F.W. Jansen

Force feedback and basic laparoscopic skills

BackgroundNot much is known about the exact role of force feedback in laparoscopy. This study aimed to determine whether force feedback influences movements of instruments during training in laparoscopic tasks and whether force feedback is required for training in basic laparoscopic force application tasks.MethodsA group of 19 gynecologic residents, randomly divided into two groups, performed three laparoscopic tasks in both the box trainer and the virtual reality (VR) trainer. The box-VR group began with the box trainer, whereas the VR-box group began with the VR trainer. The three selected tasks included different levels of force application. The box trainer provides natural force feedback, whereas the VR trainer does not provide force feedback. The performance of the two groups was compared with regard to time, path length, and depth perception.ResultsFor the tasks in which force plays hardly a role, no differences between box-VR group and the VR-box group were found. During a task in which force application (pulling and pushing forces) plays a role, the box-VR group outperformed VR-box group in the box trainer. Moreover, training with the box trainer had a positive effect on subsequent performance of the task with the VR trainer. This was not found the other way around. No differences were found between box-VR and the VR-box group in tasks not requiring force application.ConclusionForce feedback influences basic laparoscopic skills during tasks in which pulling and pushing forces are applied. For these tasks, the switch from the trainer without force feedback to the one with natural force feedback has a detrimental effect on performance. Therefore, training for tasks in which forces play an important role (e.g., stretching, grasping) should be done using systems with natural force feedback, whereas eye–hand coordination can be trained without force feedback.

The influence of experience and camera holding on laparoscopic instrument movements measured with the TrEndo tracking system

BackgroundEye–hand coordination problems occur during laparoscopy. This study aimed to investigate the difference in instrument movements between the surgeon him- or herself holding the camera and an assistant holding the camera during performance of a laparoscopic task and to check whether experience of the surgeon plays a role in this issue.MethodsThe participants were divided into three groups: experts, residents, and novices. Each participant performed positioning tasks using the right (R) and left (L) hands. During these tasks, the camera was manipulated either by the participant (Cself) or by an assistant (Cassistant). Movements of instruments were recorded with the authors’ new TrEndo tracking system. The performance was analyzed using five kinematic parameters: time, path length, three-dimensional (3D) motion smoothness, 1D motion smoothness (along the axis), and depth perception.ResultsA total of 46 participants contributed. Three tests were performed: test 1-LCself, test 2-LCassistant, and test 3-RCassistant. In all the tests, the experts performed better than the residents and novices in terms of time, path length, and depth perception. The novices performed better in tests 1-LCself and 2-LCassistant than in test 3-RCassistant in terms of path length, 3D motion smoothness, and depth perception.ConclusionsLaparoscopic experience and the camera-holding factor influenced the performance of laparoscopic tasks on the simulator. Time, path length, and depth perception clearly discriminate between different levels of experience in laparoscopy, whereas 3D and 1D motion smoothness play a limited role. Novices experienced more difficulties when an assistant held the camera. Therefore, self-manipulation of the camera seems to improve novices’ eye–hand coordination.

Gynecological laparoscopy in residency training program : Dutch perspectives

BackgroundImplementation of laparoscopy into residency training is difficult. This study was conducted to assess the current state of implementation of laparoscopic surgery into gynecological residency program, to identify factors influencing laparoscopic skills training, and to find solutions toward better training and implementation.MethodsIn 2003 a questionnaire was sent to all 68 postgraduate year 5 and year 6 residents in obstetrics and gynecology in The Netherlands. The questionnaire addressed demographics, performance of laparoscopy, self-perceived competence, simulator training, and factors influencing laparoscopic training in residency.ResultsOf the 68 residents, 60 (88%) responded; 46 (37%) were men and 78 (63%) women. Men showed significant higher mean self-perceived competence in some laparoscopic procedures than women. Of the respondents, 20% had no advanced laparoscopic gynecologist present in their teaching hospital. Residents felt that simulator training is important in relation to their performance in the operating room. Of all gynecological teaching hospitals in the Netherlands, 55% did not have the opportunity of simulator training. Of the respondents who had the possibility of simulator training, 33% did not use the simulator voluntarily. Residents who trained on a simulator felt training was significantly more important (p = 0.02) than residents who never practiced on a simulator. Respondents’ laparoscopic skills were subjectively evaluated in the operating room (92%) or were evaluated based on the number of laparoscopic procedures performed as primary surgeon (49%). Of the respondents, 47% were satisfied with their current laparoscopic skills and 27% also felt prepared for the more advanced procedures. Not having been primary surgeon in nonacademic teaching hospitals and even more so in academic teaching hospitals (p < 0.05) was a limiting factor in acquiring laparoscopic skills.ConclusionsIncorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.

Implementation of advanced laparoscopic surgery in gynecology: national overview of trends.

