Retracting and seeking movements during laparoscopic goal-oriented movements. Is the shortest path length optimal?

Aims- Minimally invasive surgery (MIS) requires a high degree of eye–hand coordination from the surgeon. To facilitate the learning process, objective assessment systems based on analysis of the instruments’ motion are being developed. To investigate the influence of performance on motion characteristics, we examined goaloriented movements in a box trainer. In general, goal-oriented movements consist of a retracting and a seeking phase, and are, however, not performed via the shortest path length. Therefore, we hypothesized that the shortest path is not an optimal concept in MIS. Methods-Participants were divided into three groups (experts, residents, and novices). Each participant performed a number of one-hand positioning tasks in a box trainer. Movements of the instrument were recorded with the TrEndo tracking system. The movement from point A to B was divided into two phases: A-M (retracting) and M-B (seeking). Normalized path lengths (given in %) of the two phases were compared. Results- Thirty eight participants contributed. For the retracting phase, we found no significant difference between experts [median (range) %: 152 (129–178)], residents [164 (126–250)], and novices [168 (136–268)]. In the seeking phase, we find a significant difference (<0.001) between experts [180 (172–247)], residents [201 (163–287)], and novices [290 (244–469)]. Moreover, within each group, a significant difference between retracting and seeking phases was observed. Conclusions- Goal-oriented movements in MIS can be split into two phases: retracting and seeking. Novices are less effective than experts and residents in the seeking phase. Therefore, the seeking phase is characteristic of performance differences. Furthermore, the retracting phase is essential, because it improves safety by avoiding intermediate tissue contact. Therefore, the shortest path length, as presently used during the assessment of basic MIS skills, may be not a proper concept for analyzing optimal movements and, therefore, needs to be revised.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized educational trial

<p>Abstract</p> <p>Background</p> <p>Several studies have found a positive effect on the learning curve as well as the improvement of basic psychomotor skills in the operating room after virtual reality training. Despite this, the majority of surgical and gynecological departments encounter hurdles when implementing this form of training. This is mainly due to lack of knowledge concerning the time and human resources needed to train novice surgeons to an adequate level. The purpose of this trial is to investigate the impact of instructor feedback regarding time, repetitions and self-perception when training complex operational tasks on a virtual reality simulator.</p> <p>Methods/Design</p> <p>The study population consists of medical students on their 4^thto 6^thyear without prior laparoscopic experience. The study is conducted in a skills laboratory at a centralized university hospital. Based on a sample size estimation 98 participants will be randomized to an intervention group or a control group. Both groups have to achieve a predefined proficiency level when conducting a laparoscopic salpingectomy using a surgical virtual reality simulator. The intervention group receives standardized instructor feedback of 10 to 12 min a maximum of three times. The control group receives no instructor feedback. Both groups receive the automated feedback generated by the virtual reality simulator. The study follows the CONSORT Statement for randomized trials. Main outcome measures are time and repetitions to reach the predefined proficiency level on the simulator. We include focus on potential sex differences, computer gaming experience and self-perception.</p> <p>Discussion</p> <p>The findings will contribute to a better understanding of optimal training methods in surgical education.</p> <p>Trial Registration</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT01497782">NCT01497782</a></p

Will the Playstation generation become better endoscopic surgeons?

A frequently heard comment is that the current "Playstation generation" will have superior baseline psychomotor skills. However, research has provided inconsistent results on this matter. The purpose of this study was to investigate whether the "Playstation generation" shows superior baseline psychomotor skills for endoscopic surgery on a virtual reality simulator. The 46 study participants were interns (mean age 24 years) of the department of surgery and schoolchildren (mean age 12.5 years) of the first year of a secondary school. Participants were divided into four groups: 10 interns with videogame experience and 10 without, 13 schoolchildren with videogame experience and 13 without. They performed four tasks twice on a virtual reality simulator for basic endoscopic skills. The one-way analysis of variance (ANOVA) with post hoc test Tukey-Bonferroni and the independent Student's t test were used to determine differences in mean scores. Interns with videogame experience scored significantly higher on total score (93 vs. 74.5; p=0.014) compared with interns without this experience. There was a nonsignificant difference in mean total scores between the group of schoolchildren with and those without videogame experience (61.69 vs. 55.46; p=0.411). The same accounts for interns with regard to mean scores on efficiency (50.7 vs. 38.9; p=0.011) and speed (18.8 vs. 14.3; p=0.023). In the group of schoolchildren, there was no statistical difference for efficiency (32.69 vs. 27.31; p=0.218) or speed (13.92 vs. 13.15; p=0.54). The scores concerning precision parameters did not differ for interns (23.5 vs. 21.3; p=0.79) or for schoolchildren (mean 15.08 vs. 15; p=0.979). Our study results did not predict an advantage of videogame experience in children with regard to superior psychomotor skills for endoscopic surgery. However, at adult age, a difference in favor of gaming is present. The next generation of surgeons might benefit from videogame experience during their childhoo

