Rajesh Aggarwal

Laparoscopic skills training and assessment

The introduction of laparoscopic techniques to general surgery was associated with many unnecessary complications, which led to the development of skills laboratories to train novice laparoscopic surgeons. This article reviews the tools currently available for training and assessment in laparoscopic surgery.

Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery

Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience.

Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery.

Objective:The aim of this study was to compare learning curves for laparoscopic cholecystectomy (LC) after training on a proficiency based virtual reality (VR) curriculum with that of a traditionally trained group. Summary Background Data:Simulator-based training has been shown to improve technical performance during real laparoscopic procedures, although research to date has not proven the persistence of this effect over subsequent cases. Material and Methods:Twenty novice surgeons underwent baseline laparoscopic skills testing followed by a 1-day didactic training session. Control subjects (n = 10) performed 5 cadaveric porcine LCs each; VR-trained subjects (n = 10) completed a VR training curriculum followed by 3 porcine LCs each. A further 10 experienced laparoscopic surgeons (>100 LCs) performed 2 porcine LCs each to define benchmark levels. Technical skill assessment was by motion analysis and video-based global rating scores (out of 35). Results:There were no intergroup differences in baseline skill. The first LC revealed significant differences between control and VR groups for time (median 4590 seconds vs. 2165 seconds, P = 0.038), path length (169.2 meters vs. 86.8 meters, P = 0.009), number of movements (2446 vs. 1029, P = 0.009), and video scores (17 vs. 25, P = 0.001). The VR group, although not a control, achieved video and dexterity scores equivalent to expert levels of performance. Conclusions:A proficiency based VR training curriculum shortens the learning curve on real laparoscopic procedures when compared with traditional training methods. This may be a more cost- and time-effective approach, and supports the need for simulator-based practice to be integrated into surgical training programs.

An Evidence-Based Virtual Reality Training Program for Novice Laparoscopic Surgeons

Objective:To develop an evidence-based virtual reality laparoscopic training curriculum for novice laparoscopic surgeons to achieve a proficient level of skill prior to participating in live cases. Summary Background Data:Technical skills for laparoscopic surgery must be acquired within a competency-based curriculum that begins in the surgical skills laboratory. Implementation of this program necessitates the definition of the validity, learning curves and proficiency criteria on the training tool. Methods:The study recruited 40 surgeons, classified into experienced (performed >100 laparoscopic cholecystectomies) or novice groups (<10 laparoscopic cholecystectomies). Ten novices and 10 experienced surgeons were tested on basic tasks, and 11 novices and 9 experienced surgeons on a procedural module for dissection of Calot triangle. Performance of the 2 groups was assessed using time, error, and economy of movement parameters. Results:All basic tasks demonstrated construct validity (Mann-Whitney U test, P < 0.05), and learning curves for novices plateaued at a median of 7 repetitions (Friedmans test, P < 0.05). Expert surgeons demonstrated a learning rate at a median of 2 repetitions (P < 0.05). Performance on the dissection module demonstrated significant differences between experts and novices (P < 0.002); learning curves for novice subjects plateaued at the fourth repetition (P < 0.05). Expert benchmark criteria were defined for validated parameters on each task. Conclusion:A competency-based training curriculum for novice laparoscopic surgeons has been defined. This can serve to ensure that junior trainees have acquired prerequisite levels of skill prior to entering the operating room, and put them directly into practice.

Consensus guidelines for validation of virtual reality surgical simulators

Abstract.The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed sub-group of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for six different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into two basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. Whilst level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org ).

Development of a virtual reality training curriculum for laparoscopic cholecystectomy

Training within a proficiency‐based virtual reality (VR) curriculum may reduce errors during real surgical procedures. This study used a scientific methodology for development of a VR training curriculum for laparoscopic cholecystectomy.

