Deborah C. Hogg

Developing a comprehensive, proficiency-based training program for robotic surgery.

INTRODUCTION Robotically assisted surgery has become very popular for numerous surgical disciplines, yet training practices remain variable with little to no validation. The purpose of this study was to develop a comprehensive, proficiency-based robotic training program. METHODS A skill deconstruction list was generated by observation of robotic operations and interviews with experts. Available resources were used, and other components were developed as needed to develop a comprehensive, proficiency-based curriculum to teach all deconstructed skills. Preliminary construct and content validity and curriculum feasibility were evaluated. RESULTS The skill deconstruction list contained 23 items. Curricular components included an online tutorial, a half-day interactive session, and 9 inanimate exercises with objective metrics. Novice (546 ± 26) and expert (923 ± 60) inanimate composite scores were different (P < .001), supporting construct validity, and substantial pre-test to post-test improvement was noted after successful training completion. All 23 deconstructed skills were rated as highly relevant (4.9 ± 0.5; 5-point scale), and no skills were absent from the curriculum, supporting content validity. CONCLUSION These data suggest that this proficiency-based training curriculum comprehensively addresses the skills necessary to perform robotic operations with early construct and content validity and feasibility demonstrated. Further validation is encouraged.

Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance

BACKGROUND The purpose of this study was to determine 2-year performance retention and certification exam pass rate after completion of a proficiency-based fundamental laparoscopic skills (FLS) curriculum and subsequent interval training. METHODS Surgery residents (postgraduate year [PGY]1-5, n = 91) were enrolled in an Institutional Review Board approved protocol. All participants initially underwent proficiency-based training on all 5 FLS tasks. Subsequently, available residents were enrolled every 6 months in an ongoing training curriculum that included retention tests on tasks 4 and 5, with mandatory retraining to proficiency if the proficiency levels were not achieved. The final retention test included the actual FLS certification examination for PGY4-5 trainees. RESULTS A 96% participation rate was achieved for all curricular components during the 2-year study period (PGY3-5, n = 33). Skill retention at retention 1-4 was 83%, 94%, 98%, and 91% for task 4 and 85%, 95%, 96%, and 100% for task 5, respectively. All PGY4-5 (n = 20) residents passed the FLS certification examination, achieving 413 +/- 28 total score on the skills portion (passing score > or =270) and demonstrating 92% retention for all 5 tasks. CONCLUSION Proficiency-based training with subsequent ongoing practice results in a very high level of skill retention after 2 years and uniformly allows trainees to pass the FLS certification examination.

Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology

BACKGROUND The authors previously developed a comprehensive, proficiency-based robotic training curriculum that aimed to address 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to determine the content and face validity of this curriculum. METHODS Expert robotic surgeons (n = 12) rated each deconstructed skill regarding relevance to robotic operations, were oriented to the curricular components, performed 3 to 5 repetitions on the 9 exercises, and rated each exercise. RESULTS In terms of content validity, experts rated all 23 deconstructed skills as highly relevant (4.5 on a 5-point scale). Ratings for the 9 inanimate exercises indicated moderate to thorough measurement of designated skills. For face validity, experts indicated that each exercise effectively measured relevant skills (100% agreement) and was highly effective for training and assessment (4.5 on a 5-point scale). CONCLUSIONS These data indicate that the 23 deconstructed skills accurately represent the appropriate content for robotic skills training and strongly support content and face validity for this curriculum.

Construct and face validity of the American College of Surgeons/Association of Program Directors in Surgery laparoscopic troubleshooting team training exercise

BACKGROUND Our aim was to develop an objective scoring system and evaluate construct and face validity for a laparoscopic troubleshooting team training exercise. METHODS Surgery and gynecology novices (n = 14) and experts (n = 10) participated. Assessments included the following: time-out, scenario decision making (SDM) score (based on essential treatments rendered and completion time), operating room communication assessment (investigator developed), line operations safety audits (teamwork), and National Aeronautics and Space Administration-Task Load Index (workload). RESULTS Significant differences were detected for SDM scores for scenarios 1 (192 vs 278; P = .01) and 3 (129 vs 225; P = .004), operating room communication assessment (67 vs 91; P = .002), and line operations safety audits (58 vs 87; P = .001), but not for time-out (46 vs 51) or scenario 2 SDM score (301 vs 322). Workload was similar for both groups and face validity (8.8 on a 10-point scale) was strongly supported. CONCLUSIONS Objective decision-making scoring for 2 of 3 scenarios and communication and teamwork ratings showed construct validity. Face validity and participant feedback were excellent.

