Validation of a six-task simulation model in minimally invasive surgery.

BACKGROUND: The content validity of currently available inanimate simulation models is questionable, because some tasks seem too far from clinical reality. The aim of this study was to validate a simulation model with six tasks commonly used in clinical practice (6-TSM) for the acquisition of psychomotor skills in minimally invasive surgery (MIS). METHODS: This was a prospective randomized trial comparing the 6-TSM to a previously described three-task training method (3-TTM). All first, second, and third postgraduate year surgical residents were eligible. The 6-TSM included clipping and dividing of a vessel, excision of lesion, appendectomy, mesh repair, suturing perforation, and hand-sewn anastomosis. The outcome measures of 6-TSM included accuracy error, tissue damage, sliding knot, leak, operating time, and dangerous movements. After completion of training, 6-TSM and 3-TTN residents were tested by the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR). Criterion-related and construct validity, responsiveness, test-retest, and interrater reliability were assessed. RESULTS: During six months, 17 residents underwent training with the 6-TSM or the 3-TTM as allocated. The mean duration of training with 6-TSM and 3-TTM was similar (7.8 vs 8.1 h). The criterion-related validity of the 6-TSM was shown by significantly increased skill improvement in the 6-TSM residents, as compared with the 3-TTM residents at MIST-VR. Construct validity the of 6-TSM was shown by the finding that the experts\u27 baseline was superior to the residents\u27 baseline. The responsiveness of the 6-TSM was shown by the significantly increased skill improvement of the 6-TSM residents in sliding knot, leak, and operating time. The test-retest reliability of the 6-TSM was good (\u3e 0.80), except for accuracy error and dangerous movements (Cronbach\u27s intraclass correlation coefficient alpha: 0.57, p \u3c 0.0001; 0.62, p \u3c 0.0001, respectively). The interrater reliability of the 6-TSM was good (\u3e0.80) except for leak (Kendall\u27s concordance coefficient tau_b:0.76, p = 0.06 for hand-sewn anastomosis) and dangerous movements (tau_b:0.72, p = 0.08 for suturing perforation and tau_b:0.68, p = 0.10 for hand-sewn anastomosis). The perresident cost for 6-TSM was 769 dollars. CONCLUSIONS: The 6-TSM is a valid and reliable learning tool for surgical residents\u27 acquisition of laparoscopic motor skills

Robotic camera holder as good as expert camera holder: a randomized crossover trial.

INTRODUCTION: This study aimed to compare the impact of robotic camera holder (RCH) and human camera holder (HCH) on product quality and procedure effectiveness of a simulated laparoscopic procedure. METHODS: This was a prospective randomized crossover trial including voluntary surgical residents. Block randomization generated RCH-HCH or HCH-RCH sequence allocation. The task was suturing a duodenal perforation on foam stomach with intracorporeally knot tying in a simulator. The camera was operated by the same robot and same expert. Product quality was measured by accuracy error, tissue damage, sliding knot, and leak. Procedure effectiveness was measured by operating time, nongoal directed actions, and dangerous actions. Kendall\u27s coefficient tau_b was used for interrater reliability between 2 blinded assessors. RESULTS: Forty-four subjects performed their tasks as allocated. Product quality and procedure effectiveness were similar when first attempt of task was compared with the repeat task by same subject ignoring the type of camera holder. There was no evidence of significant unequal carryover effect when comparison was stratified by RCH-HCH or HCH-RCH sequences. There were no differences in product quality and procedure effectiveness when RCH was compared with HCH. Coefficient tau_b was \u3e or = 0.80 for all but dangerous actions (0.72, P=0.08). CONCLUSIONS: RCH and HCH had similar impact on product quality and procedure effectiveness of simulated laparoscopic procedure

Complication rates after Hartmann\u27s reversal: open vs. laparoscopic approach.

