Prior Laparoscopic Experience Research Articles

Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience.

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown. To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013. We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training. Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible. We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training. There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Construct validity of individual and summary performance metrics associated with a computer-based laparoscopic simulator

Computer-based surgical simulators capture a multitude of metrics based on different aspects of performance, such as speed, accuracy, and movement efficiency. However, without rigorous assessment, it may be unclear whether all, some, or none of these metrics actually reflect technical skill, which can compromise educational efforts on these simulators. We assessed the construct validity of individual performance metrics on the LapVR simulator (Immersion Medical, San Jose, CA, USA) and used these data to create task-specific summary metrics. Medical students with no prior laparoscopic experience (novices, N=12), junior surgical residents with some laparoscopic experience (intermediates, N=12), and experienced surgeons (experts, N=11) all completed three repetitions of four LapVR simulator tasks. The tasks included three basic skills (peg transfer, cutting, clipping) and one procedural skill (adhesiolysis). We selected 36 individual metrics on the four tasks that assessed six different aspects of performance, including speed, motion path length, respect for tissue, accuracy, task-specific errors, and successful task completion. Four of seven individual metrics assessed for peg transfer, six of ten metrics for cutting, four of nine metrics for clipping, and three of ten metrics for adhesiolysis discriminated between experience levels. Time and motion path length were significant on all four tasks. We used the validated individual metrics to create summary equations for each task, which successfully distinguished between the different experience levels. Educators should maintain some skepticism when reviewing the plethora of metrics captured by computer-based simulators, as some but not all are valid. We showed the construct validity of a limited number of individual metrics and developed summary metrics for the LapVR. The summary metrics provide a succinct way of assessing skill with a single metric for each task, but require further validation.

Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience.

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown.To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training.We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training.Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training.There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Board 386 - Research Abstract Measuring Changes in Skill Acquisition and Mental Workload on Two Laparoscopic Tasks (Submission #628)

Introduction/Background Laparoscopy places significant demands on visual attention and requires extensive practice to become proficient. Scerbo et al. have developed a method of assessing mental workload with a secondary task that requires spatial abilities.1,2 The task is based on multiple resource theory, which states that “pools” of attentional resources are distinguished by: information processing stages, verbal/spatial codes, and visual/auditory modalities.3 When two tasks performed simultaneously require the same pool of resources, they can interfere with one another and increase mental workload. Thus, when a secondary task requiring the same attentional resources needed for laparoscopy is performed with a laparoscopic task, it can provide an index of mental workload. Our goal was to use a spatial secondary task to measure mental workload during the initial acquisition of basic laparoscopic skills on a simulator. Performance on two laparoscopic tasks differing in difficulty was measured across training sessions. We hypothesized that mental workload would initially be high (and more so on the difficult task) but would decline over sessions as trainees became more proficient as indexed by secondary task performance. Methods Fourteen surgical assistant students with no prior laparoscopic experience participated in this IRB approved, repeated measures study. They practiced cutting (high difficulty) and peg transfer (low difficulty) tasks from the Fundamentals of Laparoscopic Surgery for approximately 45 min over 11 sessions and were assessed with the secondary task at the end of each session. The secondary task presented observers with four balls in a simulated tunnel, superimposed at 50% transparency over the laparoscopic display. The balls were presented for 300 msec approximately every 4 sec. On half the presentations, one ball changed its position and participants responded to that change by pressing a foot pedal. They performed the secondary task by itself and in conjunction with the laparoscopic tasks. Results All data were analyzed with a 2 Condition x 11 Session repeated measures ANOVA. There was a significant effect for laparoscopic tasks, F(1,11) = 15.72, p = .002, partial Æž2 =.59. Completion times were faster for the peg (M = 102.57 sec, SE = 5.30) than the cutting task (M = 121.90 sec, SE = 5.08). Times declined significantly over sessions, F(10,110) = 38.88, p < .001, partial Æž2 =.77, but leveled off by the sixth and second sessions for the peg and cutting tasks, respectively. There were significant effects for the secondary task scores, F(1,12) = 31.88, p = .000, partial Æž2 =.73. The proportion of correct responses for cutting (M = .36, SE = .07) was lower than for pegs (M = .46, SE = .07), and scores on both tasks were lower than the secondary task performed by itself. Scores increased over sessions,F(10,120) = 3.11, p = .001, partial Æž2 =.21; but only the difference between the first (M = .31, SE = .05) and eleventh session (M = .45, SE = .07) was significant. Conclusion The Results show that performance on the peg and cutting tasks reached a plateau midway through the training sessions. The findings for the spatial secondary task supported expectations. Workload was initially higher (lowers scores) and remained higher for the more difficult cutting task and although the scores increased over sessions for both tasks, the improvements were modest. These Results show that the mental workload experienced by novices practicing laparoscopic tasks may be quite high. They also support findings obtained by Stefanidis et al. on a suturing task who observed high levels of mental workload by novices who had met their training goals.2 Collectively, these findings show that the spatial secondary task provides an objective index of mental workload, offering a broader picture of laparoscopic skill acquisition.

