W. Jeroen Meijerink

Voluntary autonomous simulator based training in minimally invasive surgery, residents' compliance and reflection

BACKGROUND Knot tying and suturing skills in minimally invasive surgery (MIS) differ markedly from those in open surgery. Appropriate MIS training is mandatory before implementation into practice. The Advanced Suturing Course (ASC) is a structured simulator based training course that includes a 6-week autonomous training period at home on a traditional laparoscopic box trainer. Previous research did not demonstrate a significant progress in laparoscopic skills after this training period. This study aims to identify factors determining autonomous training on a laparoscopic box trainer at home. METHODS Residents (n = 97) attending 1 of 7 ASC courses between January 2009 and June 2011 were consecutively included. After 6 weeks of autonomous, training a questionnaire was completed. A random subgroup of 30 residents was requested to keep a time log. All residents received an online survey after attending the ASC. We performed outcome comparison to examine the accuracy of individual responses. RESULTS Out of 97 residents, the main motives for noncompliant autonomous training included a lack of (training) time after working hours (n = 80, 83.3%), preferred practice time during working hours (n = 76, 31.6%), or another surgical interest than MIS (n = 79, 15.2%). Previously set training goals would encourage autonomous training according to 27.8% (n = 18) of residents. Thirty participants submitted a time log and reported an average 76.5-minute weekly training time. All residents confirmed that autonomous home practice on a laparoscopic box trainer is valuable. CONCLUSIONS Autonomous practice should be structured and inclusive of adequate and sufficient feedback points. A minimally required practice time should be set. An obligatory assessment, including corresponding consequence should be conducted. Compliance herewith may result in increased voluntary (autonomous) simulator based (laparoscopic) training by residents.

Validation of a new box trainer-related tracking device: the TrEndo

BackgroundThere is an increasing demand for structured objective ex vivo training and assessment of laparoscopic psychomotor skills prior to implementation of these skills in practice. The aim of this study was to establish the internal validity of the TrEndo, a motion-tracking device, for implementation on a laparoscopic box trainer.MethodsFace validity and content validity were addressed through a structured questionnaire. To assess construct validity, participants were divided into an expert group and a novice group and performed two basic laparoscopic tasks. The TrEndo recorded five motion analysis parameters (MAPs) and time.ResultsParticipants demonstrated a high regard for face and content validity. All recorded MAPs differed significantly between experts and novices after performing a square knot. Overall, the TrEndo correctly assigned group membership in 84.7 and 95.7% of cases based on two laparoscopic tasks.ConclusionFace, content, and construct validities of the TrEndo were established. The TrEndo holds real potential as a (home) training device.

Open knot‐tying skills: Resident skills assessed

Open knot‐tying and suturing skills are fundamental surgical skills, founding many alternative knot‐tying techniques. It is therefore mandatory for residents to possess adequate basic open knot‐tying skills. The aim of this study was to compare an objective assessment of open knot‐tying skills by residents to a residents own estimation of his or her knot‐tying skills, before and after a knot‐tying course.

Assessing pre- and postoperative activity levels with an accelerometer: a proof of concept study

BackgroundPostoperative recovery after abdominal surgery is measured mostly based on subjective or self-reported data. In this article we aim to evaluate whether recovery of daily physical activity levels can be measured postoperatively with the use of an accelerometer.MethodsIn this multicenter, observational pilot study, 30 patients undergoing laparoscopic abdominal surgery (hysterectomy, adnexal surgery, cholecystectomy and hernia inguinal surgery) were included. Patients were instructed to wear an Actigraph wGT3X-BT accelerometer during one week before surgery (baseline) and during the first, third and fifth week after surgery. Wear time, steps taken and physical activity intensity levels (sedentary, light, moderate and vigorous) were measured. Patients were blinded for the accelerometer outcomes. Additionally, an activity diary comprising patients’ self-reported time of being recovered and a list of 18 activities, in which the dates of resumption of these 18 activities were recorded after surgery, was completed by the patient.ResultsFive patients were excluded from analyses because of technical problems with the accelerometer (n = 1) and protocol non-adherence (n = 4). Light, moderate, vigorous, combined moderate and vigorous intensity physical activity (MVPA), and step counts showed a clear recovery curve after surgery. Patients who underwent minor surgery reached their baseline step count and MVPA three weeks after surgery. Patients who underwent intermediate surgery had not yet reached their baseline step count during the last measuring week (five weeks after surgery). The results of the activity diaries showed a fair agreement with the accelerometer results (Cohens Kappa range: 0.273-0.391). Wearing the accelerometer was well tolerated and not regarded as being burdensome by the patients.ConclusionsThe accelerometer appeared to be a feasible way to measure recovery of postoperative physical activity levels in this study and was well tolerated by the patients. The agreement with self-reported physical recovery times was fair.

