Flemming Bjerrum

Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized trial.

Objective:To investigate the impact of instructor feedback versus no instructor feedback when training a complex operational task on a laparoscopic virtual reality simulator. Background:Simulators are now widely accepted as a training tool, but there is insufficient knowledge about how much feedback is necessary, which is useful for sustainable implementation. Methods:A randomized trial complying with CONSORT Statement. All participants had to reach a predefined proficiency level for a complex operational task on a virtual reality simulator. The intervention group received standardized instructor feedback a maximum of 3 times. The control group did not receive instructor feedback. Participants were senior medical students without prior laparoscopic experience (n = 99). Outcome measures were time, repetitions, and performance score to reach a predefined proficiency level. Furthermore, influence of sex and perception of own surgical skills were examined. Results:Time (in minutes) and repetitions were reduced in the intervention group (162 vs 342 minutes; P < 0.005) and (29 vs 65 repetitions; P < 0.005). The control group achieved a higher performance score than the intervention group (57% vs 49%; P = 0.004). Men used less time (in minutes) than women (P = 0.037), but no sex difference was observed for repetitions (P = 0.20). Participants in the intervention group had higher self-perception regarding surgical skills after the trial (P = 0.011). Conclusions:Instructor feedback increases the efficiency when training a complex operational task on a virtual reality simulator; time and repetitions used to achieve a predefined proficiency level were significantly reduced in the group that received instructor feedback compared with the control group. Trial registration number: NCT01497782.

Surgical techniques to minimize shoulder pain after laparoscopic cholecystectomy. A systematic review

BackgroundLaparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholecystolithiasis. Despite the many advantages over open surgery, many patients complain about referred pain to the shoulder during the postoperative course. The purpose of this review was to evaluate different intraoperative surgical methods to minimize shoulder pain (SP).MethodsA search of the literature was conducted using PubMed, Excerpta Medica Database (EMBASE), and Cochrane database of systematic reviews. Eligibility criteria were: randomized clinical trials or meta-analysis evaluating intraoperative surgical methods applied to minimize incidence or severity of SP after LC. Only papers published in English were included. Data extracted were year of publication, number of participants and allocation, nonsignificant or significant effect on incidence or severity of SP.ResultsA total of 31 papers where included in the review. Seven, 8, and 12 papers investigated the effect of drains, abdominal wall lift (AWL), and low-pressure pneumoperitoneum respectively. Four papers investigated drain suction, active gas aspiration, low insufflation flow or N2O insufflation respectively. The interventions that overall showed a significant reduction on either the incidence or severity of SP were low-pressure pneumoperitoneum, low insufflation rate, and active gas aspiration.ConclusionsDrainage and AWL are not recommended to reduce SP after LC. Low-pressure pneumoperitoneum with carbon dioxide is the best documented intraoperative surgical method to minimize both the incidence and severity of SP after LC.

The Simulation Centre at Rigshospitalet, Copenhagen, Denmark

The Simulation Centre at Rigshospitalet was officially inaug-urated in December 2013 as part of the Centre for ClinicalEducation (CEKU) in Copenhagen. The advanced technicalsimulations, which constitute the bulk of the activities, havebeen developed gradually since 2006. CEKU is a research,development, and service provider for the pregraduate andpostgraduate health educations at the University of Copenha-gen and the postgraduate medical training at the CapitalRegion. The mission of CEKU, founded in 1995, was to trainmedical students in basic clinical skills as a preparation fortheir clerkships. The courses included basic procedural skills,resuscitation skills, and patient encounter skills trained usingsimulated patients. Over the years, the repertoire of clinicalskills was widened to include a variety of physical examinationskills, ultrasound skills, resuscitation at various levels, inter-professional skills, and patient communication skills, allcourses tailored to students’ academic years.

A structured four‐step curriculum in basic laparoscopy: development and validation

The objective of this study was to develop a four‐step curriculum in basic laparoscopy consisting of validated modules integrating a cognitive component, a practical component and a procedural component.

