Suturing Task Research Articles

Does variability among surgical skills diminish throughout surgical internship? Analysis of a 5-task surgical simulation assessment program starting Day 1

BackgroundSimulation assessments are not yet standardized among surgical programs. We instituted a 5-task simulation program to assess surgical technical skills longitudinally during internship. MethodsFirst-year residents completed 5 simulation tasks: suturing, knot-tying, vascular anastomosis, and the peg-transfer and the intracorporeal suturing of the Fundamentals of Laparoscopic Skills. Assessments occurred just before residency, mid-year, and at the completion of the intern year. ResultsThis study involved 19 residents: 8 categorical, 4 urology, 3 interventional radiology, 2 plastics, and 2 non-designated preliminary interns. Mean completion times improved in both the Fundamentals of Laparoscopic Skills peg-transfer (145 ± 50, 111 ± 47, and 95 ± 28 seconds) and suturing (526 ± 92, 392 ± 131, and 351 ± 158 seconds; each P < .001) tasks, and decreased variability was noted in the former. Total scores trended to improve (P = .013). Interns underwent similar training; 95% completed at least 1 core rotation by mid-year. Surgical specialty was associated with total scores during the first knot-tying session, with plastics residents scoring highest; however, all scores progressed toward the group median over time. ConclusionTechnical skills of beginning surgery residents were assessed longitudinally with the institution of a 5-task curriculum. Periodic assessments showed improvement in each task. Furthermore, as residents were exposed to equal surgical training, the variability in resident scores showed the greatest decrease in simpler motor tasks.

Multi-DOF (Degree of Freedom) Articulating Laparoscopic Instrument is an Effective Device in Performing Challenging Sutures.

PurposeAlthough laparoscopic surgery had been performed in clinical practice for over 30 years, there has not been much improvement on instruments. Several articulating laparoscopic instruments have been developed including the robotic system. A new multi-degree of freedom (DOF) articulating laparoscopic device has been developed. We compared the ability to perform challenging sutures between the new device and the robotic system.MethodsFive experienced surgeons with over 100 laparoscopic surgery cases performed the suture task with both instruments. Everyone was new at articulating instruments including a robotic system. The suturing task consisted of two vertical sutures, downward and upward vertical direction. The duration of needle grabbing, first surgical tie, square tie, and the final reverse tie was measured.ResultsWhen doing the downward suture, the median time to complete the suture was 127 vs. 136 seconds for ArtiSential® and the robot, respectively (p=0.754). Other measurements such as needle grabbing, first tie, second tie and final knot did not show any significant difference between the two instruments. Upward suture also did not show a significant difference. The total completion time was 127 vs. 112 seconds for for ArtiSential® and the robot, respectively (p=0.675). Time taken in each interval did not show any significant difference.ConclusionBoth instruments performed the suturing tasks with no difference in duration. ArtiSential® can be mixed up with usual instruments. Surgeons can choose any device, but when articulation is needed, ArtiSential® could be an alternative choice to the robotic system.

Robot assisted versus laparoscopic suturing learning curve in a simulated setting

BackgroundCompared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills like minimally invasive suturing. This study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted suturing.MethodNovice participants performed three suturing tasks on the EoSim laparoscopic augmented reality simulator or the RobotiX robot assisted virtual reality simulator. Each participant performed an intracorporeal suturing task, a tilted plane needle transfer task and an anastomosis needle transfer task. To complete the learning curve, all tasks were repeated up to twenty repetitions or until a time plateau was reached. Clinically relevant and comparable parameters regarding time, movements and safety were recorded. Intracorporeal suturing time and cumulative sum analysis was used to compare the learning curves and phases.ResultsSeventeen participants completed the learning curve laparoscopically and 30 robot assisted. Median first knot suturing time was 611 s (s) for laparoscopic versus 251 s for robot assisted (p < 0.001), and this was 324 s versus 165 (sixth knot, p < 0.001) and 257 s and 149 s (eleventh knot, p < 0.001) respectively on base of the found learning phases. The percentage of ‘adequate surgical knots’ was higher in the laparoscopic than in the robot assisted group. First knot: 71% versus 60%, sixth knot: 100% versus 83%, and eleventh knot: 100% versus 73%. When assessing the ‘instrument out of view’ parameter, the robot assisted group scored a median of 0% after repetition four. In the laparoscopic group, the instrument out of view increased from 3.1 to 3.9% (left) and from 3.0 to 4.1% (right) between the first and eleventh knot (p > 0.05).ConclusionThe learning curve of minimally invasive suturing shows a shorter task time curve using robotic assistance compared to the laparoscopic curve. However, laparoscopic outcomes show good end results with rapid outcome improvement.

