Development of a model for laparoscopic cholecystectomy video assisted training. A randomized study

Abstract Purpose: To identify the surgical trainee benefits through the use of video assisted training (VAT). Methods: Twelve cases of uncomplicated laparoscopic cholecystectomy (LC) were selected. Edited video segments focused on essential intra-operative anatomical structure identification and critical surgical steps. Evaluation of these videos was constructed on a scoring system based on pre and post-teach tests. Results: The mean value of the pre-teach score was 33.2 ± 18.0 points and in the post-teach test the mean value was 66.7 ± 9.7 points. A statistically significant difference was seen when comparing pre and post-teach results (p<.00001). Conclusion: The widespread and the systematic use of video assisted learning may be a useful and economic tool in adjunct to the surgical training techniques practiced until now throughout the surgical community.

Abdominal cavity simulator for skill progression in videolaparoscopic sutures in Brazil

Abstract Purpose: To develop and test a model of teaching by means of an abdominal cavity simulator. Methods: This study had two stages: development of a teaching model and an experimental prospective study that aimed to evaluate the residents' competence. The participants were divided into 3 groups: first-year resident, second-year resident, and senior surgeon. The two groups of resident physicians received training in the simulator, under instructor supervision for skill acquisition, according to the model proposed in first stage. The surgeons did not receive this intervention. The correlations and associations were verified through simple and multiple linear regressions. The learning curves were analysed using Cox regression models. The impact of the epidemiological characteristics was tested. Results: All residents reached the maximum score at the end of 16 steps and were comparable to the experimental (p<0.001). Conclusion: Residents who underwent training using the methodology of the proposed teaching model, which is based on realistic simulation, acquired proficiency in the accomplishment of endosutures in up to 16 hours of training in the laboratory.

Can virtual reality be as good as operating room training? experience from a residency program in general surgery / A realidade virtual pode ser tão boa como o treinamento em sala cirúrgica? experiências de um programa de residência em cirurgia geral

ABSTRACT Background: The increasingly intense usage of technology applied to videosurgery and the advent of robotic platforms accelerated the use of virtual models in training surgical skills. Aim: To evaluate the performance of a general surgery department's residents in a video-simulated laparoscopic cholecystectomy in order to understand whether training with virtual reality is sufficient to provide the skills that are normally acquired in hands-on experience at the operating room. Methods: An observational study with twenty-five first- and second-year general surgery residents. Each subject performed three video-laparoscopic cholecystectomies under supervision in a simulator. Only the best performance was evaluated in the study. Total number of complications and total procedure time were evaluated independently. The groups were defined according to total practice time (G1 and G2) and the year of residency (R1 and R2), each being analysed separately. Results: Twenty-one residents finished the three practices, with four follow-up losses. Mean practice time was 33.5 hours. Lowering of the rate of lesions in important structures could be identified after a level of proficiency of 60%, which all participants obtained regardless of previous in vivo experience. No significant difference between the R1 and R2 groups was observed. Conclusion: Learning in groups R1 and R2 was equal, regardless of whether previous practice was predominantly in vivo (R2) or with virtual reality (R1). Therefore, it is possible to consider that skills obtained in virtual reality training are capable of equalising the proficiency of first- and second-year residents, being invaluable to increase patient safety and homogenise learning of basic surgical procedures.