Ramifications of Single-Port Laparoscopic Surgery

Single-port laparoscopic surgery imposes unique psychomotor challenges. We used surgical simulation to define performance differences between surgeons with and without single-port clinical experience and examined whether a short course of training resulted in improved performance. Study participants were assigned to 3 groups: resident group (RES), experienced laparoscopic surgeons with (SP) and without (LAP) prior single-port laparoscopic experience. Participants performed the Fundamentals of Laparoscopic Surgery precision cutting task on a ProMIS trainer through conventional ports or with articulating instruments via a SILS Port (Covidien, Inc). Two iterations of each method were performed. Then, 6 residents performed 10 successive single-port iterations to assess the effect of practice on task performance. The SP group had faster task times for both laparoscopic (P = .0486) and single-port (P = .0238) methods. The LAP group had longer path lengths for the single-port task than for the laparoscopic task (P = .03). The RES group was slower (P = .0019), with longer path length (P = .0010) but with greater smoothness (P = .0186) on the single-port task than the conventional laparoscopic task. Resident performance task time (P = .005) and smoothness (P = .045) improved with successive iterations. Our data show that surgeons with clinical single-port surgery experience perform a simulated single-port surgical task better than inexperienced single-port surgeons. Furthermore, this performance is comparable to that achieved with conventional laparoscopic techniques. Performance of residents declined dramatically when confronted with the challenges of the single-port task but improved with practice. These results suggest a role for lab-based single-port training.

Instructor Feedback Versus No Instructor Feedback on Performance in a Laparoscopic Virtual Reality Simulator

To investigate the impact of instructor feedback versus no instructor feedback when training a complex operational task on a laparoscopic virtual reality simulator. : Simulators are now widely accepted as a training tool, but there is insufficient knowledge about how much feedback is necessary, which is useful for sustainable implementation. A randomized trial complying with CONSORT Statement. All participants had to reach a predefined proficiency level for a complex operational task on a virtual reality simulator. The intervention group received standardized instructor feedback a maximum of 3 times. The control group did not receive instructor feedback. Participants were senior medical students without prior laparoscopic experience (n = 99). Outcome measures were time, repetitions, and performance score to reach a predefined proficiency level. Furthermore, influence of sex and perception of own surgical skills were examined. Time (in minutes) and repetitions were reduced in the intervention group (162 vs 342 minutes; P < 0.005) and (29 vs 65 repetitions; P < 0.005). The control group achieved a higher performance score than the intervention group (57% vs 49%; P = 0.004). Men used less time (in minutes) than women (P = 0.037), but no sex difference was observed for repetitions (P = 0.20). Participants in the intervention group had higher self-perception regarding surgical skills after the trial (P = 0.011). Instructor feedback increases the efficiency when training a complex operational task on a virtual reality simulator; time and repetitions used to achieve a predefined proficiency level were significantly reduced in the group that received instructor feedback compared with the control group. NCT01497782.

Navigating the Difficult Robotic Assisted Pyeloplasty

Pyeloplasty is the gold standard therapy for ureteropelvic junction obstruction. Robotic assisted pyeloplasty has been widely adopted by urologists with and without prior laparoscopic pyeloplasty experience. However, difficult situations encountered during robotic assisted pyeloplasty can significantly add to the difficulty of the operation. This paper provides tips for patient positioning, port placement, robot docking, and intraoperative dissection and repair in patients with the difficult situations of obesity, large floppy liver, difficult to reflect colon (transmesenteric pyeloplasty), crossing vessels, large calculi, and previous attempts at ureteropelvic junction repair. Techniques presented in this paper may aid in the successful completion of robotic assisted pyeloplasty in the face of the difficult situations noted above.

