Marina Yiasemidou

Faster simulated laparoscopic cholecystectomy with haptic feedback technology

Virtual reality simulators have been gradually introduced into surgical training. One of the enhanced features of the latest virtual simulators is haptic feedback. The useful-ness of haptic feedback technology has been a matter of controversy in recent years. Previous studies have assessed the importance of haptic feedback in executing parts of a procedure or basic tasks, such as tissue grasping. The aim of this study was to assess the role of haptic feed-back within a structured educational environment, based on the performance of junior surgical trainees after undergoing substantial simulation training.

Cadaveric Spinal Surgery Simulation: A Comparison of Cadaver Types.

Study Design Single-blinded study. Objective To assess the suitability of three types of cadaver for simulating pedicle screw insertion and establish if there is an ideal. Methods Three types of cadaver—Thiel-embalmed, Crosado-embalmed, and formaldehyde-embalmed—were draped and the spines exposed. Experienced surgeons were asked to place pedicle screws in each cadaver and give written questionnaire feedback using a modified Likert scale. Soft tissue and bony properties were assessed, along with the role of simulation in spinal surgery training. Results The Thiel cadaver rated highest for soft tissue feel and appearance with a median score of 6 for both (range 2 to 7). The Crosado cadaver rated highest for bony feel, with a median score of 6 (range 2 to 7). The formaldehyde cadaver rated lowest for all categories with median scores of 2, 2.5, and 3.5, respectively. All surgeons felt pedicle screw insertion should be learned in a simulated setting using human cadavers. Conclusion Thiel and Crosado cadavers both offered lifelike simulation of pedicle screw insertion, with each having advantages depending on whether the focus is on soft tissue approach or technical aspects of bony screw insertion. Both cadaver types offer the advantage of long life span, unlike fresh frozen tissue, which means cadavers can be used multiple times, thus reducing the costs.

Mental practice with interactive 3D visual aids enhances surgical performance

BackgroundEvidence suggests that Mental Practice (MP) could be used to finesse surgical skills. However, MP is cognitively demanding and may be dependent on the ability of individuals to produce mental images. In this study, we hypothesised that the provision of interactive 3D visual aids during MP could facilitate surgical skill performance.Methods20 surgical trainees were case-matched to one of three different preparation methods prior to performing a simulated Laparoscopic Cholecystectomy (LC). Two intervention groups underwent a 25-minute MP session; one with interactive 3D visual aids depicting the relevant surgical anatomy (3D-MP group, n = 5) and one without (MP-Only, n = 5). A control group (n = 10) watched a didactic video of a real LC. Scores relating to technical performance and safety were recorded by a surgical simulator.ResultsThe Control group took longer to complete the procedure relative to the 3D&MP condition (p = .002). The number of movements was also statistically different across groups (p = .001), with the 3D&MP group making fewer movements relative to controls (p = .001). Likewise, the control group moved further in comparison to the 3D&MP condition and the MP-Only condition (p = .004). No reliable differences were observed for safety metrics.ConclusionThese data provide evidence for the potential value of MP in improving performance. Furthermore, they suggest that 3D interactive visual aids during MP could potentially enhance performance, beyond the benefits of MP alone. These findings pave the way for future RCTs on surgical preparation and performance.

Perceptions About the Present and Future of Surgical Simulation: A National Study of Mixed Qualitative and Quantitative Methodology.

OBJECTIVES Assess expert opinion on the current and future role of simulation in surgical education. DESIGN Expert opinion was sought through an externally validated questionnaire that was disseminated electronically. PARTICIPANTS Heads of Schools of Surgery (HoS) (and deputies) and Training Program Directors (TPD) (and deputies). RESULTS Simulation was considered a good training tool (HoS: 15/15, TPD: 21/21). The concept that simulation is useful mostly to novices and for basic skills acquisition was rejected (HoS: 15/15, TPDs: 21/21; HoS: 13/15, TPDs: 18/21). Further, simulation is considered suitable for teaching nontechnical skills (HoS: 13/15, TPDs: 20/21) and re-enacting stressful situations (HoS: 14/15, TPDs: 15/21). Most respondents also felt that education centers should be formally accredited (HoS: 12/15, TPDs: 16/21) and that consultant mentors should be appointed by every trust (HoS: 12/15, TPDs: 19/21). In contrast, there were mixed views on its use for trainee assessment (HoS: 6/15, TPDs: 14/21) and whether it should be compulsory (HoS: 8/15, TPDs: 11/21). CONCLUSION The use of simulation for the acquirement of both technical and nontechnical skills is strongly supported while views on other applications (e.g., assessment) are conflicting. Further, the need for center accreditation and supervised, consultant-led teaching is highlighted.

