laparoscopic education and training: considerations and feedback from our 10-year experience

Laparoscopic surgery for gastrointestinal tumors have been conducted in the Department of General Surgery of Nanfang Hospital since 2002. Within the past decade, the education and training courses of laparoscopic surgical techniques were given to over 2,000 gastrointestinal surgeons. From these experience, we believed that efficient and high quality laparoscopic surgical training program should combine the following philosophies: thorough understanding of anatomy under laparoscopic view was the cornerstone; skilled cooperation between surgeon, assistant and laparoscopist would ensure the safety and fluency of the surgery; training course should be designed according to the laparoscopic skills of the trainee. Based on these understandings of laparoscopic education and training, we would further perfect and standardize our training system so as to contribute to the future development and popularization of laparoscopic gastrointestinal surgery in China.

LAPAROSCOPIC SURGICAL TRAINING. A THREE STAGES MODEL

LAPAROSCOPIC SURGICAL TRAINING. A THREE STAGES MODEL (Abstract): The classic “Halstedian” apprenticeship model for surgical training takes place into the operating theater under the strict coordination of a senior surgeon. The development of minimally invasive surgery (MIS) rapidly revealed that this apprenticeship model is insufficient to successful fulfill the well known three stages of training of Rasmussen model – skill-based behavior (SBB), rulebased behavior (RBB) and knowledge-based behavior (KBB) – due to ethical, medico-legal and economic considerations and a specific training using different methods (theoretical and hands-on courses using simulators, animal models and web resources) is mandatory. However it isn’t a worldwide accepted laparoscopic training curriculum. We present our experience with different types of teaching methods; in this way we retrospectively reviewed our experience in laparoscopic education, presenting data using Rasmussen model, as a dynamic three stages model: 1) first stage (the beginning), from 1993 until 1995, our staff acquired SBB, RBB and KBB for basic MIS procedures: cholecystectomy, appendectomy, surgical ablation of ovarian cysts; 2) the second stage, from 1996 until 1999, characterized by continuous training of our surgical staff until the achievement of the KBB level for basic MIS procedures and training for other operations (laparoscopic treatment of the groin hernias, eso-gastric and bariatric surgery) and the teaching of the residents and the surgeons from Moldova region to achieve SBB and RBB for basic MIS procedures; 3) the third stage, from 2000 until present characterized by a continuous improvement of the surgical teams’ laparoscopic skills for different procedures, and developing a modern curricula for laparoscopic education. CONCLUSIONS: There is no universal method for laparoscopic training. Our experience demonstrates good results using a combination of training methods which allowed acquiring: SBB (Basic skills) using virtual reality (VR) simulators and box trainers; RBB (especially for laparoscopic cholecystectomy) using multimedia resources, live operations / proctorship, VR simulators (with force feed-back), box trainers (liver-gallbladder porcine model) and live pig surgery; KBB using VR simulators, multimedia resources, live operation / proctorship, and live pig surgery. An assessment method for laparoscopic training is mandatory; in this way we prefer reviewing the recording data by experts using Global Rating Score (GRS).

A Review of Medical Education in Minimally Invasive Surgery

The benefits of minimally invasive surgery have been well documented. The use of minimally invasive surgery has also been increasing in many specialties including gynecology. Medical education has a traditional motto which has been; see one, do one, teach one. However, with laparoscopy and robotics this paradigm may not be the best case for the practitioner or the patient especially with the increasing attempt to minimize the footprint of surgical education. With this in mind, we have to learn how to best educate future minimally invasive surgeons, particularly laparoscopic and robotic surgeons. The present study provides a review of similarities and differences in the medical education of laparoscopy and robotic surgery. This article also highlights the deficiencies and future work required to advance laparoscopic and robotic surgical training.

