Development of a Physical Shoulder Simulator for the Training of Basic Arthroscopic Skills

Increasingly, shoulder surgeries are performed using arthroscopic techniques, leading to reduced tissue damage and shorter patient recovery times. Orthopaedic training programs are responding to the increased demand for arthroscopic surgeries by incorporating arthroscopic skills into their residency curriculums. A need for accessible and effective training tools exists. This thesis describes the design and development of a physical shoulder simulator for training basic arthroscopy skills such as triangulation, orientation, and navigation of the anatomy. The simulator can be used in either the lateral decubitus or beach chair orientation and accommodates wet or dry practice. Sensors embedded in the simulator provide a means to assess performance. A study was conducted to determine the effectiveness of the simulator. Novice subjects improved their performance after practicing with the simulator. A survey completed by experts, recognized the simulator as a valuable tool for training novice surgeons in basic arthroscopic skills

Development and decay of procedural skills in surgery: A systematic review of the effectiveness of simulated-based medical education interventions

ContextChanges to surgical training programmes in the UK has led to a reduction in theatre time for trainees, and an increasing reliance on simulation to provide procedural experience. Whilst simulation offers opportunity for repetitive practice, the effectiveness of simulation as an educational intervention for developing procedural surgical skills is unclear.MethodsA systematic literature review was undertaken to retrieve all studies describing simulation-based medical education (SBME) interventions for the development of procedural surgical skills using the MEDLINE, PsycINFO, CINAHL, EMBASE and PUBMED databases. Studies measuring skill retention or demonstrating transferability of skills for improving patient outcomes were included in the review.ResultsSBME is superior to no training and can lead to improvement in procedural surgical skills, such that skills transfer from simulated environments into theatre. SBME results in minimal skill degradation after 2 weeks, although more significant decay results after [greater than]90 days. Many studies recruited [less than]10 participants, used a variety of methods and were restricted to endoscopic surgical techniques. All studies did not compare interventions with non-SBME teaching methods for developing procedural surgical skills. No studies compared the curriculum design of different surgical training programmes.ConclusionsSBME interventions are effective for developing procedural skills in surgery. SBME interventions are also effective for preventing the decay of procedural surgical skills. Although no studies demonstrate non-inferiority of SBME interventions compared to time in theatre developing skills, SBME interventions do enable the transfer of skills into theatre, and the potential for improving patient outcomes