A multi-specialty surgical course for residents transitioning from early to intermediate training

It has been estimated that approximately 15000 to 20000 hours are required to train a surgeon.1 However, several time-constrains imposed globally2 have significantly reduced training time in the Operating Room (OR) posing a significant challenge for surgical educators and creating an impetus for the development of new educational methods.3 Since August 2005, all medical graduates in the United Kingdom must enter a 2 year postgraduate programme prior to commencing training in their chosen medical or surgical specialty.4 What is the problem? Despite this two-year programme being a good introduction to duties as a doctor there have been some concerns that the trainees do not gain significant experience in surgical procedures leading to reduced confidence.5 Which can make transition from a second year postgraduate (Foundation) doctor (PGY2) to a surgical resident particular difficult. To gain more experience a large number of doctors undertaking additional posts, which are not part of the recognised training scheme, in the UK and abroad, or roles such as anatomy demonstrators, in order to broaden their skills and relevant knowledge prior to progressing to surgical training.6

Efficacy and Safety of a Biweekly Viscosupplementation Regimen for Knee Osteoarthritis.

Osteoarthritis is the most common form of arthritis in the Western world, causing disabling symptoms in 10% of people older than 55 years. Hyaluronic acid injections can reduce osteoarthritic pain but require three to five doses administered weekly. This preliminary study aims to assess the efficacy of a more flexible viscosupplementation regimen. Patients were given three sodium hyaluronate isotonic solution injections (Ostenil; TRB Chemedica SA, Vouvry, Switzerland), biweekly. They were then asked to record their pain before and after administration of the injections, on a visual analog score. A total of 91 knees were injected. Analysis of the data showed that the viscosupplementation injections significantly reduced the baseline pain within the first 24 to 48 hours post first injection (before injection, 68.8mm; 2 days postinjection, 48.9 mm; p < 0.001); these effects were maintained up to 6 months. No adverse effects were reported. The proposed regimen appears safe and efficient in reducing osteoarthritic pain of the knee joint. A randomized controlled study is needed to confirm these results.

0181 COMPARISON OF CADAVER TYPES FOR SPINAL SURGERY TRAINING

Background Spine pedicle screw insertion is technically demanding, with potentially serious risks if screws are misplaced, and an established learning curve of approximately 70 screws placed before there is a significant reduction in screw misplacement. Despite this most units continue to teach screw insertion for the first time in live surgery, both in the UK and worldwide. This study was a single blinded comparison of cadaver types to simulate screw insertion. Methodology Three cadaver types – Thiel, Crosado and Formaldehyde were positioned prone and a posterior approach to the spine performed. The spines were all exposed by a single surgeon. Experienced spinal surgeons placed screws in each cadaver type sequentially and gave feedback on the tissue quality and feel using a modified Likert scale. Results Thiel cadavers rated most highly for soft tissue feel and appearance with a median score of 6. Crosado cadavers rated most highly for bony properties, with a median score of 6. Formaldehyde cadavers rated poorly for soft tissue feel, appearance and bony qualities with median scores of 2, 2.5 and 3.5 respectively. Conclusions There is a strong argument that pedicle screw insertion should be taught away from the operating theatre but this will have significant cost implications. Cadaveric screw simulation offers the most realistic simulation, with Thiel and Crosado cadavers both rating highly for their properties. Further work is now needed on a larger scale to further explore this valuable resource in surgical training. References Bergeson RK, Schwend RM, DeLucia T, Silva SR, Smith JE, Avilucea FR. How accurately do novice surgeons place thoracic pedicle screws with the free hand technique? Spine 2008;33(15):E501–7 Gonzalvo A, Fitt G, Liew S, et al. The learning curve of pedicle screw placement: how many screws are enough? Spine 2009;34(21):E761–5 Gautschi OP, Schatlo B, Schaller K, Tessitore E. Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurg Focus 2011;31(4):E8