PURPOSE: This study was performed to compare open Hartmann\u27s reversal to laparoscopic Hartmann\u27s reversal with regard to complication, readmission, and reoperation rates. METHODS: Data of patients who underwent open Hartmann\u27s reversal or laparoscopic Hartmann\u27s reversal between 1998 and 2004 at two institutions were collected. End points were complications in the hospital or after discharge, readmission to the hospital, and reoperation within 6 months after initial surgery. RESULTS: Sixty-one open Hartmann\u27s reversal and 61 laparoscopic Hartmann\u27s reversal patients were well matched except for American Society of Anesthesiology grade (1.9 vs. 1.6; P = 0.008), timing of Hartmann\u27s procedure (14 vs. 6 months; P = 0.001), operation time (210 vs. 154 minutes; P = 0.001), and estimated blood loss (363 vs. 254 ml; P = 0.01). Thirty-day complication rates did not differ (18 vs. 13 percent). At 6 month follow-up, open Hartmann\u27s reversal patients had increased complication (16.4 vs. 3.3 percent; P = 0.015) and reoperation (13.1 vs. 3.3 percent; P = 0.048) rates but the same readmission rates (16.4 percent). CONCLUSIONS: Compared with open Hartmann\u27s reversal, 6 month complication and reoperation rates were lower in laparoscopic Hartmann\u27s reversal patients. Most of the six-month complications and reoperations in open Hartmann\u27s reversal were abdominal wall-related. Readmission rates were similar, but reasons for readmission were surgical in open Hartmann\u27s reversal and medical in laparoscopic Hartmann\u27s reversal

Ergonomics in laparoscopic surgery

Laparoscopic surgery provides patients with less painful surgery but is more demanding for the surgeon. The increased technological complexity and sometimes poorly adapted equipment have led to increased complaints of surgeon fatigue and discomfort during laparoscopic surgery. Ergonomic integration and suitable laparoscopic operating room environment are essential to improve efficiency, safety, and comfort for the operating team. Understanding ergonomics can not only make life of surgeon comfortable in the operating room but also reduce physical strains on surgeon

Development of a total colonoscopy rat model with endoscopic submucosal injection of the cecal wall.

BACKGROUND: Experimental models of colorectal tumor require either laparotomy for induction or anastomosis following resection. The long murine cecum avoids the need for an anastomosis, making the cecum the preferred site for induction. This study aimed to evaluate total colonoscopy with submucosal injection of cecal wall (TCWI) in rats in terms of failure rate (FR), complication rate (CR), and reproducibility (R). METHODS: A bolus of bowel prep was given. Anesthesia was injected intraperitoneally. A video fiberscope (5.9 mm outer diameter, 180/90 degrees up/down bending, 100/100 degrees right/left bending, 103 cm working length, 120 degrees view field, and 2.0 mm channel) allowed for irrigation and suction. Saline 1 ml was injected in the cecal wall through a 4-mm-long, 23-gauge needle placed on a 3-mm wire, resulting in a blister. FR was a failure to reach and inject the cecum. Rats were allowed to recover. CR was measured at necropsy. R was assessed by comparing TCWI time, FR, and CR for three investigators. Sample size of 120 (type I error, 0.05; power, 80%) was based on a pilot study. Data are presented as median (range). RESULTS: A total of two of 122 rats (1.6%) died after prep or anesthesia. Bowel prep resulted in 99.1% evacuation of solid feces. A total of 120 male Sprague-Dawley retired breeders weighing 592 g (range, 349-780) underwent TCWI. Scope depth was 28 cm (range, 20-36). Irrigating fluid was 290 ml (range, 100-600). TCWI time was 7 min (range, 4-28). FR was 4%. In three failed cases, the scope reached the ascending colon. CR was 2%. There were two perforations in the ascending colon. All three operators had similar TCWI time (p = 0.673), FR (p \u3e 0.1), and CR (p \u3e 0.1). A total of 98.3% of rats survived to planned sacrifice. At 48-h necropsy, the injection site was macroscopically identified in 118 rats. CONCLUSIONS: A safe and reproducible TCWI rat model has been achieved, which may provide a valuable tool in the future for studies of solid colorectal tumors