Less is more: creation and validation of a novel, affordable suturing simulator for anorectal surgery.

Duty hour restrictions have increased the role of simulation in surgical education. A simulation that recreates the unique visual, anatomic, and ergonomic challenges of anorectal surgery has yet to be described. The aim of this study was to develop a low-cost, low-fidelity anorectal surgery simulator and provide validity evidence for the model. A novel, low-fidelity simulator was constructed, and anorectal surgery workshops were implemented for general surgery interns at a single institution. Face and content validity were assessed with separate questionnaires using a 5-point Likert scale. Participants performed a simulated hemorrhoid excision with longitudinal wound closure, and transverse wound closure. Time-to-task completion and quality of suturing/knot tying were evaluated by a blinded observer to assess construct validity. Material cost was US $11 per simulator. We recruited 20 first-year surgery residents (novices) and 4 practicing colorectal surgeons (experts), and conducted 3 workshops in 2014-2016. All face and content validity measures achieved a median score greater than 4 (range 4.0-5.0). Time-to-task completion was significantly lower in the expert cohort (hemorrhoid excision with longitudinal wound closure: 195 vs. 477s and transverse closure: 79 vs. 192s, p < 0.001 for both). Suturing and knot-tying scores were significantly higher in the expert cohort for both tasks (p < 0.05 for all comparisons). Our low-fidelity, low-cost anorectal surgery model demonstrated evidence of face, content, and construct validity. We believe that this simulator could be a useful instrument in the education of junior surgical trainees and will allow residents to obtain proficiency in anorectal suturing tasks in conjunction with traditional surgical training.

Impact of robotic assistance on mental workload and cognitive performance of surgical trainees performing a complex minimally invasive suturing task.

Few studies have investigated the potential impact of robotic assistance on cognitive ergonomics during advanced minimally invasive surgery. The purpose of this study was to assess the impact of robotic assistance on mental workload and downstream cognitive performance in surgical trainees. Robot-naïve trainees from general surgery, urology and gynaecology, stratified by specialty and level of training, were randomised to either laparoscopic surgery (LS) or robotic-assisted laparoscopic surgery (RALS) and performed a time-limited, complex laparoscopic suturing task after watching a 5-min instructional video. The RALS group received an additional 5-min orientation to the robotic console. Subjective mental workload was measured using NASA Task Load Index. Concentration and executive cognitive function were assessed using Psychomotor Vigilance Task (PVT) and Wisconsin Card Sorting Test (WCST), respectively. A p value of 0.05 was considered significant. Sixteen senior residents (SR; ≥ PGY3) and 14 junior residents (JR; PGY1-2) completed the study. There was no difference in mental workload between LS and RALS. Within JR there was no difference in task completion time comparing LS versus RALS; however, LS was associated with impaired concentration post-task versus pre-task (PVT reaction time 306 versus 324ms, p = 0.03), which was not observed for RALS. In contrast, amongst SR, RALS took significantly longer than LS (10.3 vs. 14.5min, p = 0.02) and was associated with significantly worse performance on WCST (p < 0.01). Robotic assistance, in this setting, did not provide a technical performance advantage nor impact subjective mental workload with novice users regardless of level of surgery training. We observed a protective effect on cognitive performance offered by RALS to junior trainees with limited LS experience, yet a detrimental effect on senior trainees with greater LS ability and inadequate pre-study robotic training, suggesting that robotic consoles may be mentally taxing for robotic novices and consideration should be given to formal console training prior to initial clinical exposure.