복강경수술 훈련용 담낭 절제술 시뮬레이션 개발

Laparoscopic surgery is a surgical procedure which uses long laparoscopic instruments through tiny holes in abdomen while watching images from a laparoscopic camera through umbilicus. Laparoscopic surgeries have many advantages rather than open surgeries, however it is hard to learn the surgical skills for laparoscopic surgery. Recently, some virtual simulation systems for laparoscopic surgery are developed to train novice surgeons or resident surgeons. In this study, we introduce the techniques that we developed for laparoscopic surgical training simulator for cholecystectomy (gallbladder removal), which is one of the most frequently performed by laparoscopic surgery. The techniques for cholecystectomy simulation include modeling of human organs (liver, gallbladder, bile ducts, etc.), real-time deformable body calculation, realistic 3D visualization of surgical scene, high-fidelity haptic rendering and haptic device technology, and so on. We propose each simulation technique for the laparoscopic cholecystectomy procedures such as indentifying cystic duct and cystic artery to clamp and cut, dissecting connective tissues between the gallbladder and liver. In this paper, we describe the techniques and discuss about the results of the proposed cholecystectomy simulation for laparoscopic surgical training.

GPU-friendly gallbladder modeling in laparoscopic cholecystectomy surgical training system

A challenge in virtual reality based laparoscopic cholecystectomy simulation is to construct a fast and accurate deformable gallbladder model. This paper proposed a multi-layered mass-spring model which can adapt well to the built-in accelerating algorithms in PhysX-Engine of Graphics Processing Unit (GPU). The gallbladder was first segmented from clinical Computed Tomography (CT) images. From the segmentation result, a surface mesh of a gallbladder was constructed. The inner layers of a mass-spring model were generated from the surface mesh based on the anatomical structure of gallbladder. We configured the parameters of the springs based on the biomechanical properties of gallbladder to ensure the reality of the deformation results. Preliminary experiments demonstrated that our model was able to achieve satisfactory results in terms of both visual perception and time performance.

Effect of visual displays and locations on laparoscopic surgical training task

The number of minimally invasive surgical (MIS) procedures has substantially increased since its introduction due to health and recovery benefits for patients. However, there are potential performance issues in MIS for surgeons due to perceptual processing demands associated with supporting technologies. Monitor location has been identified as a major factor influencing performance in these types of procedures. This study examined the effect of multiple monitors on performance during a laparoscopic surgical training task (peg transfer among instruments). Twenty-four novice subjects were exposed to different monitor conditions including a default position, a biomechanically compatible position, and a position collocated with the operating surface as well as the combination of the latter two. Subjective rankings and cognitive workload were also assessed. Results revealed a significant effect of monitor position on task time when compared to subjects’ baseline training task time using the default monitor setup. Collocating the monitor with the operating surface was shown to be superior in terms of task time. There were no significant differences among monitor positions in terms of perceived workload. The results of this study provide an applicable guide for the design of MIS setups in the operating room to promote surgeon performance.

Global Evaluative Assessment of Robotic Skills: Validation of a Clinical Assessment Tool to Measure Robotic Surgical Skills

We developed and validated a standardized assessment tool for robotic surgical skills, and report its usefulness, reliability and construct validity in a clinical setting. The Global Evaluative Assessment of Robotic Skills is a tool developed by deconstructing the fundamental elements of robotic surgical procedures in consultation with expert robotic surgeons. Surgical performance was assessed during robot-assisted laparoscopic prostatectomy on a 5-point anchored Likert scale across 6 domains. An overall performance score was derived by summing the ratings in each domain. Expert surgeons and postgraduate year 4 to 6 urology residents were evaluated to determine construct validity. Assessments were completed by the attending surgeon, a trained observer and the operator. A total of 29 evaluations of 25 trainees and 4 attending surgeons were completed. Experts scored significantly higher on the assessment than novice operators (p = 0.004). Postgraduate year 4 and 5 residents scored significantly lower than the expert group (p <0.05) while no difference was observed between mean performance scores of postgraduate year 6 trainees and attending surgeons (p >0.05). The internal consistency of the assessment tool was excellent (Cronbach's α = 0.90 to 0.93). The overall assessment score ICC among raters was 0.80 (95% CI 0.65-0.90). The Global Evaluative Assessment of Robotic Skills is simple to administer and able to differentiate levels of robotic surgical expertise. This standardized assessment tool shows excellent consistency, reliability and validity. Further study is warranted to evaluate its usefulness for surgical education and the establishment of competency in robotic surgery.