RESUMO Racional: O uso cada vez mais intenso da tecnologia aplicado à cirurgia em vídeo e o advento das plataformas robóticas, aceleraram o uso de modelos virtuais no treinamento de habilidades cirúrgicas. Objetivo: Avaliar o desempenho dos médicos residentes em um serviço de cirurgia geral em colecistectomia vídeo simulada laparoscópica em um centro de realidade virtual para entender se o treinamento de realidade virtual é suficiente para equipará-lo às habilidades adquiridas no centro cirúrgico. Método: Estudo observacional transversal com 25 residentes de cirurgia geral do primeiro e segundo anos. Cada residente realizou três colecistectomias videolaparoscópicas com supervisão em um simulador. O melhor desempenho foi avaliado no estudo. O número total de complicações e tempo total do procedimento foram avaliados de forma independente. Os grupos foram definidos de acordo com o tempo total de prática (G1 e G2) e o ano de residência (R1 e R2), os quais foram analisados isoladamente. Resultados: Vinte e um médicos residentes médicos concluíram as 3 práticas, com 4 perdas de seguimento e praticaram uma média de 33,5 h. Diminuição das lesões em estruturas importantes foi identificada após nível de proficiência de 60%, que todos os participantes obtiveram independentemente da experiência anterior in vivo. Não houve diferença significativa entre os resultados dos grupos R1 e R2. Conclusões: O aprendizado dos grupos R1 e R2 pode ser considerado igual, independentemente de a prática anterior ser majoritariamente in vivo (R2) ou em realidade virtual (R1). Assim, é possível considerar que as habilidades cirúrgicas adquiridas a partir do treinamento virtual são capazes de equiparar a proficiência dos residentes de primeiro e segundo ano, sendo fundamental para aumentar a segurança dos pacientes e homogeneizar o aprendizado de procedimentos cirúrgicos básicos.

Evaluación objetiva de competencias técnicas en cirugía / [Evaluation of technical skills in surgical training].

INTRODUCTION: technical skills acquisition is considered to be of paramount importance in surgical training. Yet, formal assessment of technical skills is the weakest and less developed area. Currently available resources to evaluate technical skills are largely subjective, and lack of validity and reliability. Direct observation, one of the most frequently used methods, is largely biased by interpersonal subjectivity and personality traits. We propose the creation and use of a new procedure-specific tool for objective assessment of technical skills in surgery to evaluate validity and reliability. MATERIALS AND METHODS: laparoscopic cholecystectomy and Lichstenstein’s inguinal hernia repair were the chosen procedures. Three groups of comparison were defined according to surgical expertise: initial, intermediate, and experts. Surgeries were videorecorded in real time without identification of the patient or the surgeon. Tapes without any posterior edition were assigned to two expert surgeons in a blind and randomized sequence. A newly proposed procedure-specific rating scale was used for evaluation, as well as Reznick’s OSATS global scale. Kruskal-Wallis non-parametric test was used to assess validity. p 0.8 granted reliability. RESULTS: from April 2010 to December 2012 36 laparoscopic cholecystectomies and 31 inguinal hernia repairs were recorded. Significant difference was found among groups of comparison for every item (p<0.05). Crhonbach’s ? was largely over 0,80 for both procedures. There was no significant difference between the assessments of the two raters. There was no significant difference between our newly proposed procedure-specific instrument and Reznick’s OSTATS. DISCUSSION: the objective assessment of technical skills in surgery is feasible and useful. The tool we proposed showed construct validity and reliability. Video recording of surgical procedures grants durability over time to an ephemeral phenomenon. The objectivity is based on the explicit statements and quantification of every step to be evaluated, and the blind randomization and anonymous treatment of the sample. Sharing the same quality criteria between evaluators is of paramount importance to reach satisfactory results. The process of evaluation always implies a shortened view of the reality.

Algoritmos generales para simuladores de cirugía laparoscópica / General algorithms for laparoscopic surgical simulators

Recent advances in fields such as modeling of deformable objects, haptic technologies, immersive technologies, computation capacity and virtual environments have created the conditions to offer novel and suitable training tools and learning methods in the medical area. One of these training tools is the virtual surgical simulator, which has no limitations of time or risk, unlike conventional methods of training. Moreover, these simulators allow for the quantitative evaluation of the surgeon performance, giving the possibility to create performance standards in order to define if the surgeon is well prepared to execute a determined surgical procedure on a real patient.This paper describes the development of a virtual simulator for laparoscopic surgery. The simulator allows the multimodal interaction between the surgeon and the surgical virtual environment using visual and haptic feedback devices. To make the experience of the surgeon closer to the real surgical environment a specific user interface was developed. Additionally in this paper we describe some implementations carried out to face typical challenges presented in surgical simulators related to the tradeoff between real-time performance and high realism; for instance, the deformation of soft tissues are simulated using a GPU (Graphics Processor Unit) -based implementation of the mass-spring model. In this case, we explain the algorithms developed taking into account the particular case of a cholecystectomy procedure in laparoscopic surgery.