Characterizing the learning curve of a virtual intracorporeal suturing simulator VBLaST-SS©.

The virtual basic laparoscopic skill trainer suturing simulator (VBLaST-SS©) was developed to simulate the intracorporeal suturing task in the FLS program. The purpose of this study was to evaluate the training effectiveness and participants' learning curves on the VBLaST-SS© and to assess whether the skills were retained after 2weeks without training. Fourteen medical students participated in the study. Participants were randomly assigned to two training groups (7 per group): VBLaST-SS© or FLS, based on the modality of training. Participants practiced on their assigned system for one session (30min or up to ten repetitions) a day, 5days a week for three consecutive weeks. Their baseline, post-test, and retention (after 2weeks) performance were also analyzed. Participants' performance scores were calculated based on the original FLS scoring system. The cumulative summation (CUSUM) method was used to evaluate learning. Two-way mixed factorial ANOVA was used to compare the effects of group, time point (baseline, post-test, and retention), and their interaction on performance. Six outof seven participants in each group reached the predefined proficiency level after 7days of training. Participants' performance improved significantly (p < 0.001) after training within their assigned group. The CUSUM learning curve shows that one participant in each group achieved 5% failure rate by the end of the training period. Twelve out of fourteen participants' CUSUM curves showed a negative trend toward achieving the 5% failure rate after further training. The VBLaST-SS© is effective in training laparoscopic suturing skill. Participants' performance of intracorporeal suturing was significantly improved after training on both systems and was retained after 2 weeks of no training.

Vaginal Hysterectomy Suturing Skills Training Model and Curriculum.

Declining vaginal hysterectomy numbers in obstetrics and gynecology training programs highlights the need for innovative methods to teach vaginal surgical skills. We describe our experience with a vaginal hysterectomy skills simulation curriculum. A low-fidelity bench model was constructed to simulate four vaginal hysterectomy suturing tasks. A polyvinyl chloride downspout adapter and low-cost materials simulate the Heaney pedicle stitch, simple pedicle stitch, double ligature, and continuous running stitch. Faculty expert vaginal surgeons established proficiency levels for each task. Resident (N=30) pass rates for tasks 1, 2, and 3 were 1 of 30 (3.3%), 7 of 30 (23.3%), and 4 of 30 (13.3%), respectively, for the left side, and 3 of 30 (10%), 9 of 30 (30%), and 10 of 30 (33.3%), respectively, for the right side. For task 4, the pass rate was 14 of 30 (46.7%). The majority of residents felt that the model simulates the technical skills required for vaginal hysterectomy and agreed that vaginal skills laboratory training would improve their ability to perform procedures in the operating room. Ninety-two percent of residents felt that a vaginal surgery skills curriculum would be a useful addition to their simulation education. A proficiency-based vaginal hysterectomy skills simulation curriculum using a low-fidelity model may be an important training and evaluation tool for vaginal surgical skills training.

Competency assessment tool for laparoscopic suturing: development and reliability evaluation