Intraperitoneal instillation of saline and local anesthesia for prevention of shoulder pain after laparoscopic cholecystectomy: a systematic review

BackgroundThe laparoscopic technique has many advantages compared with open surgery for symptomatic cholecystolithiasis. Despite these advantages, many patients complain about shoulder pain (SP) after laparoscopic cholecystectomy. The purpose of this review was to evaluate intraperitoneal instillation (IPI) of saline and local anesthesia (LA) to minimize SP.MethodsA search of the literature was conducted using PubMed and Excerpta Medica Database (EMBASE). Eligibility criteria were: randomized clinical trials (RCT) evaluating IPI of saline and/or LA to minimize incidence or severity of SP after laparoscopic cholecystectomy. Only papers published in English were included. Data extracted were year of publication, number of participants and allocation, timing of IPI, and nonsignificant or significant effect on incidence or severity of SP.ResultsA total of 24 RCTs were included in the review. Four RCTs reported results on IPI saline as intervention versus nothing as control. Seven RCTs reported results on IPI LA as intervention versus nothing as control. Sixteen RCTs reported results on IPI LA as intervention versus saline as control. IPI saline resulted in a significant reduction in SP severity compared with nothing. IPI LA was associated with an overall significant reduction of SP severity compared with nothing. Results regarding the effect IPI LA versus saline showed contradictory results in regards to both SP incidence and severity.ConclusionsBoth IPI of saline and LA can be used to reduce SP severity after laparoscopic cholecystectomy. It is not possible to conclude whether the incidence of SP can be reduced with saline or LA, due to contradictive results.

A new possibility in thoracoscopic virtual reality simulation training: development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy

OBJECTIVES The aims of this study were to develop virtual reality simulation software for video-assisted thoracic surgery (VATS) lobectomy, to explore the opinions of thoracic surgeons concerning the VATS lobectomy simulator and to test the validity of the simulator metrics. METHODS Experienced VATS surgeons worked with computer specialists to develop a VATS lobectomy software for a virtual reality simulator. Thoracic surgeons with different degrees of experience in VATS were enrolled at the 22nd meeting of the European Society of Thoracic Surgeons (ESTS) held in Copenhagen in June 2014. The surgeons were divided according to the number of performed VATS lobectomies: novices (0 VATS lobectomies), intermediates (1-49 VATS lobectomies) and experienced (>50 VATS lobectomies). The participants all performed a lobectomy of a right upper lobe on the simulator and answered a questionnaire regarding content validity. Metrics were compared between the three groups. RESULTS We succeeded in developing the first version of a virtual reality VATS lobectomy simulator. A total of 103 thoracic surgeons completed the simulated lobectomy and were distributed as follows: novices n = 32, intermediates n = 45 and experienced n = 26. All groups rated the overall user realism of the VATS lobectomy scenario to a median of 5 on a scale 1-7, with 7 being the best score. The experienced surgeons found the graphics and movements realistic and rated the scenario high in terms of usefulness as a training tool for novice and intermediate experienced thoracic surgeons, but not very useful as a training tool for experienced surgeons. The metric scores were not statistically significant between groups. CONCLUSIONS This is the first study to describe a commercially available virtual reality simulator for a VATS lobectomy. More than 100 thoracic surgeons found the simulator realistic, and hence it showed good content validity. However, none of the built-in simulator metrics could significantly distinguish between novice, intermediate experienced and experienced surgeons, and further development of the simulator software is necessary to develop valid metrics.

Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized educational trial

BackgroundSeveral studies have found a positive effect on the learning curve as well as the improvement of basic psychomotor skills in the operating room after virtual reality training. Despite this, the majority of surgical and gynecological departments encounter hurdles when implementing this form of training. This is mainly due to lack of knowledge concerning the time and human resources needed to train novice surgeons to an adequate level. The purpose of this trial is to investigate the impact of instructor feedback regarding time, repetitions and self-perception when training complex operational tasks on a virtual reality simulator.Methods/DesignThe study population consists of medical students on their 4th to 6th year without prior laparoscopic experience. The study is conducted in a skills laboratory at a centralized university hospital. Based on a sample size estimation 98 participants will be randomized to an intervention group or a control group. Both groups have to achieve a predefined proficiency level when conducting a laparoscopic salpingectomy using a surgical virtual reality simulator. The intervention group receives standardized instructor feedback of 10 to 12 min a maximum of three times. The control group receives no instructor feedback. Both groups receive the automated feedback generated by the virtual reality simulator. The study follows the CONSORT Statement for randomized trials. Main outcome measures are time and repetitions to reach the predefined proficiency level on the simulator. We include focus on potential sex differences, computer gaming experience and self-perception.DiscussionThe findings will contribute to a better understanding of optimal training methods in surgical education.Trial RegistrationNCT01497782

