Box Trainer Research Articles

MP10-04 SURGEON ASSESSMENT OF A NOVEL MULTI-RESOLUTION FOVEATED LAPAROSCOPE

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I (MP10)1 Sep 2021MP10-04 SURGEON ASSESSMENT OF A NOVEL MULTI-RESOLUTION FOVEATED LAPAROSCOPE Mike Nguyen, Jamal Nhabani, Allan Hamilton, Sangyoon Lee, Jeremy Katz, and Hong Hua Mike NguyenMike Nguyen More articles by this author , Jamal NhabaniJamal Nhabani More articles by this author , Allan HamiltonAllan Hamilton More articles by this author , Sangyoon LeeSangyoon Lee More articles by this author , Jeremy KatzJeremy Katz More articles by this author , and Hong HuaHong Hua More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001983.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To improve safety in minimally invasive surgery, we developed a multi-resolution foveated laparoscope (MRFL) which can simultaneously obtain and display wide and zoomed in views in order to avoid surgical tunnel vision and improve situational awareness. We assessed surgeon objective task performance and subjective attitudes towards the MRFL for ex vivo box trainer tasks and in vivo porcine surgery. METHODS: The MRFL utilizes two sensors to simultaneously obtain a wide-angle view and obtain and pan a high-resolution magnified view. Options for displaying the two images including side by side view, full screen views, and 3 variations of overlaid images. A pedal changes views and controls retargeting of the zoomed view. 6 urologists and 2 general surgeons performed box trainer and porcine surgery tasks with both a standard laparoscope and the MRFL. Task time, use of display options, and subjective assessments were obtained. RESULTS: For box trainer tasks, task time was shorter for standard laparoscopy than MRFL for internal peg transfer tasks (28.5 vs 56.6 secs, p=0.0055) in one of two sessions but was not different for external peg transfer tasks (69.2 vs 77.2 secs, p=0.52 and 124.2 vs 127.5 secs, p=0.93). For porcine nephrectomy, laparoscopy surgical time was significantly shorter than MRFL (17.5 vs 33.3 min, p=0.049). For the simpler oophorectomy surgical task, time did not differ significantly. As a surgeon, participants were most likely to use side by side view (46.4%) followed by full screen overview or zoomed view (26.6%). Assistants predominately used the side-by-side view (80.1%). Subjectively, surgeons rated situational awareness, depth perception, and interference with other instruments as similar between the systems for the trainer session while the MRFL was rated as having less interference for the animal lab session (2 vs 6.3, p=0.0093). MRFL was rated as having lower image quality than laparoscopy in both the trainer (6.4 vs 8.4, p=0.012) and animal lab sessions (3.5 vs 9.2, p=0.0003). Participants rated having different MRFL views as being useful for different roles (8.1 out of a scale of 10) and being likely to use the MRFL for laparoscopic surgery (8.1) and robotic surgery (8.3). CONCLUSIONS: Ex vivo and in vivo surgeon assessments of the MRFL demonstrated its feasibility for performing complex surgery. Surgeons had favorable attitudes towards its functional features and expressed likelihood to use the device if it were available. Users utilized different view types based on different task needs. Poorer image quality of the prototype MRFL was associated with longer task times. Source of Funding: NIH RO1 EB18921 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e169-e170 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mike Nguyen More articles by this author Jamal Nhabani More articles by this author Allan Hamilton More articles by this author Sangyoon Lee More articles by this author Jeremy Katz More articles by this author Hong Hua More articles by this author Expand All Advertisement Loading ...

Evaluation and usability study of low-cost laparoscopic box trainer “Lap-Pack”: a 2-stage multicenter cohort study

