Fundamentals of Laparoscopic Surgery: A Surgical Skills Assessment Tool in Gynecology

This analysis suggests that the fundamentals of laparoscopic surgery skills test may be a valuable assessment tool for gynecology residents; however, the cognitive test may need further adaptation for application to gynecologists

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

Is it all about the money? : The effects of low and high cost simulator training scenarios in surgical training

Background: The learning process is complex and dependent on several factors such as for instance, the environment to learn, prior knowledge and distinct abilities, motivation, goal-orientation as well as the effects of instructor feedback. Medical education, in particular within surgical domains is imperative due to its influence on patient safety. The demand for training surgeons has shifted from the “master-apprentice/practice on patients”, towards a safer modality, involving simulators. The positive effects laparoscopic simulator training has on laparoscopic performance is extensive, as well as its impact on operating room performance. Nonetheless, the difference in learning effect using either low-cost or high-fidelity laparoscopic simulators were not totally clear prior to study start. Aims 1. To examine whether laparoscopic surgical training may be offered at a lower cost, with maintained equivalent level of training and effect in knowledge/learning using a low-cost laparoscopic Blackbox (Paper I). 2. To study the impact of PC-gaming experience, visuospatial ability and gender on the various parameters of the MIST-VR simulator and its effect on the score (Paper II). 3. To further investigate the Blackbox, and if different adjuncts (video analysis) could provide more information regarding the effects of training (Paper III). 4. To study the effects on time to learn laparoscopic knot- and suturing skills in novices using two different laparoscopic needle holders in a more advanced Blackbox, evaluate outcomes regarding performance, ergonomic discomfort and time to perform laparoscopic knot- and suturing skills, as well as to evaluate an objective video evaluation scoring table (OVEST) (Paper IV). Materials and Methods: The participants were medical students from the surgical semester at Karolinska Institutet, Stockholm (Studies I-III) and medical students at Athens University Medical School in Athens, Athens, Greece (Study IV). The studies were conducted at CAMST (Center for Advanced Medical Simulation and Training), Karolinska University Hospital, Stockholm (Studies I-III), and at MPLSC (Medical Physics-Lab Simulation Center), Athens University Medical School, Athens, Greece (Study IV). In conjunction with inclusion, the students (Studies I-II) performed a test (MRT-A; Mental Rotation Test – A) for the assessment of their visuospatial ability, and questionnaires including baseline questions (Studies I-IV). The simulator training/tests were done using different laparoscopic simulators; Blackbox (Studies I and III); LapMentor (Study I); MIST-VR (Studies I-III); Simball box (Study IV). The participants’ simulator performance analyzed; time to completion and economy of movement (Studies I-IV); optical flow metrics (path-length and total number of particles) as displayed by the automated video analysis software (Study III); knot- and suturing skills (Study IV). Results: Studies I and II showed, as previous studies, that the visuospatial ability correlated with the initial simulator training sessions. Study I showed no significant difference in performance between laparoscopic basic skills training regardless of simulator used; low-cost or high-fidelity laparoscopy simulator. Studies I, II and III showed discrepancies between prior PC-gaming experience and the simulator performance, as well as some gender-specific differences. Study III also showed that the use of a low-cost automated video analysis software may be feasibly comparable to the build-in software of the MIST-VR simulator. Study IV presented a shortened time to learn for novices performing laparoscopic knot- and suturing tasks in a simulated environment when using the newly designed laparoscopic needle holder compared to a conventional market needle holder. Conclusions: Laparoscopic simulator training clearly facilitates laparoscopic skills performance. Improved prerequisites of training opportunities for surgeons could potentiate patient safety, especially since enhanced surgical performance improves patient safety. Subsequently, as depicted in this thesis, there is not one single truth or solution, rather different angles and several factors that affect learning in general and surgical performance in particular. Therefore, considerations of for instance individual differences, gender, and motivation, should all be included when producing laparoscopic skills training curriculum for future surgical trainees

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

Development and Validation of a Surgical Workload Measure: The Surgery Task Load Index (SURG-TLX)

Background: The purpose of the present study was to develop and validate a multidimensional, surgery-specific workload measure (the SURG-TLX), and to determine its utility in providing diagnostic information about the impact of various sources of stress on the perceived demands of trained surgical operators. As a wide range of stressors have been identified for surgeons in the operating room, the current approach of considering stress as a unidimensional construct may not only limit the degree to which underlying mechanisms may be understood but also the degree to which training interventions may be successfully matched to particular sources of stress. Methods: The dimensions of the SURG-TLX were based on two current multidimensional workload measures and developed via focus group discussion. The six dimensions were defined as mental demands, physical demands, temporal demands, task complexity, situational stress, and distractions. Thirty novices were trained on the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task and then completed the task under various conditions designed to manipulate the degree and source of stress experienced: task novelty, physical fatigue, time pressure, evaluation apprehension, multitasking, and distraction. Results: The results were supportive of the discriminant sensitivity of the SURG-TLX to different sources of stress. The sub-factors loaded on the relevant stressors as hypothesized, although the evaluation pressure manipulation was not strong enough to cause a significant rise in situational stress. Conclusions: The present study provides support for the validity of the SURG-TLX instrument and also highlights the importance of considering how different stressors may load surgeons. Implications for categorizing the difficulty of certain procedures, the implementation of new technology in the operating room (man-machine interface issues), and the targeting of stress training strategies to the sources of demand are discussed. Modifications to the scale to enhance clinical utility are also suggested. © 2011 The Author(s).published_or_final_versionSpringer Open Choice, 21 Feb 201