Training laparoscopic skills : Changes in gynecological surgery

During recent decades, gynecological surgery has changed considerably, and this development affects surgical training. In Finland, the total number of gynecological procedures has decreased by 30% during the last ten years. An increasing number of basic procedures are now done under local anesthesia at outpatient clinics where training is much more demanding than in the operating room. Laparotomies are frequently replaced by laparoscopic procedures that require more complex skills than open surgery. Furthermore, operating room efficiency causes time constraints, while patients in general have more co-morbidities and the surgical procedures needed are more complex. Thus, for trainees all these factors make training more challenging, and the traditional apprenticeship model alone no longer ensures that trainees learn the needed skills. In this dissertation study our aim was to assess developments in gynecological surgery in Finland and other Nordic countries by evaluating trends in hysterectomies. In addition, we investigated outcomes of traditional surgical training, as compared to systematic cognitive and manual pre-training on laparoscopic skills. We assessed separately the effect of pretraining on the trainee’s first operative laparoscopy, and on the other hand, on laparoscopic hysterectomy, which is the most demanding laparoscopic procedure trainees perform. In Study I, we assessed the numbers of different hysterectomies from the Nordic Medico-Statistical Committee and Finnish Institute for Health and Welfare databases. We compared outcomes of different hysterectomy methods between trainees and specialists collected from the FINHYST 2006 survey. In Finland, hysterectomy rates started to decline in 2003 and reached the rate of other Nordic countries in 2008. The rate of hysterectomy in Finland declined until 2017, and the laparoscopic method has been the most common method since 2013. In the outcome comparison, it was noted that the overall operative time was longer in trainees’ operations. In the vaginal method, blood loss was higher in the trainees’ group whereas in other hysterectomy methods or in total complication rates there were no differences between the groups. In Study II, we evaluated the effectiveness of a cognitive web-course ‘Basics in Gynecological Laparoscopy’ for trainees at various levels of experience. All trainees in Finland were invited to participate in this web-based anonymous study where the level of knowledge was evaluated before and after taking the course. Participants were allocated into three groups according to their experience. After the course, improvement in knowledge gain was detected in all three groups; the less experienced group reached the starting level of the middle group and the middle group reached the starting level of the most experienced group. In Studies III and IV, the effect of simulator training on operative skills was evaluated. Trainees with no experience in operative laparoscopy were recruited for Study III. Half of the group comprised the intervention group. They did the web-based course ‘Basics in Gynecological Laparoscopy’ and trained basic skills with a virtual reality simulator. The control group took part in the traditional training only. The first live laparoscopic salpingectomy was video-recorded and evaluated. We found no differences in the surgical outcomes between the groups. In Study IV, the participants recruited were more experienced, but had not done laparoscopic hysterectomy as a first surgeon. All participants did the basic training as the intervention group in Study III. Furthermore, the intervention group trained with the hysterectomy module in a virtual reality simulator. The intervention group performed significantly better as evaluated by the Objective Assessment of Technical Skills and Visual Analog scale. Our findings indicate that the traditional apprentice model alone is no longer sufficient in trainee education due to changes in gynecological surgery. In Study III, we did not detect differences in outcomes between the groups. However, in Study IV evaluating learning of a more advanced procedure, we demonstrated better performance after training with the procedural module in a simulator. Based on these studies, we suggest that simulator training should be mandatory, with allocated training time for the trainee and supervision time for the trainer for providing feedback. As innate skills are different, a proficiency-based curriculum results in more homogeneous skills. Less experienced trainees seem to benefit the most from simulator training, thus the training should be started in the earliest stage of training.Gynekologinen kirurgia on muuttunut huomattavasti viimeisinä vuosikymmeninä: toimenpiteiden vuosittaiset kokonaismäärät ovat huomattavasti vähentyneet, polikliinisten toimenpiteiden osuudet kasvavat, avoleikkaukset ovat pääosin korvaantuneet vaativammilla tähystysleikkauksilla ja leikkaussalin tehokkuusvaatimukset ovat nousseet. Kaikki nämä muutokset vaikuttavat gynekologiaan erikoistuvien lääkäreiden kirurgiseen koulutukseen siten, ettei perinteinen oppipoikamalli ainoana koulutusmuotona enää ole riittävä Tässä väitöskirjatutkimuksessa selvitimme gynekologisen kirurgian muutoksia Suomessa sekä muissa Pohjoismaissa käyttäen esimerkkinä kohdunpoistoleikkausten suuntauksia. Arvioimme perinteisen leikkauskoulutuksen onnistumista ja toisaalta ennen leikkaussalityöskentelyä tapahtuvan systemaattisen tiedollisen ja taidollisen koulutuksen vaikutusta tähystysleikkauksen oppimiseen. Ensimmäisessä osatyössä totesimme, että Suomessa kohdunpoistomäärät alkoivat vähentyä vuoden 2003 jälkeen ja määrät saavuttivat pohjoismaisen tason vuonna 2008. Tähystysleikkaus on yleisempi toimenpidetapa Suomessa kuin muissa Pohjoismaissa ja vuoden 2013 jälkeen se on ollut yleisin kohdunpoistotapa Suomessa. Erikoistuvien ja erikoislääkäreiden tekemien kohdunpoistoleikkausten vertailututkimuksessa todettiin, että erikoistuvien lääkäreiden tekemät leikkaukset kestivät pidempään. Emättimen kautta tehdyissä leikkauksissa oli enemmän verenvuotoa erikoistuvien lääkäreiden ryhmässä, kun taas muissa kohdunpoistotavoissa tai komplikaatioiden kokonaismäärissä ei ollut eroja ryhmien välillä. Toisessa osatyössä selvitimme ’Gynekologisen laparoskopian perusteet’ -verkkokurssin vaikuttavuutta eri kokemustason omaaville erikoistuville lääkäreille. Tietotaso tutkittiin ennen ja jälkeen kurssin läpikäymisen. Osallistujat jaettiin kolmeen ryhmään kokemustason mukaisesti, ja kaikissa kolmessa ryhmässä tietotaso nousi merkittävästi. Kurssin käytyään kokemattomin ryhmä saavutti samat pisteet kuin keskiryhmä tutkimuksen alussa. Vastaavasti keskiryhmä saavutti kokeneiden ryhmän lähtötason. Sekä kolmannessa että neljännessä osatyössä tutkimme simulaattoriharjoittelun vaikutusta leikkaustaitojen oppimiseen. Kolmannen tutkimuksen osallistujat olivat kokemattomia erikoistuvia lääkäreitä, joista puolet muodosti interventioryhmän. Interventiona oli ’Gynekologisen laparoskopian perusteet’ -verkkokurssi sekä perusharjoiteohjelma virtuaalisella simulaattorilla. Ensimmäinen tähystysteitse tehty munanjohtimen poistoleikkaus videoitiin ja arvioitiin. Tässä tutkimuksessa interventioryhmän ja kontrolliryhmän tekemien leikkausten tuloksissa ei todettu eroja. Neljänteen tutkimukseen otetut erikoistuvat lääkärit olivat kokeneempia, ja kaikki osallistujat suorittivat saman harjoitusohjelman kuin interventioryhmä kolmannessa osatyössä. Tämän tutkimuksen interventioryhmä harjoitteli lisäksi virtuaalisen simulaattorin kohdunpoisto-ohjelmalla. Interventioryhmän tekemät kohdunpoistoleikkaukset sujuivat paremmin, kun ne arvioitiin leikkaustaitojen arviointilomakkeita käyttäen. Tutkimustuloksemme mukaan oppipoikamalli yksistään ei enää turvaa riittävää koulutusta johtuen gynekologisessa kirurgiassa tapahtuneista muutoksista. Internet-pohjaisia verkkokursseja voi hyödyntää myös kirurgian opetuksessa. Simulaattoriharjoittelu vaikuttaa parantavan leikkaustaitoja, mutta koska synnynnäiset taidot yksilöiden välillä ovat erilaiset, osaamisperustainen harjoitteluohjelma johtaa tasalaatuisempiin taitoihin. Simulaattoriharjoittelun tulisi olla pakollista, ja siihen pitäisi varata työaikaa sekä erikoistuvalle lääkärille että ohjaajalle palautteen antamisen mahdollistamiseksi. Kokemattomammat erikoistuvat lääkärit tuntuisivat hyötyvän simulaattoriharjoittelusta eniten, joten systemaattinen harjoittelu pitäisi aloittaa heti erikoistumisvaiheen alussa