Recientes avances en áreas tales como modelación computacional de objetos deformables, tecnologías hápticas, tecnologías inmersivas, capacidad de procesamiento y ambiente virtuales han proporcionado las bases para el desarrollo de herramientas y métodos de aprendizaje confiables en el entrenamiento médico. Una de estas herramientas de entrenamiento son los simuladores quirúrgicos virtuales, los cuales no tienen limitaciones de tiempo o riesgos a diferencia de los métodos convencionales de entrenamiento. Además, dichos simuladores permiten una evaluación cuantitativa del desempeño del cirujano, dando la posibilidad de crear estándares de desempeño con el fin de definir en qué momento un cirujano está preparado para realizar un determinado procedimiento quirúrgico sobre un paciente. Este artículo describe el desarrollo de un simulador virtual para cirugía laparoscópica. Este simulador permite la interacción multimodal entre el cirujano y el ambiente virtual quirúrgico usando dispositivos de retroalimentación visual y háptica. Para hacer la experiencia del cirujano más cercana a la de una ambiente quirúrgico real se desarrolló una interfaz cirujano-simulador especial. Adicionalmente en este artículo se describen algunas implementaciones que solucionan los problemas típicos cuando se desarrolla un simulador quirúrgico, principalmente relacionados con lograr un desempeño en tiempo real mientras se sacrifica el nivel de realismo de la simulación: por ejemplo, la deformación de los tejidos blandos simulados usando una implementación del modelo masa-resorte en la unidad de procesamiento gráfico. En este caso se describen los algoritmos desarrollados tomando en cuenta la simulación de un procedimiento laparoscópico llamado colecistectomía.

Curva de aprendizado e lesões iatrogênicas em colecistectomias videolaparoscópicas / Learning curve and iatrogenic injuries in laparoscopic cholecystectomies

OBJETIVO: Analisar a proficiência do cirurgião em colecistectomias videolaparoscópicas, de acordo com sua curva de aprendizado, como fator de risco para as lesões iatrogênicas da via biliar principal. MÉTODOS: Estudo retrospectivo de 2285 pacientes submetidos à colecistectomias videolaparoscópicas no Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro no período de janeiro de 1992 a dezembro de 2007. As características dos cirurgiões foram avaliadas através questionário no qual se procurou identificar idade, experiência profissional em cirurgia convencional e laparoscópica e métodos de aprendizado em videocirurgia. RESULTADOS: O número de lesões da via biliar principal neste estudo foi de seis (0,26 por cento), semelhante ao encontrado na literatura mundial. Todas ocorreram na segunda fase da curva de aprendizado, quando os cirurgiões já haviam realizado mais de 50 colecistectomias videolaparoscópicas. CONCLUSÃO: Certificado de habilitação, treinamento prévio e idade dos cirurgiões se relacionaram com as lesões da via biliar principal nesta série. Houve significância estatística na diferença entre as médias dos tempos de experiência dos cirurgiões e sua relação com as lesões.

Objective: the aim of this study is to analyze surgeon's proficiency, based on the different aspects of his learning curve as a risk factor for iatrogenic biliary tract injuries associated with Laparoscopic Cholecystectomy. METHODS: a retrospective study was conducted using the report information from charts of patients January 1992 through December 2007; at Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro. Analysis from data collected from charts of 2285 patients who had undergone laparoscopic cholecystectomies. Data from surgeons involved with this type of surgery was also analyzed. RESULTS: a total of six injuries (0.26 percent) were found. This result is similar to that found in international publications. All injuries had occurred in the surgeon's second phase of the learning curve with more than 50 video surgeries. CONCLUSION: it was conclude that Video surgery Certificate and previous training are not related to biliary tract injuries in this series. Surgeon's age was not a risk factor in this study. There was statistical significance between surgeons' experience and injuries.