BackgroundLaparoscopic suturing can be technically challenging and requires extensive training to achieve competency. To date no specific and objective assessment method for laparoscopic suturing and knot tying is available that can guide training and monitor performance in these complex surgical skills. In this study we aimed to develop a laparoscopic suturing competency assessment tool (LS-CAT) and assess its inter-observer reliability.MethodsWe developed a bespoke CAT tool for laparoscopic suturing through a structured, mixed methodology approach, overseen by a steering committee with experience in developing surgical assessment tools. A wide Delphi consultation with over twelve experts in laparoscopic surgery guided the development stages of the tool. Following, subjects with different levels of laparoscopic expertise were included to evaluate this tool, using a simulated laparoscopic suturing task which involved placing of two surgical knots. A research assistant video recorded and anonymised each performance. Two blinded expert surgeons assessed the anonymised videos using the developed LS-CAT. The LS-CAT scores of the two experts were compared to assess the inter-observer reliability. Lastly, we compared the subjects’ LS-CAT performance scores at the beginning and end of their learning curve.ResultsThis study evaluated a novel LS-CAT performance tool, comprising of four tasks. Thirty-six complete videos were analysed and evaluated with the LS-CAT, of which the scores demonstrated excellent inter-observer reliability. Cohen’s Kappa analysis revealed good to excellent levels of agreement for almost all tasks of both instrument handling and tissue handling (0.87; 0.77; 0.75; 0.86; 0.85, all with p < 0.001). Subjects performed significantly better at the end of their learning curve compared to their first attempt for all LS-CAT items (all with p < 0.001).ConclusionsWe developed the LS-CAT, which is a laparoscopic suturing grading matrix, with excellent inter-rater reliability and to discriminate between experience levels. This LS-CAT has a potential for wider use to objectively assess laparoscopic suturing skills.

Association of Residents' Neural Signatures With Stress Resilience During Surgery

Intraoperative stressors may compound cognitive load, prompting performance decline and threatening patient safety. However, not all surgeons cope equally well with stress, and the disparity between performance stability and decline under high cognitive demand may be characterized by differences in activation within brain areas associated with attention and concentration such as the prefrontal cortex (PFC). To compare PFC activation between surgeons demonstrating stable performance under temporal stress with those exhibiting stress-related performance decline. Cohort study conducted from July 2015 to September 2016 at the Imperial College Healthcare National Health Service Trust, England. One hundred two surgical residents (postgraduate year 1 and greater) were invited to participate, of which 33 agreed to partake. Participants performed a laparoscopic suturing task under 2 conditions: self-paced (SP; without time-per-knot restrictions), and time pressure (TP; 2-minute per knot time restriction). A composite deterioration score was computed based on between-condition differences in task performance metrics (task progression score [arbitrary units], error score [millimeters], leak volume [milliliters], and knot tensile strength [newtons]). Based on the composite score, quartiles were computed reflecting performance stability (quartile 1 [Q1]) and decline (quartile 4 [Q4]). Changes in PFC oxygenated hemoglobin concentration (HbO2) measured at 24 different locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Secondary outcomes included subjective workload (Surgical Task Load Index) and heart rate. Of the 33 participants, the median age was 33 years, the range was 29 to 56 years, and 27 were men (82%). The Q1 residents demonstrated task-induced increases in HbO2 across the bilateral ventrolateral PFC (VLPFC) and right dorsolateral PFC in the SP condition and in the VLPFC in the TP condition. In contrast, Q4 residents demonstrated decreases in HbO2 in both conditions. The magnitude of PFC activation (change in HbO2) was significantly greater in Q1 than Q4 across the bilateral VLPFC during both SP (mean [SD] left VLPFC: Q1, 0.44 [1.30] μM; Q4, -0.21 [2.05] μM; P < .001; right VLPFC: Q1, 0.46 [1.12] μM; Q4, -0.15 [2.14] μM; P < .001) and TP (mean [SD] left VLPFC: Q1, 0.44 [1.36] μM; Q4, -0.03 [1.83] μM; P = .001; right VLPFC: Q1, 0.49 [1.70] μM; Q4, -0.32 [2.00] μM; P < .001) conditions. There were no significant between-group differences in Surgical Task Load Index or heart rate in either condition. Performance stability within TP is associated with sustained prefrontal activation indicative of preserved attention and concentration, whereas performance decline is associated with prefrontal deactivation that may represent task disengagement.

Correlation of surgical trainee performance on laparoscopic versus endoscopic simulation.

Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a "desk-top" endoscopic physical simulator. Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). There was significant correlation between the participant's skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.

