Enhancing clinical proficiency through laparoscopic training using Japanese origami

Objective This study aimed to investigate the clinical efficacy of laparoscopic training using origami,a traditional Japanese papercraft,using laparoscopic forceps to create origami cranes.Methods In this retrospective study,4 surgeons were randomly divided into 2 groups:The training group,consisting of surgeons 1 and 2,and the non-training group,consisting of surgeons 3 and 4.Over the course of a one-year study period,the training group regularly underwent laparoscopic surgery training with a dry box,wherein they folded a total of 1000 origami cranes using laparoscopic instruments.The non-training group periodically underwent common laparoscopic surgery training of techniques such as suturing and ligation.Each surgeon regularly performed the transabdominal preperitoneal approach for inguinal hernias.Each training was conducted concurrently with the surgeries.The procedure time(peritoneum detachment,mesh placement,and closure of the peritoneum),total operation time(time from peritoneum detachment to closure of the peritoneum),and surgical outcomes were examined.Results The training group showed greater improvement in the total operation time and more stable performance than the non-training group.Additionally,the time taken for peritoneum detachment was significantly shorter in the training group.Conclusion Laparoscopic training using origami has the potential to enhance laparoscopic surgical skills and improve surgical outcomes.

Towards engineering a portable platform for laparoscopic pre-training in virtual reality with haptic feedback

Background Laparoscopic surgery is a surgical technique in which special instruments are inserted through small incision holes inside the body.For some time,efforts have been made to improve surgical pre training through practical exercises on abstracted and reduced models.Methods The authors strive for a portable,easy to use and cost-effective Virtual Reality-based(VR)laparoscopic pre-training platform and therefore address the question of how such a system has to be designed to achieve the quality of today's gold standard using real tissue specimens.Current VR controllers are limited regarding haptic feedback.Since haptic feedback is necessary or at least beneficial for laparoscopic surgery training,the platform to be developed consists of a newly designed prototype laparoscopic VR controller with haptic feedback,a commercially available head-mounted display,a VR environment for simulating a laparoscopic surgery,and a training concept.Results To take full advantage of benefits such as repeatability and cost-effectiveness of VR-based training,the system shall not require a tissue sample for haptic feedback.It is currently calculated and visually displayed to the user in the VR environment.On the prototype controller,a first axis was provided with perceptible feedback for test purposes.Two of the prototype VR controllers can be combined to simulate a typical both-handed use case,e.g.,laparoscopic suturing.A Unity based VR prototype allows the execution of simple standard pre-trainings.Conclusions The first prototype enables full operation of a virtual laparoscopic instrument in VR.In addition,the simulation can compute simple interaction forces.Major challenges lie in a realistic real-time tissue simulation and calculation of forces for the haptic feedback.Mechanical weaknesses were identified in the first hardware prototype,which will be improved in subsequent versions.All degrees of freedom of the controller are to be provided with haptic feedback.To make forces tangible in the simulation,characteristic values need to be determined using real tissue samples.The system has yet to be validated by cross-comparing real and VR haptics with surgeons.

Understanding the effects of structured self-assessment in directed,self-regulated simulation-based training of mastoidectomy:A mixed methods study

Objective:Self-directed training represents a challenge in simulation-based training as low cognitive effort can occur when learners overrate their own level of performance.This study aims to explore the mechanisms underlying the positive effects of a structured self-assessment intervention during simulation-based training of mastoidectomy.Methods:A prospective,educational cohort study of a novice training program consisting of directed,self-regulated learning with distributed practice(5x3 procedures)in a virtual reality temporal bone simulator.The intervention consisted of structured self-assessment after each procedure using a rating form supported by small videos.Semi-structured telephone interviews upon completion of training were conducted with 13 out of 15 participants.Interviews were analysed using directed content analysis and triangulated with quantitative data on secondary task reaction time for cognitive load estimation and participants’self-assessment scores.Results:Six major themes were identified in the interviews:goal-directed behaviour,use of learning supports for scaffolding of the training,cognitive engagement,motivation from self-assessment,selfassessment bias,and feedback on self-assessment(validation).Participants seemed to self-regulate their learning by forming individual sub-goals and strategies within the overall goal of the procedure.They scaffolded their learning through the available learning supports.Finally,structured self-assessment was reported to increase the participants’cognitive engagement,which was further supported by a quantitative increase in cognitive load.Conclusions:Structured self-assessment in simulation-based surgical training of mastoidectomy seems to promote cognitive engagement and motivation in the learning task and to facilitate self-regulated learning.