Treinamento para a colecistectomia videolaparoscópica em manequins plásticos / Laparoscopic cholecystectomy training on plastic mannequins

OBJETIVO: Este trabalho tem como objetivo disponibilizar para qualquer instituição de ensino superior em Medicina um eficaz método de curva de aprendizagem e de desenvolvimento de habilidades nessa inovadora prática cirúrgica que necessita de aperfeiçoamento em virtude das inovações tecnológicas. MÉTODOS: Foram utilizados materiais simples e de baixo custo para a confecção e a realização da colecistectomia videolaparoscópica em manequins plásticos como seria in vivo. RESULTADOS: Os resultados foram evidenciados por meio de fotos legendadas dos procedimentos cirúrgicos. CONCLUSÃO: A colecistectomia videolaparoscópica em manequins plásticos demonstrou ser um alternativo e viável método de treinamento para os estudantes de Medicina.

OBJECTIVE: The objective of this project is to offer for any Medical Education Institution an effective method of learning and developing the skills on this new surgery procedure that is necessary to improve the ability as consequence of technological innovations. METHODS: Simple and low cost materials were used for doing and carrying on the laparoscopic cholecystectomy on plastic mannequins as if it were done in vivo. RESULTS: The results were shown through illustrated photographs from the surgery procedures. CONCLUSION: Laparoscopic cholecystectomy on plastic mannequins proved to be an alternative and a feasible method of training with Medical students.

Aprendizaje de la colecistectomía laparoscópica en la residencia / Learning laparoscopic cholecystectomy in the residence

Antecedentes: el aprendizaje de la cirugía laparoscópica representa uno de los pilares fundamentales dentro de los sistemas de residencias quirúrgicas. Objetivo: mostrar la experiencia y los resultados obtenidos con la enseñanza supervisada en colecistectomía laparoscópica en una residencia de Cirugía General en un hospital público. Lugar de aplicación: Hospital Público de alta complejidad. Material y Métodos: estudio descriptivo y retrospectivo. Se incluyeron 384 pacientes por tadores de litiasis vesicular no complicada, 116 hombres y 268 mujeres, con una edad promedio de 53.4 años (r16-75), en el período Junio de 2006 a Junio de 2007. Se practicó colecistectomía laparoscópica en todos los casos. Las cirugías fueron realizadas por residentes de 2°, 3° año y por el jefe de residentes, tutorizadas en todos los casos por médicos cirujanos de planta del servicio. Se analizaron la incidencia de complicaciones, conversión a cirugía abier ta, tiempo operatorio y dificultad operatoria (rotación del residente que actuaba como cirujano para dar lugar al tutor). Resultados: el índice de complicaciones fue de 2.25 % (9 casos). Se convir tieron a cirugía abier ta a 16 pacientes (4.1 %). El tiempo operatorio promedio fue de 51 minutos (r25 û 145). No hubo mor talidad relacionada con el procedimiento. Se observaron 30 casos en los que la capacidad resolutiva del residente fue sobrepasada Conclusiones: los buenos resultados observados en esta serie de colecistectomías laparoscópicas practicadas por residentes, hacen suponer que la enseñanza de la cirugía laparoscópica en la residencia es segura y efectiva, debiendo esta ser progresiva y adecuadamente tutorizada.

Background: the learning of laparoscopic surgery represents one of the fundamental pilars in the surgeryresidence systems. Objective: to show the experience and results obtained by the supervised teaching in laparoscopic cholecystectomy in a General Surgery residence in a public hospital. Place of application: Public Hospital of high complexity. Material and Methods: retrospective and descriptive research. 384 patients who suffered from mild cholelithiasis were included, 116 men and 268 women, with an average age of 53.4 years (r16-75), from June 2006 to June 2007. Laparoscopic cholecystectomy was carried out in all cases. Surgeries were practiced by 2nd and 3rd year residents and by the chief of residents, tutored in all cases by staff surgeons. Incidence of postoperative complications, conversion to open surgery, operative time and intraoperative complications were analyzed (rotation of resident who acted as surgeon to leave place to tutor).Results: The average of complications was 2.25 % (9 cases). 16 patients (4.1%) were conver ted to opensurgery. The average operative time was 51 minutes (r25 – 145). There was no mor tality related to the procedure. 30 cases in which the resident’s solving was over-passed were observed. Conclusions: the good results observed in this series of laparoscopic cholecystectomies practiced byresidents, make us suppose that the teaching of laparoscopy in the residence is safe and effective, though it must be progressive and duly tutored.