Development, Validation, and Implementation of a Cost-Effective Intermediate-Level Proficiency-Based Knot-Tying and Suturing Curriculum for Surgery Residents

BACKGROUND The purpose of this study was to develop an intermediate-level proficiency-based knot-tying and suturing curriculum, evaluate construct validity, determine feasibility, document educational benefit, and quantify cost-effectiveness of implementation within a surgery residency program. METHODS Six tasks with standardized metrics were developed using commercially available bench models; 39 PGY-1 surgery residents were enrolled in a 2-month curriculum (orientation/pre-test, self-practice, and a proctored post-test). Baseline trainee and expert performance were compared to assess construct validity. RESULTS Baseline trainee and expert performance were significantly different (451 ± 83 vs 644 ± 10, p < 0.001), supporting construct validity. All trainees achieved proficiency during self-practice, completing 30 ± 17 repetitions over 3.4 ± 3.8 hours. Significant differences were detected between baseline and final trainee composite scores (451 ± 83 vs 607 ± 34, p < 0.001). CONCLUSIONS Implementation of this curriculum was feasible and cost-effective. Construct validity and educational benefit in terms of skill acquisition were demonstrated. The purpose of this study was to develop an intermediate-level proficiency-based knot-tying and suturing curriculum, evaluate construct validity, determine feasibility, document educational benefit, and quantify cost-effectiveness of implementation within a robust surgery residency training program.

Gastrojejunal stomal reduction with the T-tag device in porcine models (with videos)

BACKGROUND Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Gastrojejunal (GJ) stomal dilatation associated with weight regain is a late complication. Surgical revision is usually required for stomal or pouch reduction. OBJECTIVE Our purpose was to evaluate the technical feasibility, efficacy, and safety of stomal reduction with endoscopic T-tag devices. DESIGN Prospective nonsurvival studies were conducted in pigs (n = 2, 110 pounds each). INTERVENTIONS Three GJ stomas were created in each pig through a midline laparotomy by using circular staplers. Endoscopic GJ stomal reduction/revision was performed on these newly created stomas with an Olympus T-tag device. Necropsy was performed to examine the deployed T-tag locations and procedure-related adjacent tissue/organ injury and to assess the effectiveness of stomal reduction. RESULTS Endoscopic stomal revision was performed on 5 stomas with moderate stomal reduction. One GJ stoma could not be accessed easily by endoscopy because of the small size of the gastric pouch. An average of 4 T-tag devices was deployed around each stoma. The procedural time was about 61 +/- 12 minutes for each stomal reduction. Overall, 26 of 39 (66.7%) T-bars were deployed in accepted locations. The stomas were reduced from 1.60 +/- 0.21 mm x 1.44 +/- 0.14 mm to 1.28 +/- 0.29 mm x 0.98 +/- 0.17 mm and the percentage of stomal reduction was 27.3% +/- 13.3%. In the end, a therapeutic gastroscope could not be advanced through the reduced stomas. In 2 stomas, 5 of 39 (12.8%) T-bars injured or attached to the adjacent organs: isolated stomach and abdominal wall. LIMITATION Nonsurvival pig studies. CONCLUSIONS Endoscopic stomal reduction with T-tag device is technically feasible and effective in two thirds of trials. However, it is associated with a small risk of adjacent organ/tissue injury with the current prototype device and deployment method.

