Initial laparoscopic basic skills training shortens the learning curve of laparoscopic suturing and is cost-effective.

BACKGROUND: Laparoscopic suturing is an advanced skill that is difficult to acquire. Simulator-based skills curricula have been developed that have been shown to transfer to the operating room. Currently available skills curricula need to be optimized. We hypothesized that mastering basic laparoscopic skills first would shorten the learning curve of a more complex laparoscopic task and reduce resource requirements for the Fundamentals of Laparoscopic Surgery suturing curriculum. STUDY DESIGN: Medical students (n = 20) with no previous simulator experience were enrolled in an IRB-approved protocol, pretested on the Fundamentals of Laparoscopic Surgery suturing model, and randomized into 2 groups. Group I (n = 10) trained (unsupervised) until proficiency levels were achieved on 5 basic tasks; Group II (n = 10) received no basic training. Both groups then trained (supervised) on the Fundamentals of Laparoscopic Surgery suturing model until previously reported proficiency levels were achieved. Two weeks later, they were retested to evaluate their retention scores, training parameters, instruction requirements, and cost between groups using t-test. RESULTS: Baseline characteristics and performance were similar for both groups, and 9 of 10 subjects in each group achieved the proficiency levels. The initial performance on the simulator was better for Group I after basic skills training, and their suturing learning curve was shorter compared with Group II. In addition, Group I required less active instruction. Overall time required to finish the curriculum was similar for both groups; but the Group I training strategy cost less, with a savings of $148 per trainee. CONCLUSIONS: Teaching novices basic laparoscopic skills before a more complex laparoscopic task produces substantial cost savings. Additional studies are needed to assess the impact of such integrated curricula on ultimate educational benefit.

Closing the gap in operative performance between novices and experts: does harder mean better for laparoscopic simulator training?

BACKGROUND: We have previously shown that reaching expert performance on an fundamentals of laparoscopic surgery (FLS)-type simulator model for laparoscopic suturing results in measurable improvement during an actual operation; trained novices, however, demonstrate inferior operative performance compared with experts. We hypothesized that simulator training under more difficult and realistic conditions would enhance the operative performance of novices. STUDY DESIGN: Medical students (n=32) participated in an IRB-approved, randomized, controlled trial. All participants were pretested in laparoscopic suturing on a previously validated porcine Nissen model and were randomized into three groups: group I (n=6) received no training, group II (n=13) trained on the FLS videotrainer model until a previously published proficiency score (512) was achieved on 2 consecutive and 10 additional attempts, group III (n=13) trained to the same goal but had to practice in a constrained space, with a shorter suture, starting with a dropped needle, and listening to operating room noise. Training workload was measured with the validated NASA-TLX (Task Load Index) questionnaire after each training session. All groups were posttested on the porcine model. Results were compared using ANOVA; p < 0.05 was considered significant. RESULTS: All group II and III participants reached the training goal. At posttesting, group II and group III participants performed similarly, but substantially better than group I did (210+/-140 versus 218+/-139 versus 0+/-0, respectively; p < 0.001). Compared with group II, group III participants trained longer (329+/-71 minutes versus 239+/-69 minutes, p < 0.001), performed more repetitions (81+/-15 versus 59+/-14, p < 0.001), and their workload improved less by the end of training (5% versus 23%, p < 0.001). CONCLUSIONS: Proficiency-based simulator training reliably results in improved operative performance. Although increasing the level of training difficulty increased trainees' workload, the strategy we used in this study did not enhance their operative performance. Other methods for curriculum optimization are needed.

Construct and face validity and task workload for laparoscopic camera navigation: virtual reality versus videotrainer systems at the SAGES Learning Center.