Temporal Relationship Between Positive Margin Rate After Laparoscopic Radical Prostatectomy and Surgical Training

To evaluate the potential impact of the experience of the first assistant on the positive surgical margin rate (PSMR) after laparoscopic radical prostatectomy (LRP). The impact of training surgical residents and fellows on patient outcomes is difficult to quantify. A single-institution prospective database of 303 patients who underwent LRP between 2003 and 2008 was evaluated. The potential impact of the experience of the first assistant on the PSMR was evaluated by examining the relationship between the PSMR and the time of the academic year. Multivariable logistic regression analysis was used to adjust for patient age, Gleason's sum, tumor density, and pathologic stage. Overall positive margin rate was 18.2%. Positive margin rate for July and August (14/45, 31.1%) was significantly higher than for the remaining 10 months (41/258, 15.9%) P = .015. The increased risk of positive margin in July/August remained significant after adjusting for age, Gleason's sum, tumor density, and pathologic stage (OR 2.65, 95% CI 1.21-5.79, P = .015) LRP performed with the first assistant in the first 2 months of the academic training year have a significantly higher PSMR.

Video-based assistance system for training in minimally invasive surgery

In this paper, the development of an assisting system for laparoscopic surgical training is presented. With this system, we expect to facilitate the training process at the first stages of training in laparoscopic surgery and to contribute to an objective evaluation of surgical skills. To achieve this, we propose the insertion of multimedia contents and outlines of work adapted to the level of experience of trainees and the detection of the movements of the laparoscopic instrument into the monitored image. A module to track the instrument is implemented focusing on the tip of the laparoscopic tool. This tracking method does not need the presence of artificial marks or special colours to distinguish the instruments. Similarly, the system has another method based on visual tracking to localize support multimedia content in a stable position of the field of vision. Therefore, this position of the support content is adapted to the movements of the camera or the working area. Experimental results are presented to show the feasibility of the proposed system for assisting in laparoscopic surgical training.

The current state of Australian laparoscopic surgical skills training

The current state of Australian laparoscopic surgical skills training

Technology and medicine: The evolution of virtual reality simulation in laparoscopic training

Background: Virtual reality (VR) simulation for laparoscopic surgical training is now a reality. There is increasing evidence that the use of VR simulation is a powerful adjunct to traditional surgical apprenticeship in the current climate of reduced time spent in training.Aim: This article reviews the early evidence supporting the case for VR simulation training in laparoscopic surgery.Methods: A standard literature search was conducted using the following phrases – ‘virtual reality in surgical training’, ‘surgical training’, ‘laparoscopic training’ and ‘simulation in surgical training’.Results and conclusion: This article outlines the early evidence which supports the use of VR simulation in laparoscopic training and the need for further research into this new training technique.

Surgical Novice Response to Laparoscopic Surgery Training on Simulators before and after Training

Background: With the current stipulations of the 80-hour work week for residents, surgical programs are faced with dilemma of teaching surgical procedures to residents outside of the operating room. This along with the advancement of minimally invasive surgery and the public apprehension towards the “see one, do one, teach one” curriculum has lead to the introduction of simulation into surgical residency education curriculum. We looked at the ratings of usefulness training on laparoscopic surgical simulators by interns following a 2week period of daily training. We hypothesized that following the period of training novices would rate all modalities as a positive experience in accordance with their previously anticipated ratings. Methods: 32 interns rotating through the general surgery department were included in the study (10 General Surgery, 4 Orthopedic, 2 Otolaryngology, 3 Urology, 7 Radiology, 3 Plastic Surgery, 1 Vascular Surgery and 2 Neurosurgery). Participants were given an initial survey prior to their participation to evaluate their prior experience as well as their anticipated reaction to the usefulness of the teaching simulations. They then performed a laparoscopic cholecystectomy on a prosected pig liver in a box trainer (control). Following this all participants underwent 5 days of FLS training for 1.5 hours daily on the box trainer. The following week half of the participants continued to train on the FLS box trainer while the other half were randomly selected by number to train for 1.5 hours daily on the Simbionix LapMentor™ virtual reality trainer. At the end of the study they performed a laparoscopic cholecystectomy on a live pig, followed by an additional prosected pig liver in a box trainer for comparison. At the end of the study they filled out a survey assessing their experience on all modalities based on a Likert scale using questions involving perceived skill development, feedback on performance, realism and ability to better perform a laparoscopic cholecystectomy on a human. Results: Following the study, results from 28 of the 32 participants were evaluated (4 surveys were not completed with participation numbers and could not be verified for comparison). It was observed that the anticipated usefulness on all measures were decreased in the post training surveys compared to the initial surveys with statistical significance occurring in 13 of the 20 measured categories (p<0.05). The most notable significant decrease was with the skill development and feedback of the live pig (p<0.002 for each). Notable decreases in rating from perceived verse evaluative assessment for the box trainer were also found in skill development (p<0.008), feedback (p<0.01) and ability to better perform a laparoscopic cholecystectomy on a human (p<0.004). However, no statistically significant decreases were noted with the virtual reality simulator between the perceived advantage and actual assessment. Conclusion: Residents anticipated usefulness of different simulation strategies including box trainers, prosected pig livers and live pigs for laparoscopic surgical training is greater prior to training than their acknowledged usefulness following training on these simulators. Despite the overall decreased rating in usefulness for each simulation modalities, virtual reality simulators do not show a statistically significant decrease.