A Randomized Comparison of Laparoscopic, Flexible Endoscopic, and Wired and Wireless Magnetic Cameras on Ex Vivo and In Vivo NOTES Surgical Performance

Background. The influence of endoscopic video camera (VC) image quality on surgical performance has not been studied. Flexible endoscopes are used as substitutes for laparoscopes in natural orifice translumenal endoscopic surgery (NOTES), but their optics are originally designed for intralumenal use. Manipulable wired or wireless independent VCs might offer advantages for NOTES but are still under development. Objective. To measure the optical characteristics of 4 VC systems and to compare their impact on the performance of surgical suturing tasks. Methods. VC systems included a laparoscope (Storz 10 mm), a flexible endoscope (Olympus GIF 160), and 2 prototype deployable cameras (magnetic anchoring and guidance system [MAGS] Camera and PillCam). In a randomized fashion, the 4 systems were evaluated regarding standardized optical characteristics and surgical manipulations of previously validated ex vivo (fundamentals of laparoscopic surgery model) and in vivo (live porcine Nissen model) tasks; objective metrics (time and errors/precision) and combined surgeon (n = 2) performance were recorded. Results. Subtle differences were detected for color tests, and field of view was variable (65°-115°). Suitable resolution was detected up to 10 cm for the laparoscope and MAGS camera but only at closer distances for the endoscope and PillCam. Compared with the laparoscope, surgical suturing performances were modestly lower for the MAGS camera and significantly lower for the endoscope (ex vivo) and PillCam (ex vivo and in vivo). Conclusions. This study documented distinct differences in VC systems that may be used for NOTES in terms of both optical characteristics and surgical performance. Additional work is warranted to optimize cameras for NOTES. Deployable systems may be especially well suited for this purpose.

Immersive virtual reality-based training improves response in a simulated operating room fire scenario

BackgroundSAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics.MethodsThe study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their performance was videotaped for assessment.ResultsA total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014).ConclusionsInteractive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

Magnetically Anchored Cautery Dissector Improves Triangulation, Depth Perception, and Workload During Single-Site Laparoscopic Cholecystectomy

IntroductionThis study evaluated operative outcomes and workload during single-site laparoscopy (SSL) using a magnetically anchored cautery dissector (MAGS) compared with a conventional laparoscopic hook cautery (LAP).MethodsEach cautery was used to perform six SSL porcine cholecystectomies. For MAGS, the cautery device was inserted through the umbilical incision, magnetically coupled, and deployed; two graspers and a laparoscope were used. For LAP, two percutaneous retraction sutures, one grasper, a hook cautery dissector, and a laparoscope were used. Operative outcomes, surgeon ratings (scale, 1–5; 1 = superior), and workload (scale, 1–10; 1 = superior) were evaluated.ResultsNo significant differences were detected for operative outcomes and surgeon ratings, however, trends were detected favoring MAGS. Surgeon workload ratings were significantly better for MAGS (2.6 ± 0.2) vs. LAP (5.6 ± 1.1; p < 0.05). For MAGS, depth perception and triangulation were excellent and the safe handling protocol was followed with no complications. For LAP, the parallelism of instruments and lack of triangulation hindered depth perception, caused instrument conflicts, and resulted in two minor complications (one superficial liver laceration and one inadvertent burn to the diaphragm).ConclusionThese data suggest that using the MAGS device for SSL cholecystectomy results in equivalent (or better) operative outcomes and less workload compared with LAP.

Minimizing MIS Using Magnetically Anchored and Percutaneous Needlescopic Instruments for Basic and Complex Procedures

The stem cell spheroids were infected with NV1066, a third-generation herpesvirus, or NDV-F3aa-GFP, a Newcastle Disease virus mutant. Both viruses carried the marker gene green fluorescent protein (GFP), which allowed monitoring by fluorescent microscopy. Cell cycle analysis and cell migration assay were also performed. Results: Viral infection of cancer stem cells was rapid (GFP expression was seen by 24 hours). The viruses from both families each produced efficient infection and killing of cancer. At doses of multiplicity of infection (MOI, number of viruses per tumor cell) of 0.5 or 1, >95% of cells were dead by day 6. Infection with virus also produced decreased migratory capacity of the cancer stem cells and shifted the population to a higher fraction in S phase. Conclusion: Multiple types of oncolytic viruses effectively target the stem cell subpopulation of pancreatic cancer cells. Infection decreases metastatic potential and effects killing of such stem cells. These data support clinical studies of oncolytic viruses in the treatment of chemoand radioresistant tumors.