Nancy J. Hogle

Validation of laparoscopic surgical skills training outside the operating room: a long road

BackgroundSurgical skills training outside the operating room is beneficial. The best methods have yet to be identified. The authors aimed to document the predictive validity of simulation training in three different studies.MethodsStudy 1 was a prospective, randomized, multicenter trial comparing performance in the operating room after training on a laparoscopic simulator and after no training. The Global Operative Assessment of Laparoscopic Skills (GOALS) was used to evaluate operative performance. Study 2 retrospectively reviewed the operative performance of junior residents before and after implementation of a laparoscopic skills training curriculum. Operative time was the variable used to determine resident improvement. Study 3 was a prospective, randomized trial evaluating intern operative performance of laparoscopic cholecystectomy in a porcine model before and after training on a simulator. Operative performance was assessed using GOALS.ResultsAll three studies failed to demonstrate predictive validity. With GOALS used as the assessment tool, no difference was found between trained and untrained residents in studies 1 and 3. In study 2, the trained group took significantly longer to complete a laparoscopic cholecystectomy than the untrained group.ConclusionsNo correlation was found between the three types of training outside the operating room, and no improved operative performance was observed. Possible explanations include too few subjects, training introduced too late in the learning curve, and training criteria that were too easy. Additionally, simulator training focuses on precision, which may actually increase task time. Awareness of these issues can improve the design of future studies.

Reliable Assessment of Laparoscopic Performance in the Operating Room Using Videotape Analysis

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid assessment tool for objectively evaluating the technical performance of laparoscopic skills in surgery residents. We hypothesized that GOALS would reliably differentiate between an experienced (expert) and an inexperienced (novice) laparoscopic surgeon (construct validity) based on a blinded videotape review of a laparoscopic cholecystectomy procedure. Ten board-certified surgeons actively engaged in the practice and teaching of laparoscopy reviewed and evaluated the videotaped operative performance of one novice and one expert laparoscopic surgeon using GOALS. Each reviewer recorded a score for both the expert and the novice videotape reviews in each of the 5 domains in GOALS (depth perception, bimanual dexterity, efficiency, tissue handling, and overall competence). The scores for the expert and the novice were compared and statistically analyzed using single-factor analysis of variance (ANOVA). The expert scored significantly higher than the novice did in the domains of depth perception (p = .005), bimanual dexterity (p = .001), efficiency (p = .001), and overall competence ( p = .001). Interrater reliability for the reviewers of the novice tape was Cronbach alpha = .93 and the expert tape was Cronbach alpha = .87. There was no difference between the two for tissue handling. The Global Operative Assessment of Laparoscopic Skills is a valid, objective assessment tool for evaluating technical surgical performance when used to blindly evaluate an intraoperative videotape recording of a laparoscopic procedure.

Insertable stereoscopic 3D surgical imaging device with pan and tilt

In this paper, we present an insertable stereoscopic 3D imaging system for minimally invasive surgery. It has been designed and developed toward the goal of single port surgery. The device is fully inserted into the body cavity and affixed to the abdominal wall. It contains pan and tilt axes to move the camera under simple and intuitive joystick control. A polarization-based stereoscopic display is used to view the images in 3D. The camerapsilas mechanical design is based upon a single camera prototype we have previously built. We have run calibration tests on the camera and used it to track surgical tools in 3D in real-time. We have also used it in a number of live animal tests that included surgical procedures such as appendectomy, running the bowel, suturing, and nephrectomy. The experiments suggest that the device may be easier to use than a normal laparoscope since there is no special training needed for operators. The Pan/Tilt functions provide a large imaging volume that is not restricted by the fulcrum point of a standard laparoscope. Finally, the 3-D imaging system significantly improves the visualization and depth perception of the surgeon.