A Novel Haptic Simulator for Evaluating and Training Salient Force-Based Skills for Laparoscopic Surgery

Laparoscopic surgery has evolved from an \u27alternative\u27 surgical technique to currently being considered as a mainstream surgical technique. However, learning this complex technique holds unique challenges to novice surgeons due to their \u27distance\u27 from the surgical site. One of the main challenges in acquiring laparoscopic skills is the acquisition of force-based or haptic skills. The neglect of popular training methods (e.g., the Fundamentals of Laparoscopic Surgery, i.e. FLS, curriculum) in addressing this aspect of skills training has led many medical skills professionals to research new, efficient methods for haptic skills training. The overarching goal of this research was to demonstrate that a set of simple, simulator-based haptic exercises can be developed and used to train users for skilled application of forces with surgical tools. A set of salient or core haptic skills that underlie proficient laparoscopic surgery were identified, based on published time-motion studies. Low-cost, computer-based haptic training simulators were prototyped to simulate each of the identified salient haptic skills. All simulators were tested for construct validity by comparing surgeons\u27 performance on the simulators with the performance of novices with no previous laparoscopic experience. An integrated, \u27core haptic skills\u27 simulator capable of rendering the three validated haptic skills was built. To examine the efficacy of this novel salient haptic skills training simulator, novice participants were tested for training improvements in a detailed study. Results from the study demonstrated that simulator training enabled users to significantly improve force application for all three haptic tasks. Research outcomes from this project could greatly influence surgical skills simulator design, resulting in more efficient training