A multi-screen collaboration-based low-cost portable dry-lab simulator for basic laparoscopic skills training: A technical note

Laparoscopic skills training has always been crucial for novice surgeons. Readily accessible equipment, aswell as structured training curriculum should be provided to guarantee adequate practice hours and skillproficiency. Dry-lab training is typically adopted before animal model surgery, usually comprising ofpurpose-built bulky simulators that is neither accessible nor portable. In this technical note, we designed ahome-made simulator, using two 4 L water jugs as operating space that are communicated inside, plus anobservation hole taped in between to mimic the triangular working space of laparoscopic surgery. Imagingwas achieved via smartphone camera, which was wirelessly connected to a laptop and a projector for realtime display on multiple screens, using built-in multi-screen collaboration software. A self-regulated andproficiency-based training curriculum was adopted. This dry-lab simulator is low-cost, highly portable andeasily replicable for basic laparoscopic skills training for the beginners to intermediate surgeons, whichmay serve as a good way for the standardized residency and specialist training program.

Practice,training and safety of laparoscopic surgery in low and middle-income countries

Surgical management of diseases is recognised as a major unmet need in low and middle-income countries(LMICs). Laparoscopic surgery has been present since the 1980 s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with highincome countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.

Performance in the Fundamentals of Laparoscopic Surgery: Does it reflect global rating scales in the Objective Structured Assessment of Technical Skills in porcine laparoscopic surgery?

Objective:To correlate the utility of the Fundamentals of Laparoscopic Surgery(FLS)manual skills program with the Objective Structured Assessment of Technical Skills(OSATS)global rating scale in evaluating operative performance.Methods:The Asian Urological Surgery Training and Educational Group(AUSTEG)Laparoscopic Upper Tract Surgery Course implemented and validated the FLS program for its usage in laparoscopic surgical training.Delegates’basic laparoscopic skills were assessed using three different training models(peg transfer,precision cutting,and intra-corporeal suturing).They also performed live porcine laparoscopic surgery at the same workshop.Live surgery skills were assessed by blinded faculty using the OSATS rating scale.Results:From March 2016 to March 2019,a total of 81 certified urologists participated in the course,with a median of 5 years of post-residency experience.Although differences in task time did not reach statistical significance,those with more surgical experience were visibly faster at completing the peg transfer and intra-corporeal suturing FLS tasks.However,they took longer to complete the precision cutting task than participants with less experience.Overall OSATS scores correlated weakly with all three FLS tasks(peg transfer time:r=0.331,r^(2)=0.110;precision cutting time:r=0.240,r^(2)=0.058;suturing with intracorporeal knot time:r=0.451,r^(2)=0.203).Conclusion:FLS task parameters did not correlate strongly with OSATS globing rating scale performance.Although FLS task models demonstrated strong validity,it is important to assimilate the inconsistencies when benchmarking technical proficiency against real-life operative competence,as evaluated by FLS and OSATS,respectively.

First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND Laparoscopic surgery has reduced morbidity and mortality rates,shorter post-operative recovery periods and lower complication rates than open surgery.It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources.However,introducing laparoscopic surgery in low-and-middle-income countries(LMIC)can be expensive and requires resour-ces,equipment,and trainers.AIM To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.METHODS MEDLINE,EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC.Included studies were published between 1996 and 2022 with full text available in English.Exclusion criteria were studies considering only open surgery,ear,nose,and throat,endoscopy,arthro-scopy,hysteroscopy,cystoscopy,transplant,or bariatric surgery.RESULTS Ten studies out of 3409 screened papers,from eight LMIC were eligible for inclusion in the final analysis,totaling 2497 patients.Most reported challenges were related to costs of equipment and training programmes,equipment pro-blems such as faulty equipment,and access to surgical kits.Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff.The benefits of introducing laparoscopic surgery were economic and clinical,including a reduction in hospital stay,complications,and morbidi-ty/mortality.The introduction of laparoscopic surgery also provided training opportunities for junior doctors.CONCLUSION Despite financial and technical challenges,many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients.While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported,more support is critically required,in particular regarding training.