Insertable Surgical Imaging Device with Pan, Tilt, Zoom, and Lighting

In this paper we describe work we have done in developing an insertable surgical imaging device with multiple degrees of freedom for minimally invasive surgery. The device is fully insertable into the abdomen using standard 12 mm trocars. It consists of a modular camera and lens system which has pan and tilt capability provided by two small DC servo motors. It also has its own integrated lighting system that is part of the camera assembly. Once the camera is inserted into the abdomen, the insertion port is available for additional tooling, motivating the idea of single-port surgery. A third zoom axis has been designed for the camera as well, allowing close-up and far-away imaging of surgical sites with a single camera unit. In animal tests with the device we have performed surgical procedures including cholecystectomy, appendectomy, running (measuring) the bowel, suturing, and nephrectomy. Preliminary tests suggest that the new device may have advantages over a standard laparoscope including the following. • Low-cost and simple design. • Easier and more intuitive to use than a standard laparoscope. • Joystick operation requires no specialized operator training. • Pan/tilt functions provide a large imaging volume not restricted by the fulcrum point of standard laparoscope. • Time to perform procedures was better than or equivalent to a standard laparoscope. We believe these insertable platforms will be an integral part of future surgical systems. The platforms can be used with tooling as well as imaging devices, allowing many surgical procedures to be performed using such a system.

Insertable surgical imaging device with pan, tilt, zoom, and lighting

This paper describes work we have done in developing an insertable surgical imaging device with multiple degrees-of-freedom for minimally invasive surgery. The device is fully insertable into the abdomen using standard 12 mm trocars. It consists of a modular camera and lens system which has pan and tilt capability provided by 2 small DC servo motors. It also has its own integrated lighting system that is part of the camera assembly. Once the camera is inserted into the abdomen, the insertion port is available for additional tooling, motivating the idea of single port surgery. A third zoom axis has been designed for the camera as well, allowing close-up and far-away imaging of surgical sites with a single camera unit. In animal tests with the device we have performed surgical procedures including cholecystectomy, appendectomy, running (measuring) the bowel, suturing, and nephrectomy. The tests show that the new device is: (1) Easier and more intuitive to use than a standard laparoscope. (2) Joystick operation requires no specialized operator training. (3) Field of view and access to relevant regions of the body were superior to a standard laparoscope using a single port. (4) Time to perform procedures was better or equivalent to a standard laparoscope. We believe these insertable platforms will be an integral part of future surgical systems. The platforms can be used with tooling as well as imaging systems, allowing many surgical procedures to be done using such a platform.

Limiting PGY 1 Residents to 16 Hours of Duty: Review and Report of a Workshop

BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted limits on duty hours. Residents were restricted to working 80 hours/week and limited to 24 hours of continuous patient care. Effective July 2011, an additional restriction will be instituted for PGY 1 residents limiting continuous duty to 16 hours maximum. OBJECTIVE Prospective evaluation of the impact of the upcoming work shift limitations for PGY 1 residents. DESIGN/SETTING/PARTICIPANTS Review of literature and discussions among program directors, program coordinators, and residents on the effects of prior limitations of duty hours, as a point of reference, to manage the changes of duty hours for PGY 1 residents during a workshop at the Association of Program Directors in Surgery Annual Meeting. RESULTS Work-hour restrictions necessitate a change from the traditional 24-hour on-duty call schedule for PGY 1 residents. The benefits to patients of being treated by less tired doctors working in shifts may be offset by communication failures from poor handoffs, rendering the system prone to adverse events/near misses. With additional work-hour restrictions, it is imperative to anticipate problems and deal with them effectively. Continued reevaluation of the handoff system and efforts made to decrease the number of preventable adverse events that typically occur during periods of cross coverage should be undertaken. Labor costs to carry out these new restrictions are predictably high but can be made budget neutral if improvement in patient care leads to reduction in the costs of corrective actions. CONCLUSIONS Residency programs have adapted to the 2003 work-hour restrictions without apparent ill effect. We must study the effects of the July 2011 requirements prospectively as the traditional frontline physicians (PGY 1 residents) will no longer be available for 24-hour duty shifts.