Introduction: Laparoscopic training is restricted in low resource settings due to limited access to specialist training equipment and financial constraints. This study aimed to evaluate simulation skills and usability of an original low-cost laparoscopic trainer, the “Lap-Pack,” developed at the University of Leeds, UK. Methods: Stage I evaluation was conducted in Kolkata (India) between March, 12 and 14, 2019. Laparoscopic simulation training was based on the 5 domains of fundamentals of laparoscopic surgery (FLS), which assessed skill acquisition across 7 rural surgeons from North-East India. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) criteria was used to statistically analyze trainee performance between pretraining and posttraining sessions. Also, Lap-Pack was qualitatively compared with a commercial box trainer, Inovus Pyxus HD (IPHD). Stage II involved a multi-center usability study in 2 centers of India and the United Kingdom (2019). Seventy-eight participants performed 2 FLS tasks using Lap-Pack and provided scores on a 25-point questionnaire, including a preestablished Face-Validity Criteria and 4 evaluation categories—Usability, Camera, View, and, Material. Results: In stage I, the total posttraining MISTELS score for Lap-Pack was higher, that is 773.37 (SD: 183.67) than pretraining score, that is 351.2 (SD: 471.5). The posttraining scores showed laparoscopic skill acquisition with statistically significant (P<0.05) difference for precision cutting, intracorporeal and extracorporeal knot. In stage II, Lap-Pack scored highly in Face-Validity with a combined mean score of 4.81 [95% confidence interval (CI): 4.52–5.09, P<0.05] out of a possible 6. It scored highest (scale: 1=low to 7=high) in Usability 6.14 (95% CI: 6.05–6.22, P<0.05) and Camera 6.14 (95% CI: 6.01–6.27, P<0.05). The “Lightweight” (6.46, 95% CI: 6.32–6.60, P<0.05) and “Portability” (6.35, 95% CI: 6.18–6.51, P<0.05) features of Lap-Pack were appreciated. Conclusion: The Lap-Pack is a suitable low fidelity simulator for laparoscopic training in a low-resource setting.

PD41-07 ERGONOMICS IN THE OR: AN ELECTROMYELOGRAPHIC EVALUATION OF COMMON MUSCLE GROUPS USED DURING SIMULATED FLEXIBLE URETEROSCOPY

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology II (PD41)1 Sep 2021PD41-07 ERGONOMICS IN THE OR: AN ELECTROMYELOGRAPHIC EVALUATION OF COMMON MUSCLE GROUPS USED DURING SIMULATED FLEXIBLE URETEROSCOPY George Gheordunescu, Kyle O'Laughlin, Alec Sun, Juan Fulla, Naveen Kachroo, Henry Wright, and Smita De George GheordunescuGeorge Gheordunescu More articles by this author , Kyle O'LaughlinKyle O'Laughlin More articles by this author , Alec SunAlec Sun More articles by this author , Juan FullaJuan Fulla More articles by this author , Naveen KachrooNaveen Kachroo More articles by this author , Henry WrightHenry Wright More articles by this author , and Smita DeSmita De More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002051.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ergonomics in flexible ureteroscopy is poorly understood. We sought to assess the effects of different surgeon positions (sitting vs. standing) and ureteroscope types (disposable vs. non-disposable) on muscle activation as measured on electromyography (EMG) during ureteroscopy in an endourology box-trainer model and kidney phantom. METHODS: For this exploratory study, EMG was used to quantify muscle activation of three endourologists during various ureteroscopic tasks. Surface EMG electrodes (ADInstruments, Colorado Springs, CO) were placed on the scope-holding side of the following muscle groups: thenar, forearm flexor, forearm extensor, biceps, triceps, deltoid, and trapezius. “Real world” operative settings were re-created: subjects wore fitted lead aprons in an operating room suite and used a cystoscopy table with surgical drapes and an endoscopic video tower. Subjects completed each trial while sitting and standing, and while using a disposable and non-disposable scope. Each subject performed an identical set of tasks in a phantom silicone kidney and ureteroscopy box trainer used to recreate the procedural components of dusting, basketing, and navigating a renal collecting system. Raw EMG data for each task was processed and normalized as a percent of each subject’s maximum voluntary contraction (MVC) to allow comparison. The EMG activity of all subjects and tasks were compiled (Figure 1). Tasks were analyzed individually and then in aggregate because muscle activation trends were similar and a complete set of tasks better represented a ureteroscopy procedure. RESULTS: The forearm extensor was the most heavily utilized muscle regardless of posture or scope type. The trapezius muscle was activated more during sitting vs. standing. The forearm extensor muscle was activated more with the heavier non-disposable scope vs. the disposable scope. CONCLUSIONS: Our preliminary data show differences in muscle activation based on both surgical posture and type of scope used. This highlights the need for larger and more extensive EMG studies to identify techniques and equipment to optimize ergonomics and potentially minimize repetitive use injury during flexible ureteroscopy. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e683-e683 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information George Gheordunescu More articles by this author Kyle O'Laughlin More articles by this author Alec Sun More articles by this author Juan Fulla More articles by this author Naveen Kachroo More articles by this author Henry Wright More articles by this author Smita De More articles by this author Expand All Advertisement Loading ...

Virtual Reality as an Affirmative Spin-Off to Laparoscopic Training: An Updated Review.