Simulation in Surgical Education: Lessons Learned from a Multi-Site Randomised Cohort Study

Background Surgical proficiency requires expertise in both technical and non-technical (interpersonal) skills. Simulation-based education (SBE) provides a useful adjunct to traditional training methods. Studies show SBE to be effective for the development of both technical and nontechnical skills, however the best format for delivery of this training is not yet well understood. The purpose of the primary research detailed in this thesis was to determine the best format for the delivery of simulated laparoscopic skills training by investigating the efficacy and feasibility of a self-scheduled, self-directed skills course. Secondary projects utilised simulated theatre scenarios to assess the non-technical skills of surgeons to determine if level of professional surgical experience has an impact on non-technical skills, and if surgeons respond to harassment of a colleague. Methods Surgical and gynaecology trainees, junior doctors and medical students were randomised to undertake either self-directed learning (SDL) only, or a combination of supervised training in a Mobile Simulation Unit (MSU) as well as SDL. Three laparoscopic skills tasks were taught and assessed. Skills data was compared to assess the efficacy of SDL, and whether supervised training in the MSU accelerated skill acquisition. Qualitative pre- and post-course questionnaires were also conducted. In two separate studies, retrospective analyses of video-recorded simulated theatre scenarios were conducted. Firstly, the non-technical skills of surgical trainees and experienced surgeons were assessed and compared. Secondly, the participants’ response to harassment of a colleague (which was part of the scenario) was recorded and analysed, again comparing the response of trainees with that of experienced surgeons. Results A total of 207 participants enrolled, with 156 (75.4%) completing assessment requirements. The majority of participants’ skill improved, and some were able to reach expert proficiency standards in one or more tasks. In general, skills acquisition was dependent on the number of practice attempts performed, rather than where the training was undertaken. Overall efficacy of SDL was limited by poor practice session attendance. The greatest barrier to attending was lack of available time due to overriding clinical duties. Participants showed a preference for supervised training, scheduled fortnightly, after a shift. The mean scores of surgeons’ non-technical skills initially increased, peaking around the time of Fellowship, before decreasing roughly linearly over time. Harassment of a colleague was not always recognised, and the response from participants varied. The type of response depended on the nature of harassment being perpetrated and the seniority of the participant. Conclusions The efficacy of self-scheduled, self-directed laparoscopic skills training is limited by poor training attendance. To improve efficacy and feasibility of SBE, training should be conducted with a combination of supervised scheduled sessions, and SDL. Greater effort is needed by training providers to implement strategies that enable practice session attendance. Experienced surgeons are not immune to deficiencies in non-technical skills. Education and training in non-technical skills, including the recognition and management of bullying and harassment, needs to be better incorporated into the surgical training program as well as continuing professional development programs for qualified surgeons.Thesis (MPhil) -- University of Adelaide, Adelaide Medical School, 201

Development and Validation of a Hybrid Virtual/Physical Nuss Procedure Surgical Trainer

With continuous advancements and adoption of minimally invasive surgery, proficiency with nontrivial surgical skills involved is becoming a greater concern. Consequently, the use of surgical simulation has been increasingly embraced by many for training and skill transfer purposes. Some systems utilize haptic feedback within a high-fidelity anatomically-correct virtual environment whereas others use manikins, synthetic components, or box trainers to mimic primary components of a corresponding procedure. Surgical simulation development for some minimally invasive procedures is still, however, suboptimal or otherwise embryonic. This is true for the Nuss procedure, which is a minimally invasive surgery for correcting pectus excavatum (PE) – a congenital chest wall deformity. This work aims to address this gap by exploring the challenges of developing both a purely virtual and a purely physical simulation platform of the Nuss procedure and their implications in a training context. This work then describes the development of a hybrid mixed-reality system that integrates virtual and physical constituents as well as an augmentation of the haptic interface, to carry out a reproduction of the primary steps of the Nuss procedure and satisfy clinically relevant prerequisites for its training platform. Furthermore, this work carries out a user study to investigate the system’s face, content, and construct validity to establish its faithfulness as a training platform