Virtual reality training followed by box training improves the laparoscopic skills of novice surgeons

Background: The detailed influence of virtual reality training (VRT) and box training (BT) on laparoscopic performance is unknown; we aimed to determine the optimal order of imparting these training programs. Material and methods: This randomized controlled trial involved two groups, each with 20 participants without prior laparoscopic surgical experience: A BT-VRT group (60 min BT followed by 60 min VRT) and a VRT-BT group (60 min VRT followed by 60 min BT). We objectively assessed the laparoscopic skills with a motion-analysis system (Hiroshima University Endoscopic Surgical Assessment Device: HUESAD), which reliably assesses surgical dexterity. Skill assessment was performed before and after the training session. Results: No inter-group differences were identified in the study measures at the pre-training assessment. In both groups, the performance on all tasks was significantly better at the post-training assessment than at the pre-training assessment. However, the outcome of the tests using the HUESAD was significantly better in the VRT-BT group than in the BT-VRT group at the post-training assessment. Conclusions: VRT followed by BT effectively improves the dexterity of novice surgeons during initial laparoscopic (combination) training.

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.

Learning basic surgical skills through simulator training

Computer-based surgical training simulators are instrumental in skill-based training and performance measurement. However, to date, the educational employment of these tools lacks empirically founded insights and effective practical guidelines. This study examined surgical residents during computer-based simulator training of basic laparoscopic surgical skills. The quantitative analysis of residents’ performance averages from training onset to completion produced mixed results, revealing skill improvements as well as decreases, depending on the parameter. The results obtained from the simulator parameters and questionnaires showed that residents with either prior laparoscopic experience or gaming experience significantly outperformed their colleagues. Based on feedback and video-recorded performance analysis, the study concluded that autonomous training with the simulator is not sufficient for developing a minimum standard of performance. Residents need an adequate level of content-based feedback and supervisor support during training. We advise a more detailed and pedagogically informative measurement and feedback system, including specialist-instructor guidance, be developed.

Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized educational trial

BackgroundSeveral studies have found a positive effect on the learning curve as well as the improvement of basic psychomotor skills in the operating room after virtual reality training. Despite this, the majority of surgical and gynecological departments encounter hurdles when implementing this form of training. This is mainly due to lack of knowledge concerning the time and human resources needed to train novice surgeons to an adequate level. The purpose of this trial is to investigate the impact of instructor feedback regarding time, repetitions and self-perception when training complex operational tasks on a virtual reality simulator.Methods/DesignThe study population consists of medical students on their 4th to 6th year without prior laparoscopic experience. The study is conducted in a skills laboratory at a centralized university hospital. Based on a sample size estimation 98 participants will be randomized to an intervention group or a control group. Both groups have to achieve a predefined proficiency level when conducting a laparoscopic salpingectomy using a surgical virtual reality simulator. The intervention group receives standardized instructor feedback of 10 to 12 min a maximum of three times. The control group receives no instructor feedback. Both groups receive the automated feedback generated by the virtual reality simulator. The study follows the CONSORT Statement for randomized trials. Main outcome measures are time and repetitions to reach the predefined proficiency level on the simulator. We include focus on potential sex differences, computer gaming experience and self-perception.DiscussionThe findings will contribute to a better understanding of optimal training methods in surgical education.Trial RegistrationNCT01497782