Latest advancements in science lead to drastic improvements in patient health care. Techniques and technology evolved in surgery over the years have resulted in the improvement of patient outcomes by leaps and bounds. Open surgeries previously done for procedures like appendectomy and cholecystectomy evolved into laparoscopic minimally invasive procedures. Such procedures pose few challenges to the surgeons, like lack of tissue feedback and fulcrum effect of the abdominal wall. But training surgeons for such an advanced skill is still following conventional methods. These procedures can be effectively trained using Virtual Reality (VR), which can simulate operations outside the operating room (OR). To maximize the outcomes of VR training, knowledge on various strategies affecting the skills acquisition and retention in VR training is essential. This review collected information from PubMed, EMBASE, Cochrane Library (CENTRAL) databases. Data from the previous ten years are included in the review. This included documents, clinical trials, meta-analysis, randomized controlled trials, reviews, systematic reviews, letters to editors, and grey literature. After an advanced Medical Subject Headings (MeSH) search, we got 59,532 results, and after the application of filters, 189 results showed up. Out of these, studies that were not exclusively relevant to the use of VR in laparoscopic surgery were manually excluded, and a total of 35 articles were included in the study. VR is found to be an excellent training modality with promising outcomes. It helps the surgeons perform the surgery accurately at a faster pace and improves confidence and multitasking ability in OR. Instructor feedback from mentors and deliberate practice of trainees, and early introduction of haptics in VR resulted in the most effective outcomes of the VR training. Box trainers are also compared with VR trainers as they are the cheaper modalities of training. However, this area needs more research to conclude if box trainers can act as a cheaper alternative to VR training providing similar outcomes.

Engagement of lateral habenula in the extinction of the appetitive conditioned responses

Following the association of a neutral stimulus (conditioned stimulus, CS) with a biologically significant stimulus (unconditioned stimulus, US), CS-alone presentations generate extinction: a decline in the conditioned response. Many studies have revealed the neural substrates of fear extinction; however, a few have identified the brain regions responsible for appetitive extinction. Midbrain dopamine neurons are activated by presenting a reward or predictable reward cue, whereas the cue signaling the absence of reward activates the lateral habenula (LHb) neurons. We examined the engagement of the LHb in appetitive extinction. In the first phase, rats first received pairings of a CS (light) with US delivery (food pellets). In the second phase, rats in the CS-alone group underwent four CS-alone presentations, whereas those in the paired group received four pairings of light with food pellets. We also included a comparison group for CS-alone presentations: rats were placed in the training box without CS or US exposures in the first phase and received four CS-alone presentations in the second phase. Thirty minutes after the second phase, c-Fos levels in the ventral tegmental area (VTA), substantia nigra pars compacta (SNc), and LHb in these groups were measured. c-Fos levels in the LHb were higher in the paired-CS-alone group than in the paired-paired and comparison groups, while those in the VTA and SNc were significantly higher in the paired-paired group than in the other groups. On examination of LHb neurotoxic lesion effects on the decline of conditioned food-cup responses when a CS was repeatedly presented with no US, LHb lesions decelerated the decline in conditioned food-cup responses, suggesting a crucial role of LHb in appetitive extinction.

Back in control of intentional action: Improvement of ideomotor apraxia by mirror box treatment

ObjectivesA novel method of rehabilitation for ideomotor apraxia (IMA), using a modified version of the mirror box (MB), is proposed. The rationale is based on the theory that disrupted body representation occurs in IMA and that MB training may improve body representation. In the present MB training, patients observed and reproduced movements made by the experimenter in a mirror. The visual perspective gave the illusory sensation of seeing one's own affected hand in the mirror. MethodsThirteen patients were included in the study; apraxia was measured four times: i) at baseline; ii) after a week of unspecific poststroke rehabilitation (rest); iii) after a week of imitation training for apraxia, used as a control; and iv) after a week of MB training. Imitation and mirror box training were presented in counterbalanced order between participants. The effect of the mirror box on a measure of body representation was also assessed. ResultsThe results show that MB training improved apraxia when compared to the outcomes in both the imitation and rest conditions. The improvement correlates with the impact of the mirror box on the body representation (i.e., the degree of embodiment). ConclusionsMB training shows promising effects in promoting recovery from apraxia. The hypothesis is that the mirror box triggers a quickly generated sense of embodiment of the reflected moving arm into the observer's body representation. This embodiment of the visuomotor features of the observed movements would positively affect motor programming, promoting motor improvement. Crucially, this effect seems to extend to actions performed outside the mirror box setup, enhancing patients' performance on an apraxia test.