STUDY OBJECTIVE To estimate the implementation of laparoscopic surgery in operative gynecology. DESIGN Observational multicenter study (Canadian Task Force classification II-2). SETTING All hospitals in the Netherlands. SAMPLE Nationwide annual statistics for 2002 and 2007. INTERVENTIONS A national survey of the number of performed laparoscopic and conventional procedures was performed. Laparoscopy was categorized for complexity in level 1, 2, and 3 procedures. Outcomes were compared with results from 2002 to evaluate trends. MEASUREMENTS AND MAIN RESULTS In 2002, 21 414 laparoscopic and 9325 conventional procedures were performed in 74 hospitals (response rate, 74%), and in 2007, 16 863 laparoscopic and 10 973 conventional procedures were performed in 80 hospitals (response rate, 80%). Compared with 2002, in 2007, level 1 procedures were performed significantly less often and level 2 and level 3 procedures were performed significantly more often. The mean number of performed laparoscopic procedures per hospital decreased from 289 to 211 procedures. Teaching hospitals performed more than twice as many therapeutic laparoscopic procedures as nonteaching hospitals do. Cystectomy, oophorectomy, and ectopic pregnancy surgery were preferably performed using the laparoscopic approach. Laparoscopic hysterectomy was performed significantly more often, accounting for 10% of all hysterectomies. Annually, 20% of hospitals in which laparoscopic hysterectomy was implemented performed 50% of all laparoscopic hysterectomies, and 50% of the hospitals performed 20% of laparoscopic hysterectomies. CONCLUSION This study describes increasing implementation of therapeutic laparoscopic gynecologic surgery. Clinics increasingly opt to perform laparoscopic surgery rather than conventional surgery. However, implementation of advanced procedures such as laparoscopic hysterectomy seems to be hampered.

Feedback in laparoscopic skills acquisition: an observational study during a basic skills training course

This study aimed to obtain insight in the effect of expert feedback during a basic laparoscopic skills training course for residents. A questionnaire was held among participants regarding provided feedback and the self-perceived laparoscopic skills improvement. The participants (n = 24) who completed the questionnaire were in their first to fifth postgraduate year. Most feedback was directed at intracorporeal knot tying (47% reported extensive feedback), while camera navigation and body positioning received the least feedback (40% and 43%, respectively, responded to have received no feedback at all). After the course, the self-perceived competence in intracorporeal knot tying and cutting had improved significantly, while camera navigation, body positioning, pointing, and grasping tasks did not improve. In conclusion, most benefit from expert feedback can be obtained at the start of the learning curve. Therefore, the basic laparoscopic skills course should be attended early in residency. Additionally, it is crucial that training objectives are clear prior to a course for both the expert and the trainee, in order to focus the feedback on all training objectives.

Nociceptive and stress hormonal state during abdominal, laparoscopic, and vaginal hysterectomy as predictors of postoperative pain perception

The primary objective of this study is to compare pain perception during and after surgery between abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), and vaginal hysterectomy (VH). The secondary objective of this study is to investigate whether pain indicators during surgery predict pain perception and demand for analgesics postoperatively. Prospective observational analysis of intraoperative nociceptive state (by means of pulse transit time; PTT), heart rate, and stress hormone levels (adrenalin and noradrenalin) were correlated with postoperative pain scores and stress hormone levels and demand for postoperative analgesics such as morphine. Intraoperative PTT levels and perioperative and postoperative stress hormone levels did not differ significantly between AH, LH, and VH. During the first hours postoperatively, LH patients showed insignificant lower pain scores, compared to AH and VH. One day postoperatively, LH patients reported significantly lower pain scores. High intraoperative stress hormone levels predicted a significant higher demand for morphine postoperatively, accompanied with significant higher pain scores. No differences were found with respect to intraoperative pain indicators well as pain perception during the first hours after surgery between AH, LH, and VH. If VH is not applicable, LH proves to be advantageous over AH with respect to a faster decline in pain scores.

Laparoscopic Myomectomy as a New Standard: An Analysis of Risk Factors for Conversion

Study Objective: Conversion to laparotomy can be considered as quality indicator for laparoscopic surgery. Data on conversion rates for laparoscopic myomectomy (LM) are limited, with a reported incidence between 0% and 41%. The aim of this study is to evaluate patient characteristics associated with LM in comparison with abdominal myomectomy (AM), and, secondly to calculate the rate of conversion during LM and the risk factors associated with it. Design: Retrospective cohort study. Setting: Tertiary academic center. Patients: All patients who underwent LM and AM from 2009 2012. Measurements and Main Results: The cohort included 966 patients; 731 laparoscopic cases (75.7% including 343 robotic cases) and 235 abdominal cases (24.3%). Patients undergoing AM had a larger number of fibroids removed with greater specimen weight compared to the laparoscopic approach (12.6 vs. 3.54 fibroids, p=\0.001; 592.75 vs. 263.4 grams, p=\0.001). In eight LM cases a conversion was necessary (1.09%). All conversions were reactive ones and were associated with high blood loss (1381.25 vs 167.95 mL, p=\0.001) and a longer hospital stay (3.13 vs. 0.55 days, p=\0.001). Furthermore, both the number and the weight of removed fibroids were associated with a higher conversion rate (667.9 vs. 259.25 grams, p=0.003; 9.75 vs 3.48 fibroids, p=0.015), especially with fibroids weighing more than 500 grams (p=0.005). Conclusion: Conversion rate for LM was low (1.09%) in our center. Number of removed fibroids and their weight were found to be a risk factor for conversion. LM should be the standard approach for surgical management of fibroids. However, when fibroids are expected to weigh > 500 grams we suggest that only highly experienced surgeons in specialized centers should perform those cases.