Simulation training in laparoscopy using a computerized physical reality simulator.

OBJECTIVE: To describe a new simulator, SurgicalSIM LTS, and summarize our preliminary experience with system. METHODS: LTS was evaluated in 3 studies: (1) 124 participants from 3 Canadian universities: 13 students; 30 residents, fellows, attendings from surgery; 59 gynecologists; 22 urologists were classified based on laparoscopic experience as novice, intermediate, competent, or expert. All were tested on the LTS. Seventy-four were tested on the LTS and MISTELS (McGill Inanimate System for Training and Evaluation of Laparoscopic Skills). Participants completed a satisfaction questionnaire. (2) Twenty-five international gynecologists in-training at Kiel Gynaecologic Endoscopy Center, and 15 students from the center pretested on LTS underwent voluntary additional trials and posttesting. (3) Seventeen experienced laparoscopic surgeons from 3 specialties were recruited to perform on randomly assigned simulators involving 5 commercial, computer-based systems. The surgeons practiced repetitively for 1.5 days. Efficient, error-free performance was measured and proficiency score formulas were developed. RESULTS: Study A: LTS showed a good correlation with level of experience (P=0.000) and MISTELS (0.79). Satisfaction: LTS vs MISTELS 79.9 vs 70.4 (P=0.012). Study B: Posttest scores were significantly better in all tasks for both groups, P<0.0001. Group mean scores with < or =5 trials were significantly better than with 2 or 3 trials (P<0.012, P<0.018). Study C: LTS had the highest effectiveness rating of the 5 simulators. CONCLUSIONS: A new computerized physical reality simulator can be used to assess/train laparoscopic technical skills.

Criterion-based training with surgical simulators: proficiency of experienced surgeons.

OBJECTIVE: In our effort to establish criterion-based skills training for surgeons, we assessed the performance of 17 experienced laparoscopic surgeons on basic technical surgical skills recorded electronically in 26 modules selected in 5 commercially available, computer-based simulators. METHODS: Performance data were derived from selected surgeons randomly assigned to simulator stations, and practicing repetitively during one and one-half day sessions on 5 different simulators. We measured surgeon proficiency defined as efficient, error-free performance and developed proficiency score formulas for each module. Demographic and opinion data were also collected. RESULTS: Surgeons' performance demonstrated a sharp learning curve with the most performance improvement seen in early practice attempts. Median scores and performance levels at the 10th, 25th, 75th, and 90th percentiles are provided for each module. Construct validity was examined for 2 modules by comparing experienced surgeons' performance with that of a convenience sample of less-experienced surgeons. CONCLUSION: A simple mathematical method for scoring performance is applicable to these simulators. Proficiency levels for training courses can now be specified objectively by residency directors and by professional organizations for different levels of training or post-training assessment of technical performance. But data users should be cautious due to the small sample size in this study and the need for further study into the reliability and validity of the use of surgical simulators as assessment tools.

Core competency in laparoendoscopic surgery.

BACKGROUND: Concern about patient safety and physician competence was highlighted by the Institute of Medicine report, revealing the prevalence of fatal medical errors. There is also awareness that technical difficulties specific to laparoendoscopic surgery can cause medical errors. Reported herein is a review of the evidence pertaining to objective assessment of core competency components in laparoendoscopic surgery: cognitive skills, technical skills, surgical performance, and judgment. METHODS: PubMed and MedLine searches were performed to identify articles with combinations of the following key words: core competency, competency, laparoscopy, training, assessment, and curriculum. Further articles were obtained by searching reference lists of identified papers and through personal communication. CONCLUSIONS: The available evidence suggests that it is currently possible to objectively assess core competency components in laparoendoscopic surgery: knowledge and clinical judgment with well-established tests and innate technical abilities with computer-based simulators with embedded metrics. Simulation training is conducted to a proficiency criterion regardless of the number of repetitions or practice hours. Reports indicate that skills learned on a simulator transfer to the operating room. However, to date, objective assessment of surgical performance can be obtained only through review of unedited video tapes of surgical procedures by disinterested experts as recently demonstrated by our Japanese colleagues in urology.

Ischemic necrosis of small bowel following laparoscopic surgery.

BACKGROUND AND OBJECTIVE: Small bowel ischemia following laparoscopy was described recently as a rare fatal complication of the CO2 pneumoperitoneum. Of the 8 cases reported in the surgical literature, 7 were fatal, 1 was not. In this report, we describe the first gynecological case. METHODS: A 34-year-old woman who underwent laparoscopy with extensive adhesiolysis and myolysis was re-admitted with an acute abdomen on postoperative day 4. Immediate laparotomy revealed acute peritonitis, extensive adhesions, and a 3-cm defect in the small bowel. Tissue examination showed ischemic necrosis of edematous, but essentially normal, bowel mucosa. The postoperative course was extremely complicated. She was discharged after a 2-month hospital stay in the intensive care unit for rehabilitation. RESULTS: Data are available on 7 patients (including ours). All procedures were described as uneventful. The intraabdominal pressure was set at 15 mm Hg when specified. Some abdominal pain occurred in all, nausea and vomiting in 4, diarrhea in 2, abdominal distention in 1, fever in none. Quick reintervention laparotomy was performed in 2 and delayed in 5 (up to 4 days). DISCUSSION: The CO2 pneumoperitoneum is a predisposing factor for intestinal ischemia as it reduces cardiac output and splanchnic blood flow. However, critical ischemia relies on underlying vasculopathy or an inciting event. CONCLUSION: Patient selection, maintaining intraabdominal pressure at 15 mm Hg or less, and intermittent decompression of the gas represent the best options for preventing this complication.