Objective Measurement of Impact of Bench Laparoscopic Training in Novices

Background: We are currently in the era of laparoscopic surgery. It has gained popularity in the last few decades because of its well- known advantages. Laparoscopy requires different skills from those of open surgery. In a paradigm shift, learning basic surgical skills is now performed more in the skills laboratory than in the operation theater. However, there is a lack of reliable training and assessment tools for laparoscopic surgical skills. This study aimed to objectively assess the effect of bench laparoscopic training in novices.
 Methods: This prospective study was conducted at the Clinical Skills Centre of Bangalore Medical College and Research Institute (BMCRI) in Bangalore, India. Sixty interns with no previous experience in laparoscopy were included. They underwent supervised training on the box trainer for 3 days, 2 hours a day, in basic surgical tasks, including pointing dots, joining straight lines, joining curved lines, picking objects, peg transfer, and circle cut. All participants were assessed objectively in a virtual reality (VR) simulator before and after training. The objective outcomes measured were time taken, distance traveled, and error scores given by the VR simulator metrics.
 Results: The novices showed statistically significant improvement in all the tasks after the training compared with their skill levels before the training.
 Conclusion: Structured short-term training significantly improves basic laparoscopic surgery skills.

Creating a Proficiency-based Remote Laparoscopic Skills Curriculum for the COVID-19 Era

OBJECTIVESocial distancing restrictions due to COVID-19 challenged our ability to educate incoming surgery interns who depend on early simulation training for basic skill acquisition. This study aimed to create a proficiency-based laparoscopic skills curriculum using remote learning.DESIGNContent experts designed 5 surgical tasks to address hand-eye coordination, depth perception, and precision cutting. A scoring formula was used to measure performance: cutoff time - completion time - (K × errors) = score; the constant K was determined for each task. As a benchmark for proficiency, a fellowship-trained laparoscopic surgeon performed 3 consecutive repetitions of each task; proficiency was defined as the surgeon's mean score minus 2 standard deviations. To train remotely, PGY1 surgery residents (n = 29) were each issued a donated portable laparoscopic training box, task explanations, and score sheets. Remote training included submitting a pre-test video, self-training to proficiency, and submitting a post-test video. Construct validity (expert vs. trainee pre-tests) and skill acquisition (trainee pre-tests vs. post-tests) were compared using a Wilcoxon test (median [IQR] reported).SETTINGThe University of Texas Southwestern Medical Center in Dallas, TexasPARTICIPANTSSurgery internsRESULTSExpert and trainee pre-test performance was significantly different for all tasks, supporting construct validity. One trainee was proficient at pre-test. After 1 month of self-training, 7 additional residents achieved proficiency on all 5 tasks after 2-18 repetitions; trainee post-test scores were significantly improved versus pre-test on all tasks (p = 0.01).CONCLUSIONSThis proficiency-based curriculum demonstrated construct validity, was feasible as a remote teaching option, and resulted in significant skill acquisition. The remote format, including video-based performance assessment, facilitates effective at-home learning and may allow additional innovations such as video-based coaching for more advanced curricula.

Analysis of Physiological Response during Cardiopulmonary Resuscitation with Personal Protective Equipment: A Randomized Crossover Study.

The use of personal protective equipment (PPE) is required for the self-protection of healthcare workers during cardiopulmonary resuscitation (CPR) in patients at risk of aerosol transmission of infectious agents. The aim of this study was to analyze the impact of personal protective equipment on physiological parameters during CPR. A randomized, quasi-experimental, crossover design was used. The study was carried out in a training and simulation emergency box and the total sample consisted of 20 healthcare professionals. Two CPR tests were compared with the recommended sequence of 30 chest compressions and 2 ventilations. The duration of each test was 20 min. One of the CPR tests was carried out without using any PPE (CPR_control), i.e., performed with the usual clothing of each rescuer. The other test was carried out using a CPR test with PPE (i.e., CPR_PPE). The main variables of interest were: CPR quality, compressions, ventilations, maximum heart rate, body fluid loss, body temperature, perceived exertion index, comfort, thermal sensation and sweating. The quality of the CPR was similar in both tests. The maximum heart rate was higher in the active intervals (compressions + bag-valve-mask) of the test with PPE. CPR_PPE meant an increase in the perceived effort, temperature at the start of the thermal sensation test, thermal comfort and sweating, as opposed to CPR performed with usual clothing. Performing prolonged resuscitation with PPE did not influence CPR quality, but caused significant physiological demands. Rescuers were more fatigued, sweated more and their thermal comfort was worse. These results suggest that physical preparation should be taken into account when using PPE and protocols for physiological recovery after use should also be established.

A Heart Surgery Simulator With an Integrated Supervision System for Self-Learning the Key Steps and Pitfalls of the Mitral Valve Repair: Initial Investigation.