Objective versus subjective assessment of laparoscopic skill

Background. The equality of subjective- and objective-assessment methods in laparoscopic surgery are unknown. The aim of this study was to compare a subjective assessment method to an objective assessment method to evaluate laparoscopic skill. Methods. A prospective observational cohort study was conducted. Seventy-two residents completed a basic laparoscopic suturing task on a box trainer at two consecutive assessment points. Laparoscopic skill was rated subjectively using the Objective Structured Assessment of Technical Skills (OSATS) list and objectively using the TrEndo, an augmented-reality simulator. Results. TrEndo scores between the two assessment points correlated. OSATS scores did not correlate between the two assessment points. There was a correlation between TrEndo and OSATS scores at the first assessment point, but not at the second assessment point. Overall, OSATS scores correlated with TrEndo scores. There was a greater spread within OSATS scores compared to TrEndo scores. Conclusion. OSATS scores correlated with TrEndo scores. The TrEndo may be more responsive at rating individual’s laparoscopic skill, as demonstrated by a smaller overall spread in TrEndo scores. The additional value of objective assessment methods over conventional assessment methods as provided by laparoscopic simulators should be investigated.

Learning curve on the TrEndo laparoscopic simulator compared to an expert level

BackgroundThe aim of this study was to determine growth in trainee laparoscopic skill as recorded by the TrEndo laparoscopic simulator during a laparoscopic training course, compared to an expert level.MethodsA prospective observational cohort study was conducted between February 1 and November 31, 2010. Trainees in laparoscopic surgery completed a basic laparoscopic suturing task on a laparoscopic box trainer at three successive assessment points during a laparoscopic training course. Experts were assessed only once to define an expert level. The TrEndo recorded four motion analysis parameters (MAPs) individually for each hand and the amount of time taken to complete the suturing task.ResultsSeventy-two residents and 56 experts were included in this study. Overall, the amount of time taken on the suturing task and seven out of eight MAPs significantly increased toward an expert level during the course, representing an improvement in task efficiency. During the first training day, the amount of time spent on the suturing task and five out of eight MAPs improved significantly. After the retention period, five out of eight MAPS demonstrated a significant improvement compared to the end of the first training day.ConclusionsLaparoscopic skill of trainees as recorded by the TrEndo laparoscopic simulator grows toward an expert level during a laparoscopic training course in a large and heterogeneous study group. Construct validity of the TrEndo is established.

Prevention and Treatment of Major Complications After Laparoscopic Ileocecal and Right Colectomy

Laparoscopic colorectal surgery has been demonstrated to have superior outcome with earlier return of bowel function, decreased postoperative pain, shorter hospital admission, decreased morbidity, and favorable long-term outcome. Laparoscopic ileocecal or right hemicolectomy is generally considered as one of the easiest to perform laparoscopic colectomies. Presumed easy access to vascular structures and presumed little danger of damage to adjacent organs and structures contribute to this conviction. But most experienced laparoscopic surgeons agree that a right hemicolectomy is not an easy procedure. A bulky colon, proximity of a right ureter, the duodenum, and a complex venous vascular structure when dissecting the transverse colon and omentum can make an ileocecal or right hemicolectomy to a real challenge, especially in the presence of a large malignancy, inflammation as seen in Crohn’s colitis, or a complicated appendicitis.