Effect of Instructor Feedback on Skills Retention After Laparoscopic Simulator Training: Follow-Up of a Randomized Trial

BACKGROUND Instructor feedback reduces the number of repetitions and time to reach proficiency during laparoscopic simulator training. The objective of this study was to examine the effect of instructor feedback on long-term skill retention. METHODS A 6-month follow-up of a randomized trial. Participants were surgical novices (medical students). All participants (n = 99) initially practiced a laparoscopic salpingectomy on the LapSim virtual reality simulator to proficiency. The intervention group could request instructor feedback, whereas the control group could not. After 6 months, the participants (n = 65) practiced on the simulator until they reached proficiency again. The primary outcomes were the total time and the number of repetitions. RESULTS Initially, the intervention group used significantly fewer repetitions (29 vs 65, p < 0.0005) and less total training time (162 vs 342 min, p < 0.0005) than the control group to reach the proficiency level. At follow-up, both the groups used an equal number of repetitions (21 vs 20, p = 0.72) and time (83 vs 73 min, p = 0.37) to reach the same proficiency level. CONCLUSIONS Instructor feedback during proficiency-based laparoscopic simulator training does not affect the long-term retention of skills.

Designing a Standardized Laparoscopy Curriculum for Gynecology Residents: A Delphi Approach

BACKGROUND Evidence suggests that simulation leads to improved operative skill, shorter operating room time, and better patient outcomes. Currently, no standardized laparoscopy curriculum exists for gynecology residents. OBJECTIVE To design a structured laparoscopy curriculum for gynecology residents using Delphi consensus methodology. METHODS This study began with Delphi methodology to determine expert consensus on the components of a gynecology laparoscopic skills curriculum. We generated a list of cognitive content, technical skills, and nontechnical skills for training in laparoscopic surgery, and asked 39 experts in gynecologic education to rate the items on a Likert scale (1-5) for inclusion in the curriculum. Consensus was predefined as Cronbach α of ≥0.80. We then conducted another Delphi survey with 9 experienced users of laparoscopic virtual reality simulators to delineate relevant curricular tasks. Finally, a cross-sectional design defined benchmark scores for all identified tasks, with 10 experienced gynecologic surgeons performing the identified tasks at basic, intermediate, and advanced levels. RESULTS Consensus (Cronbach α=0.85) was achieved in the first round of the curriculum Delphi, and after 2 rounds (Cronbach α=0.80) in the virtual reality curriculum Delphi. Consensus was reached for cognitive, technical, and nontechnical skills as well as for 6 virtual reality tasks. Median time and economy of movement scores defined benchmarks for all tasks. CONCLUSIONS This study used Delphi consensus to develop a comprehensive curriculum for teaching gynecologic laparoscopy. The curriculum conforms to current educational standards of proficiency-based training, and is suggested as a standard in residency programs.

Training and Assessment of Hysteroscopic Skills: A Systematic Review

OBJECTIVE The aim of this systematic review was to identify studies on hysteroscopic training and assessment. DESIGN PubMed, Excerpta Medica, the Cochrane Library, and Web of Science were searched in January 2015. Manual screening of references and citation tracking were also performed. Studies on hysteroscopic educational interventions were selected without restrictions on study design, populations, language, or publication year. A qualitative data synthesis including the setting, study participants, training model, training characteristics, hysteroscopic skills, assessment parameters, and study outcomes was performed by 2 authors working independently. Effect sizes were calculated when possible. Overall, 2 raters independently evaluated sources of validity evidence supporting the outcomes of the hysteroscopy assessment tools. RESULTS A total of 25 studies on hysteroscopy training were identified, of which 23 were performed in simulated settings. Overall, 10 studies used virtual-reality simulators and reported effect sizes for technical skills ranging from 0.31 to 2.65; 12 used inanimate models and reported effect sizes for technical skills ranging from 0.35 to 3.19. One study involved live animal models; 2 studies were performed in clinical settings. The validity evidence supporting the assessment tools used was low. Consensus between the 2 raters on the reported validity evidence was high (94%). CONCLUSIONS This systematic review demonstrated large variations in the effect of different tools for hysteroscopy training. The validity evidence supporting the assessment of hysteroscopic skills was limited.