V495 NAVIGATING THE DIFFICULT ROBOTIC PYELOPLASTY: TIPS AND TRICKS

You have accessJournal of UrologyTransplantation, Urolithiasis & Hydronephrosis1 Apr 2011V495 NAVIGATING THE DIFFICULT ROBOTIC PYELOPLASTY: TIPS AND TRICKS David Thiel and Alex Rogers David ThielDavid Thiel Jackosnville, FL More articles by this author and Alex RogersAlex Rogers Jacksonville, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.591AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urology has adopted the da Vinci surgical system (Intuitive Surgical Corp, Sunnyvale, CA) for robotic assisted laparoscopic prostatectomy. Use of the technology has been expanded to other complex reconstructive urologic procedures such as pyeloplasty. Robotic assisted pyeloplasty (RAP) is being performed by many surgeons without prior laparoscopic experience. Difficult situations encountered intra-operatively can increase operating room time, increase morbidity, and decrease the success of RAP. METHODS Patient selection, port placement, ureteropelvic junction obstruction (UPJO) exposure, UPJO excision and repair are reviewed and tips given to circumvent difficult situations encountered during RAP. The video demonstrates techniques to aid in cases of extreme obesity, a large floppy liver, difficult to reflect colon (trans-mesenteric pyeloplasty), crossing vessels, large calculi, and previous attempts at UPJO repair. RESULTS Techniques to aid in successful completion of RAP in the face of extreme obesity, a large floppy liver, difficult to reflect colon (trans-mesenteric pyeloplasty), crossing vessels, large calculi, and previous attempts at UPJO repair are demonstrated. CONCLUSIONS This video demonstrates tips to aid in successful completion of UPJO repair in the face of difficult situations commonly encountered during surgery. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e202 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Thiel Jackosnville, FL More articles by this author Alex Rogers Jacksonville, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Relationship between Tests of Neurocognition and Performance on a Laparoscopic Simulator

Objective. To estimate if there is a relationship between the results of tests of neurocognition and performance on a laparoscopic surgery simulator. Methods and Materials. Twenty participants with no prior laparoscopic experience had baseline cognitive tests administered (Trail Making Test, Part A and B (TMT-A and TMT-B), Grooved Peg Board Test, Symbol Digit Modalities Test, Symbol Digit Recall Test, and Stroop Interference Test), completed a demographic questionnaire, and then performed laparoscopy using a simulator. We correlated the results of cognitive tests with laparoscopic surgical performance. Results. One cognitive test sensitive to frontal lobe function, TMT-A, significantly correlated with laparoscopic surgical performance on the simulator (correlation coefficient of 0.534 with P < .05). However, the correlation between performance and other cognitive tests (TMT-B, Grooved Peg Board Test, Symbol Digit Modalities Test, Symbol Digit Recall Test, and Stroop Interference Test) was not statistically significant. Conclusion. Laparoscopic performance may be related to measures of frontal lobe function. Neurocognitive tests may predict motor skills abilities and performance on laparoscopic simulator.

Surgical experience and results in transperitoneal laparoscopic adrenalectomy

IntroductionLaparoscopic adrenalectomy is currently the gold standard for surgical management of adrenal disease. ObjectivesTo analyze our results after 12 years of experience in this surgery and to compare them to those of the main published series. Material and methodsA descriptive, retrospective study. An analysis was made of 100 adrenalectomies performed from June 1997 to June 2009. Variables analyzed included age, size, side, preoperative diagnosis, operating time, blood loss, conversion to open surgery, mean hospital stay, and pathological report. A Fisher's exact test and a Chisquare test were used to compare categorical data. A Student's t test was used to compare independent group means with a normal distribution. A value of p<0.05 was considered statistically significant. ResultsMean patient age was 53.1 years (± 14.4). Mean lesion size was 3.7cm (± 2.2), and lesions occurred in the left side in 51% of cases. Mean follow-up time was 15 months (± 11.9). Preoperative diagnoses were functional mass (44%), pheochromocytoma (17%), incidentaloma >4cm (20%), metastasis (10%), and adrenal carcinoma (5%). Mean operating time was 145.1min (± 55.6). Mean hematocrit decrease was 6.26 points (± 3.3). Conversion to open surgery was required in 9.6% of patients. Prolonged postoperative ileus occurred in two patients. Transfusion was required in two patients. One patient died from decompensated liver cirrhosis. Eighty percent of complications occurred in the right side. Mean hospital stay was 6 days (± 5.6). In the last 30 procedures, significant differences in operating time (119.1min vs 171.2min) and mean hospital stay (4.1 vs 6.1 days) were found in the group of the last 30 procedures (p<0.05). ConclusionsTransperitoneal laparoscopic adrenalectomy is a feasible and safe surgical procedure in the hands of teams with prior laparoscopic experience. Our efficacy and morbidity results are similar to those reported by other series.

