Karl-Friedrich Kowalewski

Validation of the mobile serious game application Touch Surgery™ for cognitive training and assessment of laparoscopic cholecystectomy

BackgroundTouch Surgery™ (TS) is a serious gaming application for cognitive task simulation and rehearsal of key steps in surgical procedures. The aim was to establish face, content, and construct validity of TS for laparoscopic cholecystectomy (LC). Furthermore, learning curves with TS and a virtual reality (VR) trainer were compared in a randomized trial.MethodsThe performance of medical students and general surgeons was compared for all three modules of LC in TS to establish construct validity. Questionnaires assessed face and content validity. For analysis of learning curves, students were randomized to train on VR or TS first, and then switched to the other training modality. Performance data were recorded.Results54 Surgeons and 51 medical students completed the validation study. Surgeons outperformed students with TS: patient preparation (students = 45.0 ± 19.1%; surgeons = 57.3 ± 15.2%; p < 0.001), access and laparoscopy (students = 70.2 ± 10.9%; surgeons = 75.9 ± 9.7%; p = 0.008) and LC (students = 69.8 ± 12.4%; surgeons = 77.7 ± 9.6%; p < 0.001). Both groups agreed that TS was a highly useful and realistic application. 46 students were randomized for learning curve analysis. It took them 2–4 attempts to reach a 100% score with TS. Training with TS first did not improve students’ performance on the VR trainer; however, students who trained with VR first scored significantly higher in module 3 of TS.ConclusionTS is an accepted serious gaming application for learning cognitive aspects of LC with established construct, face, and content validity. There appeared to be a synergy between TS and the VR trainer. Therefore, the two training modalities should accompany one another in a multimodal training approach to laparoscopy.

App-based serious gaming for training of chest tube insertion: study protocol for a randomized controlled trial

BackgroundChest tube insertion is a standard intervention for management of various injuries of the thorax. Quick and accurate execution facilitates efficient therapy without further complications. Here, we propose a new training concept comprised of e-learning elements as well as continuous rating using an objective structured assessment of technical skills (OSATS) tool. The study protocol is presented for a randomized trial to evaluate e-learning with app-based serious gaming for chest drain insertion.MethodsThe proposed randomized trial will be carried out at the Department of Orthopedics and Traumatology at Heidelberg University in the context of regular curricular teaching for medical students (n = 90, 3rd to 6th year). The intervention group will use e-learning with the serious gaming app Touch Surgery (TM) for chest drain insertion, whereas the control group uses serious gaming for an unrelated procedure. Primary endpoint is operative performance of chest drain insertion in a porcine cadaveric model according to OSATS.DiscussionThe randomized trial will help determine the value of e-learning with the serious gaming app Touch Surgery (TM) for chest drain insertion by using the OSATS score. The study will improve surgical training for trauma situations.Trial registrationTrial Registration Number, DRKS00009994. Registered on 27 May 2016.

Skills in minimally invasive and open surgery show limited transferability to robotic surgery: results from a prospective study

BackgroundThere is limited evidence on the transferability of conventional laparoscopic and open surgical skills to robotic-assisted surgery. The primary aim of this study was to evaluate the transferability of expertise in conventional laparoscopy and open surgery to robotic-assisted surgery using the da Vinci Skills Simulator (dVSS). Secondary aims included evaluating the influence of individual participants’ characteristics.MethodsParticipants performed four tasks on the dVSS: Peg Board 1 (PB), Pick and Place (PP), Thread the Rings (TR), and Suture Sponge 1 (SS). Participants were classified into three groups (Novice, Intermediate, Experts) according to experience in laparoscopic and open surgery. All tasks were performed twice except for SS. Performance was assessed using the built-in scoring system.Results37 medical students and 25 surgeons participated. Experts did not perform significantly better than less experienced participants on the dVSS. Specifically, with regard to laparoscopic experience, total simulator scores were: Novices 68.2 ± 28.8; Intermediates 65.1 ± 31.2; Experts 65.1 ± 30.0; p = 0.611. Regarding open surgical experience, scores were: Novices 68.6 ± 28.7; Intermediates 68.2 ± 30.8; Experts 63.2 ± 30.3; p = 0.305. Although there were some significant differences among groups for single parameters in specific tasks, there was no constant superiority of one group. Laparoscopic and open surgical Novices improved significantly in overall score and time for all three tasks (p < 0.05). Laparoscopic intermediates improved only in PP time (4.64 ± 3.42; p = 0.006), open Intermediates in PB score (11.98 ± 13.01; p = 0.025), and open Experts in PP score (6.69 ± 11.48; p = 0.048). Laparoscopic experts showed no improvement. Participants with gaming experience had better overall scores than non-gamers when comparing all second attempts (Gamer 83.62 ± 7.57; Non-Gamer 76.31 ± 12.78; p = 0.008) as well as first and second attempts together (Gamer 72.08 ± 8.86; Non-Gamer 65.45 ± 11.68; p = 0.039). Musical and sports experience showed no correlation with robotic performance.ConclusionsRobotic-assisted surgery requires skills distinct from conventional laparoscopy or open surgery. Basic robotic skills training prior to patient contact should be required.