Laparoscopic and robot-assisted laparoscopic digestivesurgery:Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Is There an Improvement in Patient Survival/Code Blue Activation after Training Based on Simulation (Basic Life Support—BLS) Based Practice of Cardiopulmonary Resuscitation?

Background and Aim: The only way to survive a sudden cardiac arrest is when the CPR is performed immediately after the arrest. The focus of the present research study is to assess the effectiveness of a pre- and post-simulation-based BLS training (BLS) and the outcome was measured on the basis of patient survival after the cardiac arrest. Study Design: This pre- and post-training BLS/CPR training study enrolled all nursing staff, all hospital residents, internees, throughout the hospital in a simulation-based BLS training as per the standards of American Heart Association (AHA), to make them respond to immediate resuscitation and code blue activation during the cardiac arrest within the hospital premises including ED, wards, ICUs, MRI, CT and all miscellaneous areas. The providers completed self-efficacy questionnaires as per the AHA protocol before being certified and were evaluated during the emergency in hospital cardiopulmonary arrest. Results: 296 nursing staff, 206 non-healthcare professionals, 143 residents, 212 internees, and 98 medical staff grade doctors completed the BLS training (total 955 hospital staff—providers) were graded for the response by pre- and post-training testing. In the course of pre-BLS training period out of the 250 cardiac arrest patients, 68 patients (27.2%) had ROSC, while after instituting the BLS training period, 143 individuals (40.86%) of the 350 patients who had cardiac arrest had ROSC (p < 0.05). Conclusion: A simulation-based CPR and BLS training curriculum greatly improves patient outcome by reducing mortality and morbidity with improved subjectivity, self-efficiency along with the objective assessment of the performance scores during acute cardiac arrest in Emergency Cardiovascular Care (ECC).

Usefulness of Detailed Analysis with Operative Procedure of Total Laparoscopic Hysterectomy (TLH) Done a Single Surgeon, to Master the Surgical Technique of TLH and Gain Higher Proficiency

Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysis of women who underwent TLH for benign diseases between April, 2014 and March, 2016 was conducted by a single surgeon in a single hospital (Showa University of Fujigaoka Hospital). We divided the main procedures of the TLH operation into five sections, and measured the time required for each section. These cases were divided into three groups, group 1, 2, and 3. Results: There were 54 cases of TLH over two years for a single surgeon, and 21 cases that included essential operative procedures were divided into three groups of seven cases each. The average duration of the surgery (min.) was 178.3 ± 48.2 in the group 1, 128.3 ± 15.6 in the group 2, and 111.3 ± 15.9 in the group 3. A significant reduction in the required time was observed between group 1, 2, and 3 groups. As the number of cases increased, the operation time became statistically significantly shorter for every section except B and D. The skill growth rate was different at each section. Conclusion: For a single surgeon, as the number of surgical cases increased, we recognized the increased skill with the procedure in every section and the rate of skill growth differed for different sections. The difference of growth rate for each section implied that the number of operative cases required for a surgeon in each section was different.

The Relationship between Presence and Performance in Virtual Simulation Training

The use of virtual simulation-based training continues to expand, as organizations explore alternative methods to reduce the cost of training. While virtual simulation has been empirically validated to be effective in the transfer of skills to the live environment, what is still unknown is what effect, if any, that an individual’s sense of presence in the simulation has on their performance. In this paper, we examine the relationship between presence and performance while performing a psychomotor task in a virtual environment. The independent variables were visual display and expertise level. The dependent variables were presence and performance. We found evidence of a moderate relationship between the degree of presence experienced in the simulation and an individual’s performance over three training trials. Results of this study may inspire future research to investigate whether higher presence in virtual simulation results in higher performance.

Performance of single versus two operators in laparoscopic surgery

Aim:To examine the significance of team collaboration in the context of complex laparoscopic surgery,laparoscopic tasks performed by single operators are compared against that of dyad teams.Methods:The laparoscopic tasks require subjects to reach,grasp and transport a ring through a rollercoaster obstacle using a pair of laparoscopic graspers.The task was performed either bimanually(using both hands)or unimanually(using their preferred hands)in a dyad team.Results:Twelve participants completed all the tasks.The dyad teams recorded significantly greater number of anticipatory movements than individuals who performed the task bimanually(p<0.05).However,there is no significant difference in the task completion time(p=0.701)and the number of errors(p=0.860)recorded between the dyad and the bimanual group.Conclusion:Compared to a single operator,dyad operators performed the task with greater number of anticipatory movements.The increased movement synchronization can help benefit surgical education and team training.