Over the years, surgical education has dramatically improved and has become increasingly innovative. Almost all educational programs in surgery now rely on sophisticated training boxes and simulators that enable surgical instruments to be handled and surgical procedures to be trained in a safe environment. However, simulators need constant feedback from supervising senior surgeons, who only have limited teaching time available. We describe a cardiac surgery simulator with an integrated supervision system for self-learning how to repair a mitral valve. We developed a mitral surgery simulator with integrated sensors to generate, record, and display quantitative data on trainee performance in relation with the mitral valve repair procedure. A team of experienced cardiac surgeons defined critical areas of the model and an algorithm to identify inconsistent movements, in terms of error types and out-of-bound actions. The device provided real-time feedback on the accuracy of the stitches placed. Four experienced cardiac surgeons and 3 advanced cardiac-surgery used the simulator and were asked to evaluate specific parameters of the system on a scale ranging from 1 to 10. All surgeons completed a P2 resection, followed by implanting a 32-mm mitral ring. The simulator detected 2 stitches that were placed in dangerous zones and another stitch that was placed in an inappropriate position. Users scored the real tissue feeling and interactivity of the model 9.5/10. This heart-surgery simulator offers a real-life model for learning about and training in mitral valve surgery, which could potentially replace the experienced surgeon's teaching role.

Analysis of the Positional Relationship Among the Operator, Camera, and Monitor: Overcoming the Difficulties of Mirror-image Conditions During Laparoscopic Surgery.

Although methods to overcome difficulties associated with mirror-image conditions have been investigated, the ideal spatial relationship among the operator line of sight, monitor location, and camera location remains unclear. Moreover, the best training method for improving laparoscopic surgical skills under varying operator line of sight, camera, and monitor positions is unknown. We aimed to investigate the role of laparoscopic training under mirror-image conditions in improving surgical efficiency and whether prior surgical experience affects such training. This prospective study was conducted at the Department of Surgical Oncology, Tokyo University, Japan. Twenty-five surgeons participated. Novice (n=14), trained (n=7), and expert (n=4) participants performed the simulated task in a box trainer while varying the positional relationships among the surgeons, camera, and monitor. Five patterns were repeatedly performed 5 times per day for 4 days over 2 weeks. The most significant differences in terms of the time required to complete the task under mirror-image conditions among the 3 groups were on day 1 (novices: 185.8 s, trained: 79.7 s, and experts: 46.5 s, P=0.009). However, after 4 days of training, the corresponding times did not differ among the 3 groups (26.0, 30.7, and 23.1 s, respectively; P=0.415). Laparoscopic training was sufficiently effective under mirror-image conditions. Mirror-image surgical conditions provided the most difficult setting, because surgeons and assistants often became disoriented, and task performance was most degraded. However, just 4 days of training was found to be sufficient to overcome the difficulties encountered while performing laparoscopic procedures under mirror-image conditions.

Training minimally invasive surgery's basic skills: is expensive always better?

Not all hospitals have a MIS training facility because often training is not a main corporate objective and could require lots of money. We tried to build a laparoscopic simulator that was effective and that would allow to carry out an adequate laparoscopic training similar to that obtained with the models normally used in MIS training programs. To construct a box trainer that would achieve the equivalent results than those usually used. A validation study was carried out by evaluating the content validity and construct validity of our simulator in addition a comparison study of our homemade trainer vs Karl Storz box trainer was performed. The HM laparoscopic trainer was assembled using a wood frame. Two LED lights were positioned on the inside roof of the trainer and a webcam was positioned through a special support as operative optic. The webcam was then connected to a PC and the latter was used as a monitor for the operator. Participants were 20 students and a group of 6 surgeons. Students were prospectively randomized to perform 4 of the 5 tasks of the fundamental laparoscopic surgery (FLS) program on both the HM trainer and the KS trainer (pegboard transfer, pattern cut, placement of ligating loop and intracorporeal knot suture). Simple paired t test was performed to compare times between the trainers. Then students performed two more sets of exercises on the HM. The group of surgeons performed three sets of the same exercises performed by the students on the HM. The time taken by surgeons and students to complete the exercises was compared using t test. At the end, all the participants carried out a questionnaire to evaluate their experience with the HM box trainer. For the questionnaire it was chosen to use a Linkert 1-5 scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree). HM vs KS BT: Comparing time to complete the 4 tasks performed by students on both the BT, for the first task the p value was 0.30, for the second task 0.48, for the third task 0.80, for the fourth task 0.93, and for the total time 0.86. The comparison between the mean time of the first set of tasks of the participants who started with the HM BT and one of the participants who started on the KS p value was 1 p = 0.09; task 2 p = 0.32; task 3 p = 0.62; task 4 p = 0.32; total time p = 0.81. The comparison between the meantime of the second set of tasks of the participants who switched to the HM BT with the one of those who switched to the KS BT showed a p value of: p = 0.20 tasks 1 p = 0.53 task 2; p = 0.39 task 3; p = 0.30 task 4; p = 0.56 total time. Construct validity: The mean experts and students time of every single task and the total one showed a p value of: p < 0.01 for task 1; p < 0.01 task 2; p < 0.01 task 3; p < 0.01 task 4; p < 0.01 total time. Content validity: Both experts and students indicated the HM BT as a useful training tool and appreciated its easy use. Both groups would use it at home if it were available. Valid MIS trainer can be easily built at home with few low-cost materials. Our study shows how training programs can be structured even with few resources in a creative and innovative way.