Use of Biomechanical Motion Analysis to Evaluate Endotracheal Intubation Skill in a Simulated Clinical Setting

Title from PDF of title page, viewed on August 25, 2015Thesis advisor: Gregory W. KingVitaIncludes bibliographic references (pages 102-107)Thesis (M.S.)--School of Computing and Engineering. University of Missouri--Kansas City, 2015This study evaluated, using motion capture technology, the performance characteristics of novice and experienced medical personnel performing endotracheal intubation in a simulated clinical setting. Few objective measures exist that quantify the differences in intubation techniques between providers of various skill levels. These measures are inadequate for providing useful feedback towards training or performance-based research. Motion analysis may be a potential solution for the quantitative evaluation of endotracheal intubation among healthcare professionals of different skill levels. This study hypothesized that experienced personnel would exhibit movement patterns associated with higher performance and efficiency when compared to novice personnel. Twelve subjects were recruited for this study, among whom eight were novice participants and four were expert participants, based on the number of times they had performed endotracheal intubation. Each subject donned a full body 41 marker motion capture suit and performed simulated endotracheal intubation on an Airway mannequin using a Macintosh blade-fitted laryngoscope. Intubation success was defined by visible lung inflation of the mannequin. The obtained motion capture data was used to calculate path length, average path speed and use time of the laryngoscope, as well as the overall intubation time. Angular ranges of motion were calculated for the left wrist, elbow, the neck, and both knees of study subjects. Experts, when compared to novices, intubate faster and with lower overall movement (path length). One way ANOVA and two sample t-tests were conducted on all outcome variables, wherein significant p-values were obtained from the wrist abduction/adduction (p = 0.009) and elbow abduction/adduction (p=0.002) ranges of motion among novices and experts, indicating significant difference. Combined with a lower completion time and the lower overall laryngoscope movement, the lower range of motion for the wrist and the elbow in experts may indicate that experts are implementing finer, more economic maneuvers in order to achieve successful intubation. These results supports the study hypothesis that experienced personnel, compared to novice, will exhibit measurable movement patterns associated with higher performance and efficiency.Introduction -- Background -- Study -- Conclusion -- Appendix A. Equipment photographs, layout schematics, study illustrations -- Appendix B. Tables -- Appendix C. MATLAB Code -- Appendix D. Study forms and document