BACKGROUND: Laparoscopic camera navigation (LCN) training on simulators has demonstrated transferability to actual operations, but no comparative data exist. The objective of this study was to compare the construct and face validity, as well as workload, of two previously validated virtual reality (VR) and videotrainer (VT) systems. METHODS: Attendees (n = 90) of the SAGES 2005 Learning Center performed two repetitions on both VR (EndoTower) and VT (Tulane Trainer) LCN systems using 30 degrees laparoscopes and completed a questionnaire regarding demographics, simulator characteristics, and task workload. Construct validity was determined by comparing the performance scores of subjects with various levels of experience according to five parameters and face validity according to eight. The validated NASA-TLX questionnaire that rates the mental, physical, and temporal demand of a task as well as the performance, effort, and frustration of the subject was used for workload measurement. RESULTS: Construct validity was demonstrated for both simulators according to the number of basic laparoscopic cases (p = 0.005), number of advanced cases (p < 0.001), and frequency of angled scope use (p < 0.001), and only for VT according to training level (p < 0.001) and fellowship training (p = 0.008). Face validity ratings on a 1-20 scale averaged 15.4 +/- 3 for VR vs. 16 +/- 2.6 for VT (p = 0.04). Ninety-six percent of participants rated both simulators as valid educational tools. The NASA-TLX overall workload score was 69.5 +/- 24 for VR vs. 68.8 +/- 20.5 for VT (p = 0.31). CONCLUSIONS: This is the largest study to date that compares two validated LCN simulators. While subtle differences exist, both VR and VT simulators demonstrated excellent construct validity, good face validity, and acceptable workload parameters. These systems thus represent useful training devices and should be widely used to improve surgical performance.

Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention.

BACKGROUND: Proficiency-based training in laparoscopic suturing and knot tying translates to the operating room, but little is known about the durability of acquired skill. The purpose of this study was to determine the effect of maintenance training on skill retention after demonstration of proficiency. STUDY DESIGN: Medical students (n=18) with no previous laparoscopic or simulator experience were enrolled in an IRB-approved randomized controlled trial. All subjects trained to proficiency (score of 512, based on time and errors) on a previously validated suturing model (Fundamentals of Laparoscopic Surgery videotrainer). Subjects were then randomized to a control group, which received no additional training, and an ongoing training group, which trained again to proficiency at 1 and 3 months (immediately after testing). Simulator testing was repeated at 2 weeks, 1 month, 3 months, and 6 months after initial training. No subject had interval operative experience. RESULTS: Both groups demonstrated excellent skill retention during followup; performance scores, reported as means+/-SD, were 488+/-57 versus 482+/-55 at 2 weeks (p=ns), 483+/-81 versus 491+/-64 at 1 month (p=ns), 467+/-75 versus 470+/-67 at 3 months (p=ns), and 462+/-62 versus 492+/-43 at 6 months (p=0.02) for the control versus ongoing training groups, respectively. At 6 months, the ongoing training group showed better skill retention (95% versus 90%; p=0.02) and a trend for achieving the proficiency level (33% versus 18%; p=0.2) more often than the control group. CONCLUSIONS: Although proficiency-based training results in excellent skill retention, ongoing training substantially enhances performance and minimizes skill loss. Curricula should incorporate training that fosters maintenance of proficiency.

Intensive continuing medical education course training on simulators results in proficiency for laparoscopic suturing.

BACKGROUND: The purpose of this study was to determine the feasibility and effectiveness of implementing a validated suturing curriculum as a free-standing continuing medical education (CME) course. METHODS: Eighteen participants (9 practicing surgeons, 9 surgery residents) attended a 4-hour laparoscopic suturing CME course. After viewing an instructional videotape all participants had their baseline performance measured on a fundamentals of laparoscopic surgery-type videotrainer suture model. Participants then practiced on the model with active instruction from 6 proctors until a previously reported proficiency level was achieved or until the course ended. Performance was scored objectively based on time and errors. Precourse and postcourse questionnaires were collected. RESULTS: Participants trained for 2.6 +/- .8 hours and performed 37 +/- 11 repetitions. Although no participant was proficient at baseline, 72% achieved the proficiency level by the end of the course. Participants showed 44% improvement in objective scores and 34% improvement according to subjective self-rating. CONCLUSIONS: Although 4 hours may be insufficient for some trainees, an intensive half-day CME course is feasible and effective in significantly improving performance and allowing the majority of participants to achieve proficiency.