0061 Should Simulation Training Be Compulsory For Trainees In All Surgical Specialties

Background Simulation is a useful adjunct to surgical training and there is a plethora of evidence demonstrating its value.1,2 In our region there are seven state of the art simulation centres hosting both low and high fidelity simulators. Use of these facilities requires commitment by both trainees and trainers. Thus, we have compared the uptake of simulation in ophthalmology where the programme is compulsory to both general surgery and gynaecology that run optional programmes. Methods One of the skills centres, hosts virtual reality simulators for ophthalmology (EyeSim/SimSci, US), general surgery (LapMentor, Simbionix/Israel) and obstetrics and gynaecology (LapMentor, Simbionix/Israel). Access to them has been booked online since August 2013. Data from the booking system was retrieved (Aug ’13-May ’14) to determine the use. Results EyeSim (SimSci, US) was used 163 times whilst the LapMentor (Simbionix/Israel) was used on 34 occasions (26/34 for research purposes rather than training) and 43 times by general surgery and gynaecology trainees respectively. Bookings for the EyeSim (SimSci, US) were made by 28 individuals, whilst only 7 general surgery trainees (including 2 research fellows conducting a trial) booked time on the LapMentor (Simbionix/Israel). By comparison 17 gynaecology trainees used the simulator. Within our region there are twice as many trainees in general surgery and gynaecology compared to ophthalmology. Discussion A significantly larger proportion of ophthalmology trainees have trained on simulators compared to both surgery and gynaecology with surgical trainees making least use of the facility. Furthermore, the frequency of usage by trainees was greater for ophthalmology trainees. This suggests that simulation training should become compulsory for trainees and that confirmation of appropriate learning should be demonstrated prior to operating on patients. References Kurashima Y, Feldman LS, Kaneva PA, Fried GM, Bergman S, Demyttenaere SV, Li C, Vassiliou MC. Simulation-based training improves the operative performance of totally extraperitoneal (TEP) laparoscopic inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc. 2014 Mar;28(3):783–8 Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev. 2013;27:8

0075 Improving Trainees’ Confidence With A Novel Multidsciplinary Simulated Surgical Course

Background Due to increasing requirements of service provision and the introduction of the European Working Time Directive, Foundation trainees have limited exposure to surgical procedures.1 Confidence of novice trainees to perform procedures is improved by undergoing simulation training.2 We have therefore designed a novel, multidisciplinary course aiming to familiarise foundation doctors to surgical procedures. The aim of this study is to evaluate the impact of such a course on their confidence. Methodology 23 Foundation Year 2 doctors due to start Core Surgical Training from August 2014 attended the Essential Surgical Skills Course over 2 days. Trainees rotated around a circuit of sub-speciality skills workshops undertaking simulated procedures in General Surgery, Urology, Trauma and Orthopaedics and Plastic surgery, all led by Consultant faculty. Pre and post-course questionnaires were distributed, assessing confidence to perform each skill on a Likert scale (1–5). Results Median values were calculated across each speciality’s skills. General Surgery and Urology demonstrated an increase in median value for all 23 participants pre- and post-course. Median differences pre- and post-course ranged from 1–3.5 in both General Surgery and Urology. 22 out of 23 demonstrated an increase in median value for Trauma and Orthopaedics, (median difference range 1–4), one participant had equal median values. 20 out of 23 demonstrated an increase in median value for Plastic Surgery, (median difference range of 1–4), three participants had equal median values. Conclusions and recommendations Participants were overall increasingly confident in performing these core surgical skills having undertaken the course. Simulation is a critical part of surgical training in an era where surgical exposure in the operating theatre is more time-restricted. Trainees feel that a course simulating surgical skills, taught by Consultant surgeons, is important in enhancing confidence and skill acquisition; aiding in bridging the gap between completing foundation training and entering a surgical career. References Varley et al. Changes in caseload and the potential impact on surgical training: a retrospective review of one hospital’s experience. BMC Medical Education 2006;6:6 Green-Carlsen et alet al. Is Current Surgical Training Efficient? J Surg Educ 2014;71(3):367–74