Face and construct validity of virtual reality simulation of laparoscopic gynecologic surgery

The objective of the study was to validate virtual reality simulation in assessing laparoscopic skills in gynecology by establishing the extent of realism of the simulation to the actual task (face validity) and the degree to which the results of the test one uses reflects the subject tested (construct validity). Subjects (n = 56) were divided into 3 groups: novices (n = 15), intermediates (n = 20), and experts (n = 21). Participants completed 3 repetitions of a training program consisting of 4 basic skills and 3 gynecologic procedural simulations. The performance was compared between groups using a post hoc Student t test with the Bonferroni technique. Face validity was determined by using a questionnaire of 27 statements. Resulting from the questionnaire, the opinion about the realism and training capacities of the tasks was favorable among all groups. The degree of prior laparoscopic experience was reflected in the outcome performance parameters of the tasks. Experts achieved significant better scores on specific parameters. The results of this study indicate acceptance and thus face validity of the system among both reference (novice, intermediate) and expert group. There is a significant difference between subjects with different laparoscopic experience and thereby construct validity for the laparoscopic simulator could be established.

Adoption of Laparoscopic Colectomy: Results and Implications of ASCRS Hands-On Course Participation

Beginning in 2003, the American Society of Colon and Rectal Surgeons has annually sponsored a laparoscopic colon and rectal surgery instructional course using a cadaver model. This study reports the adoption rate and postcourse practice patterns of participants. All prior participants of hands-on courses from 2003 to 2005 were asked to participate in a 25-question survey. Questions probed practice setting, prior laparoscopic experience, motivation for course participation, time to, indication for, and type of first laparoscopic colectomy, experience prior to cancer resection, factors facilitating skill acquisition, and impact on practice from course completion. A total of 43 of 63 participants completed the survey and 53% had performed at least 1 laparoscopic colon resection prior to the course. A laparoscopic colon resection was performed within 1 week of the course by 52% of participants and within 1 month by 90%. Laparoscopic colectomy was performed frequently postcourse with 42% performing between 1 and 5 laparoscopic colectomies/month and 42% between 5 and 10. Hand-assisted technologies lowered the threshold for performance of first laparoscopic colectomy for 62% of participants. Cancer resection was the first procedure for 31% and 36% performed between 5 and 10 colectomies prior to cancer resection. Most important factor in particular course selection was a cadaver model (77%). A majority of the participants would require course completion prior to granting hospital privileges (73%) and would recommend the course to other surgeons (97%). Cadaver course completion enables rapid integration of laparoscopic colon resection into clinical practice. Experience prior to laparoscopic resection of cancer is modest. Hand-assisted technologies promote technique acquisition.

Laparoscopic Renal Oncological Surgery in the Presence of Abdominal Aortic and Vena Caval Pathology: 8-Year Experience

To our knowledge the outcomes of laparoscopic renal oncological surgery in patients with major aortic and/or inferior vena caval pathology are unknown. We present our experience spanning an 8-year period. From March 1998 to October 2006, 1,826 laparoscopic renal procedures were performed for tumor. Of these patients 66 (3.6%) had major abdominal aortic or vena caval pathology concomitantly. Demographics, specific entities of the vascular disease, and intraoperative and postoperative data were reviewed. A total of 66 patients had a history of abdominal aortic disease (54), vena caval disease (9) or both (3). Of the patients 85% had 3 or greater comorbidities, 88% had an American Society of Anesthesiologists score of 3 or greater and 88% were on chronic anticoagulation therapy. A total of 27 patients (41%) had undergone prior surgical treatment for vascular pathology. Laparoscopic renal surgery, which was transperitoneal in 25 cases and retroperitoneal in 41, included radical nephrectomy in 20, partial nephrectomy in 17 and cryoablation in 29. Open conversion was performed in 3 patients (5%). There were 3 intraoperative (5%) and 9 postoperative (14%) complications. One patient died of pulmonary sepsis. There was no statistically significant difference in perioperative outcomes between the aortic and vena caval disease groups. The retroperitoneal approach was associated with less blood loss and shorter operative time (p = 0.0003 and 0.004, respectively). Laparoscopic surgery for renal tumor in the presence of aortic or vena caval disease is safe and feasible. Considerable prior laparoscopic experience is necessary when treating these patients at high risk.