The simulated operating theatre: comprehensive training for surgical teams

Surgical excellence is traditionally defined in terms of technical performance, with little regard for the importance of interpersonal communication and leadership skills. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organisation of simulation based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating theatre project. This enables technical and non-technical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room, and provides an opportunity for constructive feedback. The scenarios have good face validity and junior surgeons can benefit from the process of learning new technical skills in a realistic environment. The effect of external influences such as distractions, new technology, or a crisis scenario can also be defined, with the ultimate aim of reducing the number of adverse events arising in the real operating room.

Toward feasible, valid, and reliable video-based assessments of technical surgical skills in the operating room.

Objective:To determine the feasibility, validity, inter-rater, and intertest reliability of 4 previously published video-based rating scales, for technical skills assessment on a benchmark laparoscopic procedure. Summary Background Data:Assessment of technical skills is crucial to the demonstration and maintenance of competent healthcare practitioners. Traditional assessment methods are prone to subjectivity through a lack of proven validity and reliability. Methods:Nineteen surgeons (6 novice and 13 experienced) performed a median of 2 laparoscopic cholecystectomies each (range 1–5) on 53 patients within 2 Academic Surgical Departments. All patients had a diagnosis of biliary colic. Surgical technical skills were rated posthoc in a blinded manner by 2 experienced observers on 4 video-based rating scales. The different scales used had been developed to assess generic or procedure-specific technical skills in a global manner, or on a procedure-specific checklist. Results:Six of 53 procedures were excluded on the basis of intraoperative difficulty. Of the remaining 47 procedures, 14 were performed by 6 novice surgeons and 33 by the 13 experienced surgeons. There were statistically significant differences between performance of the 2 groups on the generic global rating scale (median 24 vs. 27, P = 0.031), though not on procedural or checklist-based scales. All scales demonstrated inter-rater reliability (α = 0.58–0.76), though only the global rating scales exhibited intertest reliability (α = 0.72). Conclusions:Video-based technical skills evaluation in the operating room is feasible, valid and reliable. Global rating scales hold promise for summative assessment, though further work is necessary to elucidate the value of procedural rating scales.

An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room

Objective:To assess the use of a synchronized video-based motion tracking device for objective, instant, and automated assessment of laparoscopic skill in the operating room. Summary Background Data:The assessment of technical skills is fundamental to recognition of proficient surgical practice. It is necessary to demonstrate the validity, reliability, and feasibility of any tool to be applied for objective measurement of performance. Methods:Nineteen subjects, divided into 13 experienced (performed >100 laparoscopic cholecystectomies) and 6 inexperienced (performed <10 LCs) surgeons completed LCs on 53 patients who all had a diagnosis of biliary colic. Each procedure was recorded with the ROVIMAS video-based motion tracking device to provide an objective measure of the surgeons dexterity. Each video was also rated by 2 experienced observers on a previously validated operative assessment scale. Results:There were significant differences for motion tracking parameters between the 2 groups of surgeons for the Calot triangle dissection part of procedure for time taken (P = 0.002), total path length (P = 0.026), and number of movements (P = 0.005). Both motion tracking and video-based assessment displayed intertest reliability, and there were good correlations between the 2 modes of assessment (r = 0.4 to 0.7, P < 0.01). Conclusions:An instant, objective, valid, and reliable mode of assessment of laparoscopic performance in the operating room has been defined. This may serve to reduce the time taken for technical skills assessment, and subsequently lead to accurate and efficient audit and credentialing of surgeons for independent practice.

Warm-up in a virtual reality environment improves performance in the operating room.

Objective:To assess the impact of warm-up on laparoscopic performance in the operating room (OR). Background:Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR. The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP. Methods:Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR. Participants were randomized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group. After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up. All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale (from 7 to 35). Results:There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up, median 28.5 (range = 18.5–32.0) versus median 19.25 (range = 15–31.5), P = 0.042. The results demonstrated excellent reliability of the assessment tool used (Cronbachs &agr; = 0.92). Conclusion:This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP. The suggested program is short, easy to perform, and therefore realistic to implement in the daily life in a busy surgical department. This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR resources.