Initial trial of a stereoscopic, insertable, remotely controlled camera for minimal access surgery

BackgroundAlthough video-laparoscopy has enabled successful minimal access surgery, the nature of the technology causes many troublesome limitations: (1) the fulcrum effect of the insertion site through the abdominal wall limits the angle of view, (2) the camera operator must use counterintuitive movements, (3) the laparoscope occupies an incision which otherwise could be used for an instrument, and (4) the laparoscope provides a two-dimensional image.MethodsA stereoscopic, insertable, remotely controlled camera was developed to overcome the limitations imposed by traditional video-laparoscopy. Additional functionality included digital zoom, picture-in-picture (PIP), and tracking capability for autonomous function of the camera. Four surgical tasks were performed twice in a porcine model, once using the insertable camera and once using a standard video-laparoscope setup for visualization. Running the bowel, simulated laparoscopic appendectomy, laparoscopic nephrectomy, and laparoscopic suturing and tying were measured for time, blood loss, and complications. Digital zoom, PIP, and the ability of the computer to move the camera to track a marked instrument were subjectively evaluated.ResultsThe tasks were aborted in one animal because a new three-dimensional (3D) display could not be synchronized with the camera and in another animal because a motor in the camera failed. The tasks were all completed twice in two animals. The mean time was less for all procedures using the insertable camera. There was no significant blood loss and there were no complications. Digital zoom and PIP displaying both a close-up and a panoramic view were subjectively felt to improve visualization by all observers. The computer could reliably move the camera to track a marked instrument to keep it in the center of the field of view.ConclusionsThis preliminary proof-of-concept study suggests that a stereoscopic, insertable, remotely controlled camera may provide better visualization during minimal access surgery by overcoming many of the limitations of video-laparoscopy.

Efficacy of Novel Robotic Camera vs a Standard Laparoscopic Camera

To improve visualization during minimal access surgery, a novel robotic camera has been developed. The prototype camera is totally insertable, has 5° of freedom, and is remotely controlled. This study compared the performance of laparoscopic surgeons using both a laparoscope and the robotic camera. The MISTELS (McGill Inanimate System for the Training and Evaluation of Laparoscopic Skill) tasks were used to test six laparoscopic fellows and attending surgeons. Half the surgeons used the laparoscope first and half used the robotic camera first. Total scores from the MISTELS sessions in which the laparoscope was used were compared with the sessions in which the robotic camera was used and then analyzed with a paired t test (P< .05 was considered significant). All six surgeons tested showed no significant difference in their MISTELS task performance on the robotic camera compared with the standard laparoscopic camera. The mean MISTELS score of 963 for all subjects who used a laparoscope and camera was not significantly different than the mean score of 904 for the robotic camera (P= .17). This new robotic camera prototype allows for equivalent performance on a validated laparoscopic assessment tool when compared with performance using a standard laparoscope.

Comparison of Monoscopic Insertable, Remotely Controlled Imaging Device With a Standard Laparoscope in a Porcine Model

Laparoscopic imaging has remained relatively unchanged since the introduction of the rod—lens system. The intent here is to improve imaging by designing and building sensors and effectors placed directly into the body and controlled remotely. An 11-mm monoscopic insertable pan/tilt endoscopic imaging device with an integrated light source was studied. In vivo testing included simulated appendectomy, nephrectomy, suturing, and running the bowel in a porcine model (n = 6). Subjective impression and time for each procedure were compared using each imaging modality. The insertable imaging device seemed easier and more intuitive to use than a standard laparoscope. Time to perform procedures was better than or equivalent to a standard laparoscope. The insertable camera was subjectively preferred, and times for completion of complex tasks were shorter using the insertable camera. The insertable imaging device has the potential to be an integral part of surgical system platforms.

High Definition in Minimally Invasive Surgery: A Review of Methods for Recording, Editing, and Distributing Video

The use of high-definition cameras and monitors during minimally invasive procedures can provide the surgeon and operating team with more than twice the resolution of standard definition systems. Although this dramatic improvement in visualization offers numerous advantages, the adoption of high definition cameras in the operating room can be challenging because new recording equipment must be purchased, and several new technologies are required to edit and distribute video. The purpose of this review article is to provide an overview of the popular methods for recording, editing, and distributing high-definition video. This article discusses the essential technical concepts of high-definition video, reviews the different kinds of equipment and methods most often used for recording, and describes several options for video distribution.