Entrenamiento en un biosimulador y su impacto sobre la destreza en colecistectomía laparoscópica / Biosimulator training and its impact on skill in laparoscopic cholecystectomy

Objetivo: determinar el impacto educacional del entrenamiento en un biosimulador inanimado en términos de efectividad, tiempo y complicaciones, respecto a la colecistectomía laparoscópica. Material y métodos: estudio comparativo, experimental de una cohorte, prospectivo y longitudinal. Tres médicos residentes de primer año de cirugía y un interno de pregrado, fueron entrenados y evaluados en habilidades laparoscópicas elementales mediante el empleo de un biosimulador (maniquí de fibra de vidrio en el que se introducen órganos de animales ex vivo). Los sujetos fueron su propio control: realizaron un procedimiento inicial en el que se determinó tiempo quirúrgico, complicaciones y efectividad. Posteriormente observaron un corto video que mostraba el desarrollo idóneo de la colecistectomía, y en el que se identificaban las desviaciones específicas del desempeño adecuado. Posteriormente cada sujeto realizó 10 procedimientos. Resultados: no existieron diferencias en la evaluación inicial de habilidades elementales. Los individuos completaron todos los procedimientos propuestos. Las disecciones de las estructuras císticas y de la vesícula biliar fueron 61 % más rápidas al finalizar el estudio (p < 0.001); la tasa de complicación fue de 0.67 % (p <0.009). Conclusión: el entrenamiento de habilidades en cirugía endoscópica por medio de un biosimulador inanimado es mejor que el entrenamiento tradicional, ya que disminuye el tiempo quirúrgico y las complicaciones en la sala de operaciones.

OBJECTIVE: We undertook this study to determinate the educational impact of training in an inanimate biosimulator in terms of effectiveness, time and complications in performing laparoscopic cholecystectomy. METHODS: We used a comparative, experimental cohort, prospective and longitudinal. Three first-postgraduate-year residents and one pre-grade internship physician were trained and assessed in basic laparoscopic skills using a biosimulator (fiberglass [quot ]dummy[quot ] where animal organs are introduced ex-vivo). The participants acted as their own control, performing a procedure to determine surgical time, complications and effectiveness. Later they observed a short video demonstrating the suitable development of laparoscopic cholecystectomy. The video defined the specific deviations from the ideal cholecystectomy, which were considered as errors. Every procedure was videotaped, beginning with the careful dissection of cystic structures and clipping them, continuing with the dissection of the gallbladder from the liver with the standardized method. Each participant performed ten procedures. RESULTS: There were no differences in baseline assessment of basic skills. All participants completed all proposed procedures. Surgical time was 61% faster at the end of the study (p<0.001), as well as demonstrating a lower rate of complications of 0.67% (p<0.009). CONCLUSIONS: Skills training in endoscopic surgery by means of an inanimate biosimulator is superior to traditional training because it decreases surgical time and surgical complications without ethical considerations and the effect of a learning curve in the operating room.

A comparison of open and laparoscopic cholecystectomy done by a surgeon in training / Comparación de Colecistectomías abiertas y laparoscópicas realizadas por un cirujano durante su adiestramiento

Laparoscopic cholecystectomy has virtually replaced conventional open cholecystectomy as the gold standard for symptomatic cholelithiasis. The laparoscopic approach brings numerous advantages at the expense of higher complication rates, especially in training facilities. This comparative 18-month review examines the outcomes of 52 cholecystectomies performed by a single surgical resident at the University Hospital of the West Indies--a teaching hospital in Jamaica. The advantages of laparoscopic cholecystectomy have been demonstrated and it has been found to be safe and effective in this training facility.

La colecistectomía laparoscópica ha reemplazado virtualmente la colecistectomía abierta convencional, siendo ahora la norma de oro para la colelitiasis sintomática. El abordaje laparoscópico trae consigo numerosas ventajas a expensas de tasas de complicación más altas, sobre todo en las instalaciones de adiestramiento. Este estudio comparativo realizado a lo largo 18 meses, examina los resultados de 52 colecistectomías realizadas por un residente de cirugía del Hospital Universitario de West Indies – un hospital docente de Jamaica. Las ventajas de la colecistectomía laparoscópica han quedado demostradas, y el tratamiento ha probado ser seguro y efectivo en esta instalación docente.