Objective Assessment of Surgical Skills in a 2-Day Visceral Anastomoses Techniques Course held in the Annual Congress of the German Surgical Society (DGCH)

Introduction Simulation skill laboratories are being increasingly marketed from different institutions and are widely accepted in Europe and the United States of America (USA). Furthermore, residency training programs in the USA incorporate such laboratories into their residency curricula after having been mandated by the American College of Surgery (ACS) since 2008 and use them in the last few years to evaluate the competency of their surgical residents (Varban et al. 2013). Unlike to North America, the literature to date has shown a little or none about simulation skill laboratories and curricula in Europe, despite their existence in private institutes or few residency training programs. European training programs still rely mainly on traditional training methods and surgical simulators are still predominantly aimed at attracting attention at surgical equipment exhibitions. One of the well-known simulation skill laboratories in Germany is held yearly in the annual meetings of the German Society for Surgery (DGCH) since 2005. This skill laboratory is subdivided into different courses over four days with different modules in station-setting which include common trunk surgical skills, visceral laparoscopic techniques, and conventional visceral anastomoses techniques as well as courses in vascular and orthopedic surgery. A valid and reliable objective assessment tool was developed in Canada and is currently used widely by residency training programs in the USA and Canada to evaluate the efficacy of technical skill development outside the operating room in a bench setting. This tool is called, the Objective Structured Assessment of Technical Skills (OSATS) (Martin et al. 1997; Ault et al. 2001). The aim of our study is to demonstrate the improvement of surgical skills through the participation in a selected training module using this validated international assessment tool (OSATS). Materials und Methods The visceral anastomoses course which includes five training modules on animal models and takes place over two days was selected for evaluation. Performance of the participants in one module (end-to-end bowel anastomoses) was measured by qualified surgeons using a task specific checklist at the beginning and at the end of the course with instructor to participant ratio 1 to 10. The improvement in OSATS scores pre-post the course was assessed using paired T-Test. Participants were asked to perform a baseline bowel anastomoses independent of the course and their scores were analyzed as a possible correlation factor with final OSATS scores. Demographic data of the participants as well as subjective evaluation forms were collected. Results A total of 38 surgical residents completed the 2-day visceral anastomoses course. The mean age was 34 ± 6 years. 58 % were males. Most of the participants were in their 4th and 5th year of residency training. 66% reported having performed ≤ 10 bowel anastomoses since the beginning of their surgical training. 21% were able to perform an end-to-end bowel anastomoses independent of the course in terms of self-reporting and scored a mean of 15 ± 3 in OSATS. OSATS scores improved significantly after completing the course (p= 0.000018) with a mean of 15.7 ± 3.5 vs. 18.8 ± 2.4 at the beginning and end of the course, respectively. In the regression analysis, factors like the ability to perform the procedure before the course, number of in-training so far performed bowel anastomoses or current level of surgical training did not predict the improvement of OSATS scores of the participants pre-post the curriculum (p= 0.6, 0.5 and 0.07, respectively). Furthermore, 95 % of the participants reported subjective improvement in their skills and all participants gave a positive answer when asked whether to include simulation laboratories into their residency curricula. Conclusions Our results show a significant improvement of the surgical skills of residents regardless of their training level after participating in the simulation course as measured by OSATS. We highly recommend the integration of simulation laboratories in the curricula of our national residency training programs as a complementary part of traditional surgical training in the OR

The Effects of a Multi-View Camera System on Spatial Cognition, Cognitive Workload and Performance in a Minimally Invasive Surgery Task

abstract: Minimally invasive surgery is a surgical technique that is known for its reduced patient recovery time. It is a surgical procedure done by using long reached tools and an endoscopic camera to operate on the body though small incisions made near the point of operation while viewing the live camera feed on a nearby display screen. Multiple camera views are used in various industries such as surveillance and professional gaming to allow users a spatial awareness advantage as to what is happening in the 3D space that is presented to them on 2D displays. The concept has not effectively broken into the medical industry yet. This thesis tests a multi-view camera system in which three cameras are inserted into a laparoscopic surgical training box along with two surgical instruments, to determine the system impact on spatial cognition, perceived cognitive workload, and the overall time needed to complete the task, compared to one camera viewing the traditional set up. The task is a non-medical task and is one of five typically used to train surgeons’ motor skills when initially learning minimally invasive surgical procedures. The task is a peg transfer and will be conducted by 30 people who are randomly assigned to one of two conditions; one display and three displays. The results indicated that when three displays were present the overall time initially using them to complete a task was slower; the task was perceived to be completed more easily and with less strain; and participants had a slightly higher performance rate.Dissertation/ThesisMasters Thesis Human Systems Engineering 201

Autonomous Camera Movement for Robotic-Assisted Surgery: A Survey

In the past decade, Robotic-Assisted Surgery (RAS) has become a widely accepted technique as an alternative to traditional open surgery procedures. The best robotic assistant system should combine both human and robot capabilities under the human control. As a matter of fact robot should collaborate with surgeons in a natural and autonomous way, thus requiring less of the surgeons\u27 attention. In this survey, we provide a comprehensive and structured review of the robotic-assisted surgery and autonomous camera movement for RAS operation. We also discuss several topics, including but not limited to task and gesture recognition, that are closely related to robotic-assisted surgery automation and illustrate several successful applications in various real-world application domains. We hope that this paper will provide a more thorough understanding of the recent advances in camera automation in RSA and offer some future research directions