The future of patient safety: Surgical trainees accept virtual reality as a new training tool

BACKGROUND: The use of virtual reality (VR) has gained increasing interest to acquire laparoscopic skills outside the operating theatre and thus increasing patients' safety. The aim of this study was to evaluate trainees' acceptance of VR for assessment and training during a skills course and at their institution. METHODS: All 735 surgical trainees of the International Gastrointestinal Surgery Workshop 2006-2008, held in Davos, Switzerland, were given a minimum of 45 minutes for VR training during the course. Participants' opinion on VR was analyzed with a standardized questionnaire. RESULTS: Fivehundred-twenty-seven participants (72%) from 28 countries attended the VR sessions and answered the questionnaires. The possibility of using VR at the course was estimated as excellent or good in 68%, useful in 21%, reasonable in 9% and unsuitable or useless in 2%. If such VR simulators were available at their institution, most course participants would train at least one hour per week (46%), two or more hours (42%) and only 12% wouldn't use VR. Similarly, 63% of the participants would accept to operate on patients only after VR training and 55% to have VR as part of their assessment. CONCLUSION: Residents accept and appreciate VR simulation for surgical assessment and training. The majority of the trainees are motivated to regularly spend time for VR training if accessible

Postsurgical pain outcome of vertical and transverse abdominal incision: Design of a randomized controlled equivalence trial [ISRCTN60734227]

BACKGROUND: There are two ways to open the abdominal cavity in elective general surgery: vertically or transversely. Various clinical studies and a meta-analysis have postulated that the transverse approach is superior to other approaches as regards complications. However, in a recent survey it was shown that 90 % of all abdominal incisions in visceral surgery are still vertical incisions. This discrepancy between existing recommendations of clinical trials and clinical practice could be explained by the lack of acceptance of these results due to a number of deficits in the study design and analysis, subsequent low internal validity, and therefore limited external generalisability. The objective of this study is to address the issue from the patient's perspective. METHODS: This is an intraoperatively randomized controlled observer and patient-blinded two-group parallel equivalence trial. The study setting is the Department of General-, Visceral-, Trauma Surgery and Outpatient Clinic of the University of Heidelberg, Medical School. A total of 172 patients of both genders, aged over 18 years who are scheduled for an elective abdominal operation and are eligible for either a transverse or vertical incision. To show equivalence of the two approaches or the superiority of one of them from the perspective of the patient, a primary endpoint is defined: the pain experienced by the patient (VAS 0–100) on day two after surgery and the amount of analgesic required (piritramide [mg/h]). A confidence interval approach will be used for analysis. A global α-Level of 0.05 and a power of 0.8 is guaranteed, resulting in a size of 86 patients for each group. Secondary endpoints are: time interval to open and close the abdomen, early-onset complications (frequency of burst abdomen, postoperative pulmonary complications, and wound infection) and late complications (frequency of incisional hernias). Different outcome variables will be ranked by patients and surgeons to assess the relevance of possible endpoints from the patients' and surgeons' perspective. CONCLUSION: This is a randomized controlled observer and patient-blinded two-group parallel trial to answer the question if the transverse abdominal incision is equivalent to the vertical one due to the described endpoints

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND: Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands. METHODS: Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire. RESULTS: A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines. CONCLUSIONS: A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training course