Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training.

BACKGROUND: Laparoscopic simulator training translates into improved operative performance. Proficiency-based curricula maximize efficiency by tailoring training to meet the needs of each individual; however, because rates of skill acquisition vary widely, such curricula may be difficult to implement. We hypothesized that psychomotor testing would predict baseline performance and training duration in a proficiency-based laparoscopic simulator curriculum. METHODS: Residents (R1, n = 20) were enrolled in an IRB-approved prospective study at the beginning of the academic year. All completed the following: a background information survey, a battery of 12 innate ability measures (5 motor, and 7 visual-spatial), and baseline testing on 3 validated simulators (5 videotrainer [VT] tasks, 12 virtual reality [minimally invasive surgical trainer-virtual reality, MIST-VR] tasks, and 2 laparoscopic camera navigation [LCN] tasks). Participants trained to proficiency, and training duration and number of repetitions were recorded. Baseline test scores were correlated to skill acquisition rate. Cutoff scores for each predictive test were calculated based on a receiver operator curve, and their sensitivity and specificity were determined in identifying slow learners. RESULTS: Only the Cards Rotation test correlated with baseline simulator ability on VT and LCN. Curriculum implementation required 347 man-hours (6-person team) and 795,000 dollars of capital equipment. With an attendance rate of 75%, 19 of 20 residents (95%) completed the curriculum by the end of the academic year. To complete training, a median of 12 hours (range, 5.5-21), and 325 repetitions (range, 171-782) were required. Simulator score improvement was 50%. Training duration and repetitions correlated with prior video game and billiard exposure, grooved pegboard, finger tap, map planning, Rey Figure Immediate Recall score, and baseline performance on VT and LCN. The map planning cutoff score proved most specific in identifying slow learners. CONCLUSIONS: Proficiency-based laparoscopic simulator training provides improvement in performance and can be effectively implemented as a routine part of resident education, but may require significant resources. Although psychomotor testing may be of limited value in the prediction of baseline laparoscopic performance, its importance may lie in the prediction of the rapidity of skill acquisition. These tests may be useful in optimizing curricular design by allowing the tailoring of training to individual needs.

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.

Skill retention following proficiency-based laparoscopic simulator training.

BACKGROUND: Proficiency-based curricula using both virtual reality (VR) and videotrainer (VT) simulators have proven to be efficient and maximally effective, but little is known about the retention of acquired skills. The purpose of this study was to assess skill retention after completion of a validated laparoscopic skills curriculum. METHODS: Surgery residents (n=14) with no previous VR or VT experience were enrolled in an Institutional Review Board-approved protocol and sequentially practiced 12 Minimally Invasive Surgical Trainer-VR and 5 VT tasks until proficiency levels were achieved. One VR (manipulate diathermy) and 1 VT (bean drop) tasks were selected for assessment at baseline, after training completion (posttest), and at retention. RESULTS: All residents completed the curriculum. Posttest assessment occurred at 13.2 +/- 11.8 days and retention assessment at 7.0 +/- 4.0 months. After an early performance decrement at posttest (17%-45%), the acquired skill was maintained up to the end of the follow-up period. For VR, scores were 81.5 +/- 23.5 at baseline, 33.3 +/- 1.8 at proficiency, 48.4 +/- 9.2 at posttest, and 48.4 +/- 11.8 at retention. For VT, scores were 49.4 +/- 12.5 at baseline, 22.0 +/- 1.4 at proficiency, 25.6 +/- 3.6 at posttest, and 26.4 +/- 4.2 at retention. Skill retention was better for VT, compared with VR (P < .02). The extent of skill deterioration did not correlate with training duration or resident level. CONCLUSIONS: Although residents do not retain all acquired skills (more so for VR than for VT) according to simulator assessment, proficiency-based training on simulators results in durable skills. Additional studies are warranted to further optimize curriculum design, investigate simulator differences, and establish training methods that improve skill retention.

Simulator training for laparoscopic suturing using performance goals translates to the operating room.

BACKGROUND: The purpose of this study was to develop a performance-based laparoscopic suturing curriculum using simulators and to test the effectiveness (transferability) of the curriculum. STUDY DESIGN: Surgical residents (PGY1 to PGY5, n = 17) proficient in basic skills, but with minimal laparoscopic suturing experience, were enrolled in an IRB-approved, randomized controlled protocol. Subjects viewed an instructional video and were pretested on a live porcine laparoscopic Nissen fundoplication model by placing three gastrogastric sutures tied in an intracorporeal fashion. A blinded rater objectively scored each knot based on a previously published formula (600 minus completion time [sec] minus penalties for accuracy and knot integrity errors). Subjects were stratified according to pretest scores and randomized. The trained group practiced on a videotrainer suturing model until an expert-derived proficiency score (512) was achieved on 12 attempts. The control group received no training. Both the trained and control groups were posttested on the porcine Nissen model. RESULTS: For the training group, mean time to demonstrate simulator proficiency was 151 minutes (range 107 to 224 minutes) and mean number of attempts was 37 (range 24 to 51 attempts). Both the trained and control groups demonstrated significant improvement in overall score from baseline. But the trained group performed significantly better than the control group at posttesting (389 +/- 70 versus 217 +/- 140, p < 0.001), confirming curriculum effectiveness. CONCLUSIONS: These data suggest that training to a predetermined expert level on a videotrainer suture model provides trainees with skills that translate into improved operative performance. Such curricula should be further developed and implemented as a means of ensuring proficiency.

Multicenter construct validity for southwestern laparoscopic videotrainer stations.

BACKGROUND: The "Southwestern" videotrainer stations have demonstrated concurrent validity (transferability to the operating room). The purpose of this study was to evaluate the Southwestern stations for construct validity (the ability to discriminate between subjects at different levels of experience). MATERIALS AND METHODS: From two surgical training programs, Institutional Review Board approved protocol data were collected from 142 subjects, including novice (medical students and R1, n = 66), intermediate (R2-R4, n = 67), and advanced (R5 and expert surgeons, n = 9) groups. All participants performed three repetitions on each of five stations. Completion time was scored for each task. Laparoscopic experience was determined from residency case log databases and from expert surgeon personal case logs. Results for the three groups were compared using one-way ANOVA, including relevant pair-wise comparisons. Correlations between number of laparoscopic cases performed and task scores were determined by Pearson's and Spearman's rho-correlation coefficients. RESULTS: The mean number of laparoscopic cases performed prior to completing the five tasks was 0 for novices, 9 for intermediates, and 431 for the advanced group. Significant differences (P < 0.001) were noted between groups for all five tasks and composite score. Task scores and composite scores significantly correlated with laparoscopic experience (P < 0.01). CONCLUSION: These data suggest that differences in laparoscopic ability are detected by performance on the videotrainer; thus, construct validity is demonstrated. Moreover, scores accurately reflect laparoscopic experience. Further validation may allow such simulators to be used for testing and credentialing purposes.