Assessment of technical skills based on learning curve analyses in laparoscopic surgery training

BackgroundObjective force- and motion-based assessment is currently lacking in laparoscopic skills curricula. This study aimed to evaluate the added value of parameter-based assessment and feedback during training. MethodsLaparoscopy-naïve surgical residents that took part in a 3-week skills training curriculum were included. A box trainer equipped with the ForceSense system was used for assessment of tissue manipulation- (MaxForce) and instrument-handling skills (Path length and Time). Learning curves were established using linear regression tests. Pre- and post-course comparisons indicated the overall progression and were compared to predefined proficiency levels. A post-course survey was carried out to assess face validity. ResultsIn total, 4,268 trials, executed by 24 residents, were successfully assessed. Median (interquartile range) MaxForce outcomes improved from 2.7 Newton (interquartile range 1.9–3.8) to 1.8 Newton (interquartile range 1.2–2.4) between pre- and post-course assessment (P ≤ .009). Instrument Path length improved from 7,102.2 mm (interquartile range 5,255.2–9,025.9) to 3,545.3 mm (interquartile range 2,842.9–4,563.2) (P ≤.001). Time to execute the task improved from 159.8 seconds (interquartile range 119.8–219.0) to 60.7 seconds (interquartile range 46.0–79.5) (P ≤ .001). The learning curves revealed during what training phase the proficiency benchmarks were reached for each trainee. In the survey outcomes, trainees indicated that this curriculum should be part of a surgical residency program (mean visual analog scale score of 9.2 ± 0.9 standard deviation). ConclusionForce-, motion-, and time-parameters can be objectively measured during basic laparoscopic skills curricula and do indicate progression of skills over time. The ForceSense parameters enable curricula to be designed for specific proficiency-based training goals and offer the possibility for objective classification of the levels of expertise.

Creation of a High Fidelity, Cost Effective, Real World Surgical Simulation for Surgical Education

Background How do surgical residents learn to operate? What is a surgical plane? How does one learn to see and dissect the plane? How do surgical residents learn tissue handling and suturing (sewing)? One method to learn and practice performing surgery is through the use of simulation training. Surgical training models include laparoscopic box trainers (a plastic box with holes for instruments) with synthetic materials inside to simulate tissues, or computer-based virtual reality simulation for laparoscopic, endoscopic, and robotic techniques. These methods, however, do not use real tissues. They lack the haptic and kinesthetic feedback of real tissue. These simulations fail to recreate the fidelity of soft tissues, do not foster the ability to accurately see surgical planes, do not accurately mimic the act of dissecting surgical planes, do not allow for complex surgical procedures, and do not provide accurate experience to learn tissue handling and suturing. Despite their poor performance, these plastic and virtual trainers are extremely costly to purchase, maintain, and keep up to date - with prices starting at $700 for basic plastic training boxes to thousands of dollars for virtual simulation. Also, there are additional costs of maintenance and software curriculum. Despite the cost of software, virtual simulators do not include a simulation for every surgery. Our aim was to create a life-like surgical simulation as close to real world as possible that allows trainees to learn how to see and dissect surgical planes, learn how soft tissues move, and learn the dynamics of soft tissue manipulation. We created a laparoscopic simulator using porcine tissues for gallbladder removal, acid reflux surgery, and surgery to treat swallowing difficulties (cholecystectomy, Nissen fundoplication, and Heller myotomy, respectively). Second year general surgery residents were able to practice these procedures on real tissues, enabling them to learn the steps of each procedure, increase manual dexterity, improve use of laparoscopic equipment, all while maintaining life-like haptic, soft-tissue feedback and enabling them to develop the ability to see real surgical planes. Methods The abdomen was recreated by purchasing intact porcine liver, gallbladder, (Cholecystectomy simulation) and intact esophagus, stomach, and diaphragm (Nissen and Heller simulation) from a packing supplier. Each organ system was placed into a laparoscopic trainer box with the ability to re-create laparoscopic ports. Surgical residents were then able to perform the procedures using real laparoscopic instruments, laparoscopic camera/video imaging, and real-time electrocautery. The simulation included all critical steps of each procedure such as obtaining the critical view of safety and removing the gallbladder from the liver bed (cholecystectomy), wrapping the stomach around the esophagus and laparoscopic suturing (Nissen fundoplication), and dissecting the muscular portion of the esophageal wall (Heller myotomy). Because these porcine tissues were readily available, several stations were set-up to teach multiple residents during each session (10-12 residents / session). Discussion Surgeons develop haptic perception of soft tissues by cutaneous or tactile feedback and kinesthetic feedback (Okamura, 2009). Kinesthetic feedback is the force and pressure transmitted by the soft tissues along the shaft of the laparoscopic instruments (Okamura, 2009). This soft tissue simulation re-creates the ability to experience what soft tissue feedback feels like, outside a normal operative environment. Real tissue learning allows trainees to learn how to see surgical planes, learn how soft tissues feel and move, develop proficiency in surgical dissection, and learn how to suture laparoscopically. This is the only model that recreates the movement of soft tissues and visualization of dissection planes outside the operative environment. Because this model utilizes the laparoscopic instruments used in the operating room, residents also develop familiarity with laparoscopic instruments, thus, flattening another learning curve. A literature review found that this is the only real tissue simulation being performed for foregut procedures used specifically for resident training. By building a realistic, anatomical model with inherent accurate soft tissue surgical planes, surgical trainees can have a more realistic surgical experience and develop skills in a safe, low pressure environment without sacrificing the hepatic learning and surgical visualization that is critical to performing safe laparoscopic surgery. All residents that participated in the stimulation reported positive feedback and felt that is contributed to their surgical education.