An Efficient Single-session Spatial Skill Trainer for Robot-assisted Surgery: A Randomized Trial

To introduce and examine a single session of spatial skill training as an efficient means of improving surgical suturing performance in robot-assisted surgery. A randomized, controlled trial. A tertiary university medical center in Israel. A purposive sample composed of 41 residents with no robotic suturing skills. A computer-based simulator training of spatial skills. Participants were randomly assigned to training (n = 21: mean age of 34 years [standard deviation (SD) = 1.92]) and control (n = 20: mean age of 32 years [SD = 3.17]) conditions. The training group underwent a session of spatial skills training, whereas the control group engaged in a neutral activity. After 1 participant was lost to the follow-up of the posttraining performance test, data of 40 participants were analyzed. Robotic suturing task performance with the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) was evaluated using the da Vinci Skills Simulator built-in measure of "excess tissue piercing" and an expert rating of "tissue tearing." The mean number of excess tissue piercing after training (but not after the neutral activity) was significantly lower than before training (3.25 [SD = 1.996] vs 6.75 [SD = 3.68], respectively; p <.001), reflecting an improvement of 52% (decreasing the mean number of excess tissue piercing in a single suture by 3.5 excess piercing trials). After the interventions, the extent of tissue tearing was rated lower in the training group (p = .01), and there was no change in the control group (p = .14). We showed the efficiency of a training approach that focuses on spatial skills critical in robot-assisted surgery. We showed that surgeons who received a 1 session spatial skill training with a cognitive spatial skill trainer immediately improved the performance of a robotic suturing task compared with surgeons who did not receive such training.

Optimal timing of assessment tasks depending on experience level of surgical trainees

Introduction: Box trainers with motion analysis are important add-ons to surgical training and skills assessment outside the operating room, given that they exhibit construct validity.Material and methods: Four different tasks were tested for construct validity on a new laparoscopic box trainer with integrated motion analysis. Tracking data from the simulator were analyzed for eighteen parameters per task using an in-house software comparing participants with three different experience levels.Results: In total, ten novices, 22 intermediates and 16 experts enrolled. No or limited significant differences were found for the peg picker and rope race. For the precision cutting task 12 parameters showed significant difference between novices and intermediates, 14 between novices and experts and one between intermediates and experts. For the suture task the corresponding results were one, 15 and six.Conclusions: The precision cutting and suture task both showed construct validity for many of the parameters. While the precision cutting task distinguished best between novices and the other two groups, the suture task distinguished best between experts and the other two groups. These results show the importance of the timing of an assessment task, and that an assessment task might have limited value if experience levels are not considered.

Feasibility of remote administration of the fundamentals of laparoscopic surgery (FLS) skills test using Google wearable device.

The fundamentals of laparoscopic surgery (FLS) program is a simulation-based training program designed to teach and assess the basic skills necessary for laparoscopic surgery. Preliminary work has demonstrated the feasibility of using Skype™ as a telesimulation modality in reliably scoring the exam for remote centers. Google Glass (GG) (Mountain View, California) is referred to as a wearable computer containing a heads-up display and front-facing camera allowing point-of-view video transmission. The objective of this study was to evaluate the feasibility of GG in scoring the technical skills component of the FLS exam. Twenty-eight participants were asked to complete the peg transfer and intracorporeal knot tasks of FLS using both GG and Skype™ setups. GG employed a third-party HIPAA-compliant video software (Pristine; Austin, TX) for video transmission. Participants were alternated between setups and evaluated by onsite and remote proctors. Times and errors were recorded by both proctors. Interrater reliability of their FLS scores was compared using Intraclass Correlation Coefficients (ICCs). GG experience was evaluated based on participant survey responses using a 5-point Likert scale. Interrater reliability for GG demonstrated a statistically significant correlation between onsite (OP) and remote (RP) proctors with ICCs of 0.985 (95% Confidence Interval [CI], 0.969-0.993) and 0.997 (95% CI 0.993-0.998), respectively, for peg and suture tasks. Skype™ demonstrated ICCs of 1.0 (95% CI 1.0-1.0). Average Likert scale responses found GG to be distracting (2.71), obstructive of the view (2.79), and a limitation to task execution (2.75). Overall, there was no statistical difference in scores between GG and Skype™ setups for either the peg (t = 1.446, p = 0.154) or suture task (t = - 0.710, p = 0.480), only 1 participant found the use of GG superior to Skype™. Our findings suggest that although GG are feasible in remote assessment of FLS with strong interrater reliability (ICC > 0.95), Skype™ was the preferred modality.