Does rating the operation videos with a checklist score improve the effect of E-learning for bariatric surgical training? Study protocol for a randomized controlled trial

BackgroundLaparoscopic training has become an important part of surgical education. Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed. Surgeons must be well trained prior to operating on a patient. Multimodality training is vital for bariatric surgery. E-learning with videos is a standard approach for training. The present study investigates whether scoring the operation videos with performance checklists improves learning effects and transfer to a simulated operation.Methods/designThis is a monocentric, two-arm, randomized controlled trial. The trainees are medical students from the University of Heidelberg in their clinical years with no prior laparoscopic experience. After a laparoscopic basic virtual reality (VR) training, 80 students are randomized into one of two arms in a 1:1 ratio to the checklist group (group A) and control group without a checklist (group B). After all students are given an introduction of the training center, VR trainer and laparoscopic instruments, they start with E-learning while watching explanations and videos of RYGB. Only group A will perform ratings with a modified Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale checklist for all videos watched. Group B watches the same videos without rating. Both groups will then perform an RYGB in the VR trainer as a primary endpoint and small bowel suturing as an additional test in the box trainer for evaluation.DiscussionThis study aims to assess if E-learning and rating bariatric surgical videos with a modified BOSATS checklist will improve the learning curve for medical students in an RYGB VR performance. This study may help in future laparoscopic and bariatric training courses.Trial registrationGerman Clinical Trials Register, DRKS00010493. Registered on 20 May 2016.

Study protocol for a randomized controlled trial on a multimodal training curriculum for laparoscopic cholecystectomy – LapTrain

Highlights • The first structured multi-modality laparoscopy training curriculum.• Assessing the value of a multimodal training platform in medical education.• Optimizing efficiency of facilities and courses in laparoscopic surgical training.

The Heidelberg VR Score: development and validation of a composite score for laparoscopic virtual reality training

IntroductionVirtual reality (VR-)trainers are well integrated in laparoscopic surgical training. However, objective feedback is often provided in the form of single parameters, e.g., time or number of movements, making comparisons and evaluation of trainees’ overall performance difficult. Therefore, a new standard for reporting outcome data is highly needed. The aim of this study was to create a weighted, expert-based composite score, to offer simple and direct evaluation of laparoscopic performance on common VR-trainers.Materials and methodsAn integrated analytic hierarchy process-Delphi survey was conducted with 14 international experts to achieve a consensus on the importance of different skill categories and parameters in evaluation of laparoscopic performance. A scoring algorithm was established to allow comparability between tasks and VR-trainers. A weighted composite score was calculated for basic skills tasks and peg transfer on the LapMentor™ II and III and validated for both VR-trainers.ResultsFive major skill categories (time, efficiency, safety, dexterity, and outcome) were identified and weighted in two Delphi rounds. Safety, with a weight of 67%, was determined the most important category, followed by efficiency with 17%. The LapMentor™-specific score was validated using 15 (14) novices and 9 experts; the score was able to differentiate between both groups for basic skills tasks and peg transfer (LapMentor™ II: Exp: 86.5 ± 12.7, Nov. 52.8 ± 18.3; p < 0.001; LapMentor™ III: Exp: 80.8 ± 7.1, Nov: 50.6 ± 16.9; p < 0.001).ConclusionAn effective and simple performance measurement was established to propose a new standard in analyzing and reporting VR outcome data—the Heidelberg virtual reality (VR) score. The scoring algorithm and the consensus results on the importance of different skill aspects in laparoscopic surgery are universally applicable and can be transferred to any simulator or task. By incorporating specific expert baseline data for the respective task, comparability between tasks, studies, and simulators can be achieved.

Does rating with a checklist improve the effect of E-learning for cognitive and practical skills in bariatric surgery? A rater-blinded, randomized-controlled trial

BackgroundMental training of laparoscopic procedures with E-learning has been shown to translate to the operating room. The present study aims to explore whether the use of checklists during E-learning improves transfer of skills to the simulated OR on a Virtual Reality (VR) trainer for Roux-en-Y gastric bypass (RYGB).MethodsLaparoscopy naive medical students (n = 80) were randomized in two groups. After an E-learning introduction to RYGB, checklist group rated RYGB videos using the validated Bariatric Objective Structured Assessment of Technical Skills (BOSATS) checklist while group without checklist only observed the videos. Participants then performed RYGB on a VR-trainer twice and were evaluated by a blinded expert rater using BOSATS. A multiple choice (MC) knowledge test on RYGB was performed. Suturing on a cadaveric porcine small bowel was evaluated using objective structured assessment of technical skill (OSATS).ResultsChecklist group was better in the knowledge test (A 8.3 ± 1.1 vs. B 7.1 ± 1.3; p ≤ 0.001) and there was a trend towards better VR RYGB performance (BOSATS) on the first try (85.9 ± 10.2 vs. 81.1 ± 11.5; p = 0.058), but not on the second try (92.0 ± 9.7 vs. 89.3 ± 10.5; p = 0.251). Suturing as measured by OSATS was not different (29.5 ± 3.0 vs. 29.0 ± 3.5; p = 0.472).ConclusionThis study presents evidence that the use of a BOSATS checklist during E-learning helps trainees to improve their knowledge acquisition with E-learning. The transfer from mental training to the simulated OR environment seems to be partially enhanced by use of the BOSATS checklist. However, more research is required to investigate potential benefits.

Learning from the surgeon’s real perspective – First-person view versus laparoscopic view in e-learning for training of surgical skills? Study protocol for a randomized controlled trial

Highlights • Development of intuitive laparoscopic training methods.• First-person perspective may enhance learning curves.• New standards in e-learning modules may be implemented.