Is In-Vivo laparoscopic simulation learning a step forward in the Undergraduate Surgical Education?

BACKGROUND: Essentials Skills in the Management of Surgical Cases - ESMSC is an International Combined Applied Surgical Science and Wet Lab course addressed at the Undergraduate level. Laparoscopic Skills is a fundamental element of Surgical Education and various Simulation-Based Learning (SBL) models have been endorsed. This study aims to explore if there is any significant difference in delegates' performance depending on whether they completed In Vivo module prior to the equivalent in the laparoscopic simulator. MATERIALS AND METHODS: 37 Medical Students from various EU countries were divided in 2 groups, and both completed the "Fundamentals in Laparoscopic Surgery" module in the Dry-lab Laparoscopic Simulator as well as the same module "In Vivo" on a swine model. Group A (18 students, 48.6%) completed the "Fundamentals in Laparoscopic Surgery - FLS" module prior to the "In Vivo", whereas group B completed the "In Vivo" module first. Direct Observation of Procedural Skills (DOPS) were used to assess delegates' performance. RESULTS: The mean DOPS scores for the "FLS" and "In Vivo" models were 2.27 ± 0.902 and 2.03 ± 0.833, respectively, and the delegates' performance was not statistically significantly different between them (p = 0.128). There was no statistically significant difference in the scores among different gender, year of study, school and handedness groups. The alteration in the sequence between Dry-lab "FLS" and "In Vivo" modules did not affect the performance in neither the "FLS" nor the "In Vivo" models. CONCLUSIONS: The inexpensive, but low-fidelity "FLS" model could serve an equal alternative Simulation-Based Learning model for the early undergraduate training. Our study demonstrated that high fidelity In Vivo simulation for laparoscopic skills does not affect significantly the improvement in the delegates' performance at the undergraduate level. Further studies should be conducted to identify at which stage of training should high fidelity simulation be introduced

The use of curved vs. straight instruments in single port access surgery, on standardized box trainer tasks

BACKGROUND: Single-port access (SPA) surgery is a novel surgical technique to create nearly "scarless" surgery. SPA surgery appears to be safe and feasible, but the exposure and handling of tissue may not be optimal. Therefore, the performance of SPA surgery with different instruments used and conventional laparoscopy is compared. METHODS: Fifteen participants (>50 laparoscopic procedures) performed three basic tasks (translocation, clip & cut, and tissue dissection, based on the fundamentals of laparoscopic surgery) in the box trainer in laparoscopy and SPA settings with both (conventional) crossed and curved instruments. All participants completed a questionnaire, which asked their opinion on the use of instruments and preference. RESULTS: Translocation was performed significantly faster in both laparoscopy and SPA crossed than SPA curved (means, 130.3 and 137.7 vs. 170.7 sec; p < 0.001 and p = 0.005). The errors also were less in laparoscopy and SPA crossed (means, 0.9 and 1.2 vs. 1.6), but not significant. The time to complete the dissection was almost equal between laparoscopy and SPA curved settings, but took longer for SPA crossed, although not significantly (148.1 and 150.8 vs. 179.5 sec). The errors only differed significantly between laparoscopy and SPA crossed (means, 0.5 vs. 1.27; p = 0.044). Fourteen participants still favored conventional laparoscopy and one SPA curved. They also thought SPA curved was better than crossed (means, 3.6 vs. 2.47; p = 0.003) and that exposure is superior in curved (means, 3.4 vs. 2.27; p = 0.002). CONCLUSIONS: Although conventional laparoscopy may appear most effective for proper dissection and exposure of tissue, single-port access surgery shows potential. Especially in the tissue dissection task, there is no significant difference in time or errors between conventional laparoscopy and SPA surgery, using specially designed curved instruments. Although the participants favor conventional laparoscopy, this could evolve to a more accepting mind when SPA surgery becomes more available and used in the clinical setting

Retention of basic laparoscopic skills after a structured training program

The purpose of this study was to test the retention of basic laparoscopic skills on a box trainer 1 year after a short training program. For a prior study, eight medical students without prior experience (novices) underwent baseline testing, followed by five weekly training sessions and a final test. During each of seven sessions, they performed five tasks on an inanimate box trainer. Scores were calculated by adding up the time to completion of the task with penalty points, consequently rewarding speed and precision. The sum score was the sum of the five scores. One year later, seven of them underwent retention testing for the current study. The final test results were compared with retention test results as a measure of durability of acquired skills. Novices’ scores did not worsen significantly for four out of five tasks (i.e., placing a pipe cleaner p = 0.46, placing beads p = 0.24, cutting a circle p = 0.31, and knot tying p = 0.13). However, deterioration was observed in the performance on stretching a rubber band (p < 0.05), as well as in the sum score (p < 0.05). Nevertheless, all retention scores remained better than the baseline results. In conclusion, basic laparoscopic skills acquired during a short training program merely sustain over time. However, ongoing practice is advisable, especially to preserve tissue-handling skills, since these may be the first to deteriorate

Contraindications of sentinel lymph node biopsy: Áre there any really?

BACKGROUND: One of the most exciting and talked about new surgical techniques in breast cancer surgery is the sentinel lymph node biopsy. It is an alternative procedure to standard axillary lymph node dissection, which makes possible less invasive surgery and side effects for patients with early breast cancer that wouldn't benefit further from axillary lymph node clearance. Sentinel lymph node biopsy helps to accurately evaluate the status of the axilla and the extent of disease, but also determines appropriate adjuvant treatment and long-term follow-up. However, like all surgical procedures, the sentinel lymph node biopsy is not appropriate for each and every patient. METHODS: In this article we review the absolute and relative contraindications of the procedure in respect to clinically positive axilla, neoadjuvant therapy, tumor size, multicentric and multifocal disease, in situ carcinoma, pregnancy, age, body-mass index, allergies to dye and/or radio colloid and prior breast and/or axillary surgery. RESULTS: Certain conditions involving host factors and tumor biologic characteristics may have a negative impact on the success rate and accuracy of the procedure. The overall fraction of patients unsuitable or with multiple risk factors that may compromise the success of the sentinel lymph node biopsy, is very small. Nevertheless, these patients need to be successfully identified, appropriately advised and cautioned, and so do the surgeons that perform the procedure. CONCLUSION: When performed by an experienced multi-disciplinary team, the SLNB is a highly effective and accurate alternative to standard level I and II axillary clearance in the vast majority of patients with early breast cancer