Modeling Surgical Technical Skill Using Expert Assessment for Automated Computer Rating.

Computer vision was used to predict expert performance ratings from surgeon hand motions for tying and suturing tasks. Existing methods, including the objective structured assessment of technical skills (OSATS), have proven reliable, but do not readily discriminate at the task level. Computer vision may be used for evaluating distinct task performance throughout an operation. Open surgeries was videoed and surgeon hands were tracked without using sensors or markers. An expert panel of 3 attending surgeons rated tying and suturing video clips on continuous scales from 0 to 10 along 3 task measures adapted from the broader OSATS: motion economy, fluidity of motion, and tissue handling. Empirical models were developed to predict the expert consensus ratings based on the hand kinematic data records. The predicted versus panel ratings for suturing had slopes from 0.73 to 1, and intercepts from 0.36 to 1.54 (Average R2 = 0.81). Predicted versus panel ratings for tying had slopes from 0.39 to 0.88, and intercepts from 0.79 to 4.36 (Average R2 = 0.57). The mean square error among predicted and expert ratings was consistently less than the mean squared difference among individual expert ratings and the eventual consensus ratings. The computer algorithm consistently predicted the panel ratings of individual tasks, and were more objective and reliable than individual assessment by surgical experts.

Evaluating a Solely Mechanical Articulating Laparoscopic Device: A Prospective Randomized Crossover Study.

The FlexDex® (FD) is a solely mechanical articulating device that combines the functionality of robotic surgery with the relative low cost and simplicity of laparoscopy. We sought to evaluate the performance of first-time FD users while performing a simple suture task at locations of varying degrees of difficulty. A prospective, randomized crossover study was performed comparing the FD to standard laparoscopy (SL). Two specific groups were evaluated; Group 1 consisted of complete novices, and Group 2 consisted of surgical trainees. Participants performed a simple suture with both FD and SL locations of varying degrees of difficulty (Easy, Moderate, and Hard). The following outcomes were evaluated: Instrument Function and Ergonomics (Comfort/Ergonomics survey), Task Difficulty (National Aeronautics and Space Administration Task Load Index [NASA-TLX]), Task Performance Quality (Objective Structured Assessment of Technical Skills [OSATS]), and Time (seconds). Twenty-two participants were enrolled with 12 participants in Group 1 and 10 participants in Group 2. Group 1-FD participants experienced overall less shoulder strain (1.2 ± 0.40 versus 1.9 ± 0.90, P = .01), and Group 2-FD participants experienced less shoulder (2.5 ± 0.66 versus 4.0 ± 0.50, P = .01), back (1.1 ± 0.32 versus 1.9 ± 0.74, P = .01), and forearm strain (1.9 ± 0.88 versus 2.5 ± 1.1, P = .04). Group 1 participants using the FD experienced higher mental demand (73 ± 17 versus 48 ± 27, P < .01) and perceived effort (70 ± 20 versus 54 ± 23, P < .001). Both Group 1 and Group 2 FD participants performed tasks at the Hard location more effectively. Both Group 1 (70 versus 87, P = .21) and Group 2 (53 versus 60, P = .55) performed tasks at the Hard location in similar times, while Group 1 (80 versus 177, P = .03) and Group 2 (33 versus 70, P = .001) performed tasks at the Easy location in shorter times using SL. This study demonstrates the first assessment of the FD, a mechanically articulating laparoscopic tool. First-time FD users demonstrated improved ergonomics and effectiveness suturing at difficult locations. Future studies will focus on comparison to robotic surgery and translation into clinical applications.