845 Flattening the Learning Curve: The Evaluation of Extended Laparoscopic Simulation Training for Novice Surgeons

Abstract Introduction Associated with faster postoperative recovery, reduced length of hospital stays and scarring; laparoscopy has become the favoured approach for many surgical procedures across a range of specialties. However, due to its challenging learning curve, it has also been associated with increased theatre time and higher complication rates. Method A prospective, observational study with box trainers was carried out by novice medical students and trainees to evaluate the efficacy of long duration courses on skill acquisition. The novice group undertook a 5-week curriculum composed of lectures, demonstrations and spaced timed-assessments involving 3 tasks: hoop placement, stacking of sugar cubes and surgical cutting. Results Time taken for novice participants to complete a task individually and collectively improved markedly from the first to the third attempt, with an overall 44% reduction in time observed over the 5-weeks. We invited back 6 novice participants and 6 core surgical trainees after 4-weeks to complete the same tests. There was a further 18% time improvement in the novice group, with 44% faster task completion. Conclusions Given the success of this study and other simulation courses reported in the literature, we recommend more courses adopt a spaced-out approach; and a simulation curriculum for surgical trainees to cultivate greater skill acquisition.

525 Automated Continuous Instrument Tracking in Laparoscopic Box Trainers Predicts Performance at Assessment: A Prospective Cohort Study in Core Surgical Trainees

Abstract Introduction Box-trainers enable deliberate practice of laparoscopic skills and can be equipped with instrument tracking metrics to provide feedback. However, the relationship between metrics, assessment outcomes and practice are unclear. Method Core surgical trainees were provided take-home box trainers with SurgTrac™ instrument tracking metrics for practice (eoSurgical Ltd., Scotland, UK). Practice was incentivised by certification and video assessment of a basic task, peg capping. Assessment was by consultant general surgeons, using objective structured assessment of technical skills (OSATS). The following metrics were analysed: task duration, distance moved by instruments, average instrument speed, average instrument acceleration, left- or right-handedness and instrument smoothness. Metrics were correlated to OSATS scores using regression analysis. Threshold for significance was p = 0.05. Results During the study period, there were 1639 peg capping performances by 85 trainees; 103 video recordings were submitted for assessment. All metrics were significantly associated with OSATS score, except instrument acceleration. The multiple linear regression model was highly correlated with actual scores (Pearson correlation 0.658; p &amp;lt; 0.001). Practice was positively correlated with regression model predicted OSATS score (regression analysis; ANOVA p &amp;lt; 0.001). Conclusions Instrument tracking metrics reliably predict OSATS performance and practice improves predicted score. Trainees can use metrics in unsupervised practice and gauge whether they are improving as expected.