The Impact of Using a Porcine Model in Laparoscopic Partial Nephrectomy Training

Purpose: We assessed the impact of using a porcine model on the training of laparoscopic partial nephrectomy (LPN) and compared the training effectiveness between surgeons with and without previous laparoscopic experience. Materials and Methods: Surgeon A had previous laparoscopic experience, with the exception of LPN, while surgeon B had no prior laparoscopic experience. A tumor model was created by subcapsular injection of liquid plastic (Smooth-Cast 320) in the kidney. We recorded the total operation time, the bowel dissection time, the renal pedicle dissection time, the warm ischemic time, the mass resection time, the suture time, and the presence of major complications for each surgeon. Results: The mean operation time was significantly shorter for surgeon A compared to surgeon B (49.1±4.5 and 63.6±8.4 minutes, respectively, p< 0.001). Although the mass resection time was significantly shorter for surgeon A as well, there were no significant differences between the two surgeons in terms of warm ischemia time and suture time. As the training progressed, surgeon B improved in all surgical steps and surgeon A showed improvement in time for warm ischemia and suturing the defect. Five complications occurred (two cases by surgeon A and three cases by surgeon B). Conclusions: A porcine model improved the skills needed for LPN, including shortening the warm ischemia and suture times. LPN is a procedure requiring technically-demanding skills that can be improved by training using a animal model, regardless of the previous laparoscopic experiences. (Korean J Urol 2008;49:868-873) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Does a One-Day Course Influence Surgeon Adoption of Laparoscopic Ventral Herniorrhaphy?

New laparoscopic techniques introduced after residency have created a new teaching paradigm focused on animate courses and preceptor instruction. The aim of this study was to test the effectiveness of animate course instruction in teaching laparoscopic ventral hernia repair (LVHR), its success in relationship to the course participants' previous minimally invasive surgery experience, and the role of preceptors in adapting these techniques. Surgeons participating in a one-day LVHR course (lectures/animal laboratory) at the Carolinas Medical Center were surveyed concerning professional demographics, prior laparoscopic experience, and their performance of LVHR before and after the encounter. Standard statistics were used to determine significance (P<0.05). Of the 234 surgeons attending a LVHR course between 1999 and 2004, 171 (73%) answered the survey. Mean follow-up after the course was 427 days (range: 34-1202 d). Mean age was 45.9 years (range: 28-67 y). Mean time since residency was 14.4 years (range: 0.5-37 y), and 106 (62%) had learned at least basic laparoscopy in residency. One hundred twenty-six (73.7%) were in private practice. Since the course, 122 (71.3%) had performed a LVHR. They had performed a total of 2049 LVHRs (mean: 16.5; range: 1-102) compared with 1098 open herniorrhaphies (mean: 9; range: 1-23). There was no difference between those performing and not performing LVHR or the number executed with respect to practice type (P=0.67), age (P=0.47), years in practice (P=0.19), or laparoscopic experience in residency (P=0.42). Fifty-four (32%) surgeons had been precepted, and all have since performed LVHR. Surgeons with advanced laparoscopic experience were more likely to perform LVHR compared with those with only laparoscopic cholecystectomy experience (87% versus 33%, P=0.02). Indeed, of those with only laparoscopic cholecystectomy experience who performed LVHR, 80% were precepted. In the subset of surgeons who had not yet performed LVHR, 28 intended to start, 17 requested assistance, and 4 planned not to begin. A one-day course impacts surgeon practice patterns despite age or type of practice. Surgeons with advanced laparoscopic skills are more likely to perform LVHR. Most with limited experience will begin after working with a preceptor. Didactic instruction and a precepted experience may determine the future performance of advanced laparoscopy.

Optimal teaching environment for laparoscopic ventral herniorrhaphy

Background: New laparoscopic techniques introduced after residency have created a new teaching paradigm focused on animate courses and preceptor instruction. The aim of this study was to test the effectiveness of animate courses and preceptor instruction in learning laparoscopic ventral hernia repair(LVHR). Methods: Surgeons participating in a 1-day LVHR course(lectures/animal lab) were surveyed concerning professional demographics, prior laparoscopic experience, and their LVHR performance. Standard statistics were used to determine significance(p<0.05).