Is the Human Brain Capable of Controlling Seven Degrees of Freedom?

BackgroundConventional rigid laparoscopic instruments offer five degrees of freedom (DOF). Robotic instruments add two independent DOFs allowing unconstrained directional steering. Several nonrobotic instruments have been developed with the additional DOFs, but with these devices, surgeon's wrist movements are not intuitively transmitted into tip movements. In this study, a new articulated instrument has been evaluated. The aim of the study was to compare learning curves and performances of conventional laparoscopic instruments, the da Vinci system and Steerable devices in a crossover study. Materials and methodsA total of 16 medical students without any laparoscopic experience were trained for 27 h to operate all of a rigid, a robotic, and a new Steerable instrument in a random order. Learning curves and ultimate experience scores were determined for each instrument. Strain in wrist and shoulders was assessed with a visual analog score. ResultsPerforming the suturing task with rigid and robot instruments required 4 h of training, compared with 6 h to master the Steerable instrument. After 9 h of training with each instrument, completing the complex suturing pattern required 662 ± 308 s with rigid instruments, 279 ± 90 s with the da Vinci system, and 279 ± 53 s with the Steerable instrument. Pain scores were significantly higher after using the rigid instruments compared with the Steerable instruments. ConclusionsTransmission of torque and the presence of additional two DOFs in combination with reduced crosstalk significantly improved the instrument dexterity where the Steerable platform is concerned. Although the learning curve is longer, once mastered, it provides enhanced surgical freedom.

Construct, content and face validity of the eoSim laparoscopic simulator on advanced suturing tasks

BackgroundThe purpose of this study was to validate the eoSim, an affordable and mobile inanimate laparoscopic simulator with instrument tracking capabilities, regarding face, content and construct validity on complex suturing tasks.MethodsParticipants recruited for this study were novices (no laparoscopic experience), target group for this training (surgical/gynaecologic/urologic residents, > 10 basic and < 20 advanced laparoscopic procedures) and experts (> 20 advanced laparoscopic procedures). Each participant performed the intracorporeal suturing exercise (Task 1), an upside down needle transfer (Task 2, developed for this study) and an anastomosis needle transfer (Task 3). Following, the participants completed a questionnaire regarding their demographics and opinion on the eoSim in terms of realism, didactic value and usability. Measured outcome parameters were time, distance, percentage of instrument tip off-screen, working area, speed, acceleration and smoothness.ResultsIn total, 104 participants completed the study, of which 60 novices, 31 residents and 13 experts. Face and content validity results showed a mean positive opinion on realism (3.9 Task 1, 3.6 Task 2 and 3.7 Task 3), didactic value (4.0, 3.4 and 3.7, respectively) and usability (4.2. 3.7 and 4.0, respectively). There were no significant differences in these outcomes between the specified expertise groups. Construct validity results showed significant differences between experts, target group or novices for Task 1 in terms of time (means 339, 607 and 1224 s, respectively, p < 0.001) and distance (means 8.1, 15.6 and 21.7 m, respectively, p < 0.001). Task 2 showed significant differences between groups regarding time (p < 0.001), distance (p 0.003), off-screen (p < 0.001) and working area (p < 0.001). Task 3 showed significant differences between groups, after subanalyses, on total number of stitches (p < 0.001), time per stitch (p < 0.001) and distance per stitch (p < 0.001).ConclusionsThe results of this study indicate that the eoSim is a potential meaningful and valuable simulator in the training of suturing tasks.