Different forms of laparoscopic training: review and comparison

Σκοπός : Να γίνει σύγκριση και εκτίμηση της αποτελεσματικότητας των διαφόρων μορφών λαπαροσκοπικής εκπαίδευσης. Μέθοδοι : Πραγματοποιήθηκε ανάλυση εργασιών μέσω αναζητήσεων σε Pubmed, Medline και Cochrane Library, των τελευταίων δέκα ετών. Χρησιμοποιήθηκαν εργασίες οι οποίες τηρούσαν τις κατευθυντήριες οδηγίες του οργανισμού για την ιατρική εκπαίδευση που στηρίζεται στις καλύτερες ενδείξεις (BEME) και του προγράμματος αξιολόγησης τεχνολογιών (TAP). Αποτελέσματα : Πραγματοποιήθηκε ανάλυση επτά ανεξάρτητων συστηματικών ανασκοπήσεων και μιας ανασκόπησης, που περιείχαν εκατόν είκοσι τυχαιοποιημένες ελεγχόμενες μελέτες (RCTs) και διακόσιες πενήντα εργασίες. Η εκπαίδευση με εξομοιωτές εικονικής πραγματικότητας (VR) φάνηκε να υπερτερεί σε σχέση με καμία εκπαίδευση. Οι εξομοιωτές επαυξημένης πραγματικότητας (AR) αποδείχθηκαν ως το πιο σύγχρονο και με πολλές δυνατότητες σύστημα λαπαροσκοπικών εξομοιωτών, το οποίο παρέχει περισσότερα οφέλη από τους παραδοσιακούς εξομοιωτές λαπαροσκοπικών επεμβάσεων και τους εξομοιωτές εικονικής πραγματικότητας. Συμπεράσματα : Οι ιατρικοί εξομοιωτές υψηλής πιστότητας και ακρίβειας στην απόδοση, διευκολύνουν και προωθούν την διαδικασία της εκπαίδευσης και της μεταφοράς των ικανοτήτων που ανακτώνται, στην αίθουσα του χειρουργείου. Οι εξομοιωτές επαυξημένης πραγματικότητας θα πρέπει να ενταχθούν στα σύγχρονα προγράμματα λαπαροσκοπικής εκπαίδευσης.Objectives : To compare and evaluate the effectiveness of different forms in laparoscopic training. Methods : Studies were analyzed through searches of Pubmed, Medline and the Cochrane Library over the last ten years. Included studies were identified according to guidelines adapted from a Best Evidence in Medical Education (BEME) and a Technology Assessment Program (TAP) review. Results : Seven independent systematic reviews and one review, with one hundred twenty randomized controlled trials (RCTs) and two hundred fifty studies, were able to be included. Virtual reality (VR) training for laparoscopic procedures is better than no training. Augmented reality (AR) simulators are a potent new modality laparoscopic simulator system, that have better benefits from the traditional box trainers and the VR simulators. Conclusion : High – fidelity medical simulations are educationally effective and results in skills transfer to the operating setting. AR simulators should be implemented in current laparoscopic training

Assessment of laparoscopic surgical skills acquired on laparoscopic virtual reality simulator compared to box trainer: an analysis of obstetrics-gynaecology residents

Background: Laparoscopic surgery requires very different set of psychomotor skills compared to open surgery, such as working in three-dimensional environment with two-dimensional view, four instead of six degrees of freedom, eye-hand coordination, depth perception and bimanual manipulation. Laparoscopic surgical training using laparoscopic simulators overcomes these inherent differences and improves efficiency of learning and patient safety. The aim of this study was to compare the effectiveness of virtual reality (VR) simulator and box-trainer and determine whether one has advantages over the other as training tool for relatively simple laparoscopic procedures. Methods: A prospective, randomized, blinded, comparative trial enrolled 20 residents in Obstetrics and Gynaecology with minimal laparoscopic experiences to participate in practical exercises with either virtual reality (LapVR) simulator (group-A), or laparoscopic Box-Trainer (group-B). The candidates acted as their own control. Subjects within one group were not allowed to practice, on the opposing trainers. Initial teaching session was given to obtain all participants familiarization with the virtual reality simulator and they carried out laparoscopic salpingotomy and laparoscopic salpingectomy for ectopic pregnancy on LapVR (pretest). Performance was recorded by LapVR for parameters of total time taken, time of cautery used, total blood loss and economy of motion. The subjects were then randomized to either group-A or group-B for series of laparoscopic exercises. The residents of group-A were practiced on LapVR in laparoscopic peg transfer, clipping and cutting and certain parameters were assessed by LapVR. The practical exercises on laparoscopic Trainer-Box were based in the tasks of “ovarian cystectomy” and “salpingotomy” for ectopic pregnancy and they were captured on DVD and scored for time and accuracy by a blinded expert investigator. After 2-day sessions lasting one and half hours each, all subjects were reassessed on the initial same procedures on LapVR (post-test). Results: Both groups showed improvement after their training tasks. Performance of two groups was comparable before and after training for both laparoscopic ectopic pregnancy procedures on LapVR. The participants’ satisfaction according to post-training questionnaire was high for the training modality as a whole and showed no differences between groups. Conclusions: Neither LapVR nor Box-Trainer simulator showed any superiority over other for training laparoscopic skills to novice learners. Laparoscopic training laboratories in laparoscopic training hospitals could include virtual reality simulators as reasonable alternative to Box-Trainer simulators for laparoscopic training of inexperienced residents in laparoscopy