Graphic and haptic modelling of the oesophagus for VR‐based medical simulation

Medical simulators with vision and haptic feedback have been applied to many medical procedures in recent years, due to their safe and repetitive nature for training. Among the many technical components of the simulators, realistic and interactive organ modelling stands out as a key issue for judging the fidelity of the simulation. This paper describes the modelling of an oesophagus for a real-time laparoscopic surgical simulator. For realistic simulation, organ deformation and tissue cutting in the oesophagus are implemented with geometric organ models segmented from the Visible Human Dataset. The tissue mechanical parameters were obtained from in vivo animal experiments and integrated with graphic and haptic devices into the laparoscopic surgical simulation system inside an abdominal mannequin. This platform can be used to demonstrate deformation and incision of the oesophagus by surgical instruments, where the user can haptically interact with the virtual soft tissues and simultaneously see the corresponding organ deformation on the visual display. Current laparoscopic surgical training has been transformed from the traditional apprenticeship model to simulation-based methods. The outcome of the model could replace conventional training systems and could be useful in effectively transferring surgical skills to novice surgeons.

Review of Laparoscopic Training in Pediatric Surgery in the United Kingdom

To review the exposure pediatric surgery trainees have to laparoscopic surgery in the United Kingdom (UK). A confidential postal questionnaire was sent to all trainees working at registrar level in centers responsible for pediatric surgical training in the UK. Questions assessed the number of consultants with an interest in laparoscopic surgery, types of cases performed laparoscopically, and trainees' role in laparoscopic appendicectomy (LA). Questionnaires were sent to 112 trainees with a 55% response rate (62 replies). At least one response was received from each unit. Based on responses, 49 to 67 consultants in 21 training centers have an interest in laparoscopic surgery (0%-100% of consultants per unit). LA was offered in 20 out of 21 training centers. There was no significant difference in the proportion of appendicectomies performed laparoscopically by junior (years 1-3) and senior (years 4-6) trainees. A significantly higher proportion of junior trainees had not performed any LAs (P = 0.02). Seventy-three percent of trainees were the principal operator. For trainees who were principal operators, the cameraperson was a consultant in 52% and a junior trainee in 17%. The time of day affected the likelihood of a procedure being carried out laparoscopically in 43 (81%) responses. The majority of trainees' exposure to laparoscopic surgery could be viewed as suboptimal; however, the exposure gained varies significantly between different units throughout the UK. In an age moving in favor of minimal access surgery, all units must be in a position to offer pediatric laparoscopic surgical training.

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.

New Practical Course for Laparoscopy Training: Anatomizing the Orange

Purpose: The aim of this study was to evaluate whether anatomizing the orange reliably improves laparoscopic skills and can therefore be used as a course in laparoscopic surgical training. Materials and Methods: 12 trainees were required to practice baseline laparoscopic skills for 10 days and were then randomized into groups: 6 people who anatomized the orange for 1 h daily for 5 days and 6 in a control group who continued to practice the baseline laparoscopic skills. The trainees were tested on completing porcine laparoscopic nephrectomy. Operative performance was measured using a global assessment scale of surgical skill. Results: The total score of global rating scale was 23.4 ± 4.1 for the group who anatomized the orange and 18.3 ± 2.7 for the control group (p < 0.05). Operative performance significantly improved in the group anatomizing the orange. Conclusion: Anatomizing the orange resulted in improving laparoscopic skills and can be incorporated into the laparoscopic training course. This could be beneficial for those who wish to develop the advanced skills required for various laparoscopic surgery procedures.