Performance and perception of haptic feedback in a laparoscopic 3D virtual reality simulator

Background: The benefit of haptic feedback in laparoscopic virtual reality simulators (VRS) is ambiguous. A previous study found 32% faster acquisition of skills with the combination of 3 D and haptic feedback compared to 2 D only. This study aimed to validate perception and effect on performance of haptic feedback by experienced surgeons in the previously tested VRS. Material and methods: A randomized single blinded cross-over study with laparoscopists (>100 laparoscopic procedures) was conducted in a VRS with 3 D imaging. One group started with haptic feedback, and the other group without. After performing the suturing task with haptics either enabled or disabled, the groups crossed over to the opposite setting. Face validity was assessed through questionnaires. Metrics were obtained from the VRS. Results: The haptics for ‘handling the needle’, ‘needle through tissue’ and ‘tying the knot’ was scored as completely realistic by 3/22, 1/22 and 2/22 respectively. Comparing the metrics for maximum stretch damage between the groups revealed a significantly lower score when a group performed with haptics enabled p = .027 (haptic first group) and p < .001(haptic last group). Conclusion: Haptic feedback in VRS has limited fidelity according to the tested laparoscopic surgeons. In spite of this, significantly less stretch damage was caused with haptics enabled.

Refining How We Define Laparoscopic Expertise.

Traditional stratification of expertise in laparoscopic simulation assigns participants to novice, intermediate, or expert groups based on case numbers. We hypothesized that expert video assessment might refine this discrimination of psychomotor expertise, especially in light of new measurable parameters. One hundred five participants performed a defined intracorporeal suturing task in the pediatric laparoscopic surgery simulator armed with force-sensing capabilities. Participants were stratified into novice, intermediate, and expert groups via three classification schemes: (1) number of complex laparoscopic cases, (2) self-declared level of expertise, and (3) average expert rating of participants' videos. Precision, time to task completion, and force analysis parameters (FAP = total, maximum and mean forces in three axes) were compared using one-way analysis of variance tests. P < .05 was considered significant. Participants stratified on the basis of case numbers and on the basis of self-declared level of expertise had statistically significant differences in time to task completion, but no significant difference in FAP. When participants were restratified according to expert assessment of their video performance, time to task completion as well as total and mean forces in X, Y, and Z axes allowed discrimination between novices, intermediates, and experts, thus establishing construct validity for the latter. Precision did not allow discrimination in any stratification scheme. Compared with traditional stratification, video assessment allows refined discrimination of psychomotor expertise within a simulator. Assessment of FAP may become a relevant tool for teaching and assessing laparoscopic skills.

The effectiveness of box trainers in improving laparoscopic suturing skills in surgery

Background: Simulation training is an integral part of the laparoscopic training curriculum. To recognize the role of laparoscopy in modern surgery, residency programs rapidly incorporated it into their training regimen. Box trainers are useful to practice laparoscopic skills. Laparoscopy requires a long-learning curve. The simulation training model gives opportunities to practice the procedures efficiently until competency is achieved without exposing the live patient to undue risk. Hence, this study was conducted to assess the overall effectiveness of the box training to improve the skills in laparoscopic suturing. Materials and Methods: This was a prospective and observational study conducted over a period of 6 months including 30 residents of the surgery department. The department of surgery has an indoor laboratory that consists of an isolated room with two box-trainers. Participants were given a task to perform suturing by using box trainers for 2 h/week for 6 months. For the quantitative and qualitative assessment, a direct observation checklist was prepared, i.e., task-specific checklist having a maximum score of 15. Each participant performed a suturing task. Pre- and posttraining score was calculated and was compared to see the efficacy of the box trainers. Results: Around 30 participants’ surgery, residents were enrolled. Twenty-six male and 4 female residents were included in the training, with the age of all residents ranges from 26 to 30 years. The mean pretraining score was 3.1667, and it is improved significantly to 12.3667 after training. The unpaired t-test was calculated (20.5050). The two-tailed P is less than 0.0001; hence, it is statistically significant. Conclusions: This study proves the efficacy of box trainers in improving laparoscopic suturing skills.