Teodor P. Grantcharov

Randomized clinical trial of virtual reality simulation for laparoscopic skills training

This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy.

Effect of virtual reality training on laparoscopic surgery: randomised controlled trial

Objective To assess the effect of virtual reality training on an actual laparoscopic operation. Design Prospective randomised controlled and blinded trial. Setting Seven gynaecological departments in the Zeeland region of Denmark. Participants 24 first and second year registrars specialising in gynaecology and obstetrics. Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls). Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes. Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79. Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures. Trial registration ClinicalTrials.gov NCT00311792.

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.

Laparoscopic performance after one night on call in a surgical department: prospective study

The study was carried out in a gastroenterological surgical unit at a teaching hospital. A night shift started at 3 30 pm and finished at 9 am the following day. A total sleep time of less than three hours was necessary for inclusion in the study. All 14 surgeons in training at our department— 11 men and three women—participated in the study. The median age was 34 (range 24-43) and the median time since graduation was six years (1-11 years). All trainees had similar, limited experience in laparoscopic surgery; the median number of cholecystectomies they had performed was 0 (0–5). All participants received identical pretraining on the minimally invasive surgical trainer-virtual reality (MIST-VR, Mentice Medical Simulation, Gothenburg, Sweden) by performing nine repetitions of six tasks. 1 2 The laparoscopic surgical …

Teaching procedural skills.

“See one, do one” is not the best way to teach the complex technical procedures needed in many hospital based specialties

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.

Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills.

Introduction:Virtual reality (VR) simulation provides unique training opportunities. This study evaluates whether the deliberate practice (DP) can be successfully applied to simulated laparoscopic cholecystectomy (LC) for enhancement of the quality of surgical skills. Methods:Twenty-six inexperienced surgeons underwent a training program for LC on a VR simulator. Trainees were randomly allocated to 1 of 2 specific protocols of 10 sessions comprising a total of 20 LCs. For each session, the control group performed 2 LCs separated by 30 minutes of occupational activities; the DP group were assigned 30 minutes of DP activities in between 2 LCs. Each participant then performed 2 LCs on a cadaveric porcine model. Quantitative parameters were recorded from the simulator and a motion tracking device; qualitative assessment utilized validated rating scales. Results:Twenty-two subjects completed training. Learning curves on the VR simulator were significant for time taken and number of movements in both groups. The DP group was slower from the third LC (1373 vs. 872 seconds, P = 0.022) and utilized more movements from the seventh (942 vs. 701, P = 0.033). Global rating scores improved significantly in both groups over repeated LCs. The DP group revealed higher scores than control from tenth (19.5 vs. 14, P = 0.014) until the twentieth LC (22 vs. 16, P = 0.003). On the porcine model, the DP group also achieved higher global rating scores (25.5 vs. 19.5, P = 0.002). Conclusions:VR training improved dexterity for both groups, and led to transfer of skill onto a porcine LC model. The DP group achieved higher quality, and demonstrated superior transfer onto real tissues.

Can everyone achieve proficiency with the laparoscopic technique? Learning curve patterns in technical skills acquisition

BACKGROUND The study was carried out to determine the learning curve patterns for basic laparoscopic technical skills. METHODS Thirty-seven surgical residents with limited laparoscopic experience performed 10 repetitions of 6 tasks on a virtual-reality trainer (MIST-VR) with standardized distribution of practice. Assessment was based on time, errors, and economy of motion as measured by MIST-VR. Proficiency levels were established by testing experienced laparoscopic surgeons. RESULTS Four learning curve patterns were determined. Surgeons in group 1 (5.4%) demonstrated proficiency from the beginning; group 2 (70.3%) achieved predefined expert criteria between 2 and 9 repetitions; group 3 (16.2%) demonstrated improvement but was unable to achieve proficiency within 10 repetitions. Group 4 (8.1%) underperformed and showed no tendency of skills improvement, reflecting a group of subjects who probably are unable to learn laparoscopic technique. CONCLUSIONS The results indicated that a group of subjects could not reach proficiency in the psychomotor skills relevant for laparoscopy. We believe that this is an important issue that should be addressed in future research.