Evaluating the influence of music at different sound pressure levels on medical students\u2019 performance of standardized laparoscopic box training exercises

BackgroundThe influence of music on the performance of surgical procedures such as laparoscopy is controversial and methodologically difficult to quantify. Here, outcome measurements using laparoscopic box training tools under standardized conditions might offer a feasible approach. To date, the effect of music exposure at different sound pressure levels (SPL) on outcome has not been evaluated systematically for laparoscopic novices.MethodsBetween May 2017 and October 2018, n = 87 students (49 males, 38 females) from Heidelberg University Medical School performed three different laparoscopy exercises using the “Luebecker Toolbox” that were repeated twice under standardized conditions. Time was recorded for each run. All students were randomly assigned to four groups exposed to the same music compilation but at different SPLs (50–80 dB), an acoustically shielded (earplug) group, or a control group (no intervention).ResultsBest absolute performance was shown under exposure to 70 dB in all three exercises (a, b, c) with mean performance time of 121, 142, and 115 s (p < 0.05 for a and c). For the control group mean performance times were 157, 144, and 150 s, respectively. In the earplug group, no significant difference in performance was found compared to the control group (p > 0.05) except for exercise (a) (p = 0.011).ConclusionMusic exposure seems to have beneficial effects on training performance. In comparison to the control group, significantly better results were reached at 70 dB SPL, while exposure to lower (50 or 60 dB) or higher (80 dB) SPL as well as under acoustic shielding did not influence performance.

The Influence of Different Genres of Music on the Performance of Medical Students on Standardized Laparoscopic Exercises

Whether and how music influences the performance of surgical procedures such as laparoscopy is unclear and can be feasibly determined using laparoscopic box training tools under standardized conditions. The aim of this prospective study is to evaluate the effect of different genres of music on the performance of laparoscopic novices. Between May 2018 and December 2018, n = 82 students (38 male, 44 female) from Heidelberg University Medical School performed 3 different laparoscopic exercises (A, B, C) from the "Luebecker Toolbox" with 2 repetitions each under standardized conditions. Time was recorded for each exercise. The students were assigned either to one of four groups, each of which was exposed to a compilation of music from 1 genre (hip hop, classical, rock, or mixed radio music), or to a fifth, control group, without exposure to music. The music was played at a constant sound pressure level of 70 decibels . Each group was compared with the others using a t-test for independent samples. Exposure to music generally led to better performance compared with the control group. Compared with exposure to mixed radio music or to rock, significantly better performance could be demonstrated for exposure to classical music in Exercise B, with an average exposure time of 127 s needed (± 21.4; p < 0.05). No significant differences could be demonstrated for Exercise A, though for classical music, best performance was possible with 120 s (±17.3) of exposure. In Exercise C, hip hop triggered significantly better performance than rock or radio music (p < 0.05). At an sound pressure level of 70 decibels, exposure to classical music or hip hop appears to have beneficial effects on training performance for surgical novices under standardized conditions.

Training on Minimally Invasive Colorectal Surgery during Surgical Residency: Integrating Surgical Education and Advanced Techniques.

Surgery is an ever-evolving discipline and continually incorporates new technologies that have improved the ability of the operating room surgeon to perform. The next generation of minimally invasive surgery includes laparoscopic and robotic-assisted procedures. Graduating residents may be expected to have the skills to perform common colorectal procedures using these technologies, and residency programs are developing curriculums to teach these skills. Minimally invasive techniques are challenging and learning only by observation and practice alone is difficult. This requires dedicated training and mentoring. New simulation methods have been conceived specifically for minimally invasive procedures, and these embrace a combination of virtual reality simulators and box trainers, with animal and human tissue, as well as synthetic materials. The aim of this review is to provide an overview of training in minimally invasive colorectal surgery with a focus on different types of simulators that build the basis to develop and include a multistep training approach in a structured training curriculum for minimally invasive colorectal procedures.

Influence of viewing distance on visual color differentiation in vitro.

To investigate whether viewing distance influences the results of visual tooth color differentiation. A total of 65 students underwent both theoretical and practical training by a standardized lecture on the use of an internet learning module (Toothguide Trainer, VITA Zahnfabrik) and a standardized training program (Toothguide Training Box) for visual shade-taking. Each student matched 10 randomly selected shade tabs presented at different viewing distances (arm's length distance [AL, 70 cm] and AL/2 [35cm]) under lateral, non-glare lighting at a 45-degree angle with a color differentiation lamp. The results were recorded as to what extent the presented and selected tabs of the color determination matched. The overall median values of perceived color difference (ΔE) were 1.6 for AL/2 and 3.2 for AL, and these values were significantly different (P < .001). Within the limitations of this study, it was shown that the viewing distance had a significant influence on the color deviation in tooth color assessment. Therefore, a smaller viewing distance of 35 cm for shade determination is recommended.