Laparoscopy training in gynecologic oncology fellowship programs

ObjectiveTo assess the adequacy of laparoscopic surgical training as perceived by gynecologic oncology fellows-in-training and to compare current opinions to those on a 2003 survey. Study designFellows were surveyed via mail or an internet website. ResultsSeventy-eight (64%) of 121 fellows responded. One-hundred percent now state that laparoscopy is important or very important in gynecologic oncology practice compared to 86% in 2003. Ninety-five percent reported that much or maximum emphasis should be placed on laparoscopic training compared to 70% previously. Currently, 69% believe that their fellowship training in laparoscopy is very good or good compared to only 25% who felt this way 4 years ago. Importantly, fellows now believe they are getting better laparoscopic training in fellowship than they did in residency. Seventy-eight percent stated that their perceived laparoscopic skills were good or very good. Upon completion of fellowship, 94% plan to perform ≥6 cases per month laparoscopically. ConclusionsRespondents believe that laparoscopic training should be emphasized in fellowship training and perceive their laparoscopic training to be significantly improved compared to 2003. They also envision a key role for laparoscopy in their future practice.

Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery

Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience. Randomized clinical trials addressing this issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, grey literature and reference lists. Standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis. Twenty-three trials (mostly with a high risk of bias) involving 622 participants were included in this review. In trainees without surgical experience, VR training decreased the time taken to complete a task, increased accuracy and decreased errors compared with no training. In the same participants, VR training was more accurate than video trainer (VT) training. In participants with limited laparoscopic experience, VR training resulted in a greater reduction in operating time, error and unnecessary movements than standard laparoscopic training. In these participants, the composite performance score was better in the VR group than the VT group. VR training can supplement standard laparoscopic surgical training. It is at least as effective as video training in supplementing standard laparoscopic training.

Laparoscopic Colorectal Surgical Training: A Curricular Approach

Large, prospective, multi-centre randomized trials have confirmed the role of minimally invasive colorectal procedures in the armamentarium of the surgical specialist. However, the learning curve for this procedure has been stated to be of the order of 50 to 400 procedures for a variety of different resections. This is known to vary between surgeons, and can also be influenced by patient selection and operative complexity. The aim of this article is to develop a structured, proficiency-based training program, with the facets of curricular design taken from a previously published framework of technical skills training, known as STATS (Systematic Training and Assessment in Technical Skills). There is a heavy emphasis on the use of simulated tissues to teach skills required. In order to enable objective assessment of performance, a procedure-specific global rating scale has been developed for assessment of performance during a laparoscopic anterior resection. An important part of the training program is to deliver team-based training for laparoscopic colorectal surgery. A key aspect of the curriculum is to focus on training the trainers, and it is with this advancement that opportunities shall evolve for surgical residents to learn these novel techniques, leading to their safe delivery with direct benefit to patients.

Validated robotic laparoscopic surgical training in a virtual-reality environment

A robotic virtual-reality (VR) simulator has been developed to improve robot-assisted training for laparoscopic surgery and to enhance surgical performance in laparoscopic skills. The simulated VR training environment provides an effective approach to evaluate and improve surgical performance. This study presents our findings of the VR training environment for robotic laparoscopy. Eight volunteers performed two inanimate tasks in both the VR and the actual training environment. The tasks were bimanual carrying (BC) and needle passing (NP). For the BC task, the volunteers simultaneously transferred two plastic pieces in opposite directions five times consecutively. The same volunteers passed a surgical needle through six pairs of holes in the NP task. Both tasks require significant bimanual coordination that mimics actual laparoscopic skills. Data analysis included time to task completion, speed and distance traveled of the instrument tip, as well as range of motion of the subject's wrist and elbow of the right arm. Electromyography of the right wrist flexor and extensor were also analyzed. Paired t-tests and Pearson's r were used to explore the differences and correlations between the two environments. There were no significant differences between the actual and the simulated VR environment with respect to the BC task, while there were significant differences in almost all dependent parameters for the NP task. Moderate to high correlations for most dependent parameters were revealed for both tasks. Our data shows that the VR environment adequately simulated the BC task. The significant differences found for the NP task may be attributed to an oversimplification in the VR environment. However, they do point to the need for improvements in the complexity of our VR simulation. Further research work is needed to develop effective and reliable VR environments for robotic laparoscopic training.