Direct Instruction by an Experienced Surgeon Can Shorten the Learning Curve for Laparoscopic-Assisted Distal Gastrectomy

Aim: Laparoscopy-assisted distal gastrectomy (LADG) with regional lymph node dissection is a treatment option for patient with early gastric cancer. However, LADG is a technically complex and advanced procedure, which is challenging for inexperienced surgeons. In this report, we retrospectively evaluated the learning curve for LADG of a single surgeon with no previous experience in LADG and the usefulness of direct instruction by a surgeon experienced in LADG in shortening the learning curve. Patients and Methods: This study was analyzed 80 consecutive patients, who underwent LADG by a single surgeon (first assistant in 10 cases and operator in 70 cases) between January 2008 and December 2012. Patients were divided into 3 sequential groups of 10 (training period), 30 (learning period), and 40 (operating period) cases in each group. Median operation time and estimated blood loss for these 3 groups were determined. Other learning indicators, including transfusion requirement, postoperative complications, number of lymph node harvested, and rate of conversion open gastrectomy, were also evaluated. Results: During the training period, median operation time and estimated blood loss were 219.5 min and 83.0 ml, respectively. During the learning period, the operation time was significantly longer than that of training period. In the operating period, the operation time was significantly lesser than that during the learning period. However, the operation time was not different from that during the training period and reached a plateau. The estimated blood loss during the operating period was significantly lesser than that during the learning period. The difference in the number of lymph nodes retrieved between each group was not significant. Conclusions: Direct instructions by an experienced surgeon can decrease the number of cases required for learning. Because LADG is technically more complex than other laparoscopic procedures, standardization of LADG and an effective training system for performing it should be established.

Laparoscopic training of urology in China： current status

B eginning in the early 1990s, to an established technique laparoscopy has evolved for the management of many urological diseases including difficult and advanced procedure. As we know, laparoscopy does require a set of skills much different from those of open surgery, among them are reduced depth perception, loss of haptic feedback, restrictive freedom of movement, and requirement of a video-eye-hand coordination. The learning curve for many laparoscopic procedures is steep and laparoscopic-skill acquisition is in fact more difficult than that for open surgery, which further validates the need for training.

Gallbladder Removal Simulation for Laparoscopic Surgery Training: A Hybrid Modeling Method

Laparoscopic surgery has many advantages, but it is difficult for a surgeon to achieve the necessary surgical skills. Recently, virtual training simulations have been gaining interest because they can provide a safe and efficient learning environment for medical students and novice surgeons. In this paper, we present a hybrid modeling method for simulating gallbladder removal that uses both the boundary element method （BEM） and the finite element method （FEM）. Each modeling method is applied according to the deformable properties of human organs： BEM for the liver and FEM for the gallbladder. Connective tissues between the liver and the gallbladder are also included in the surgical simulation. Deformations in the liver and the gallbladder models are transferred via connective tissue springs using a mass-spring method. Special effects and techniques are developed to achieve realistic simulations, and the software is integrated into a custom-designed haptic interface device. Various computer graphical techniques are also applied in the virtual gallbladder removal laparoscopic surgery training. The detailed techniques and the results of the simulations are described in this paper.

进阶整合二段式腹腔镜模拟培训课程在外科住院医师规范化培训中的应用探讨

目的:探讨采取进阶整合二段式腹腔镜模拟培训课程在外科住院医师规范化培训中的可行性及课程设计的合理性。方法:2019年12月至2021年12月于我院进行规范化培训的2019—2020级外科住院医师中开展进阶整合二段式腹腔镜模拟培训课程。课程分为2个阶段。一阶段BEST课程(best essential surgical technique train‐ing)采用达尔文^(■)腔镜培训系统、天堰^(■)腔镜培训系统、微创医疗^(■)3D腹腔镜以及简易模具进行培训。二阶段BEST PLUS课程采用一阶段培训系统及动物离体模型进行培训。采取问卷调查法(课前与课后问卷)对课程形式、课程使用模具、教师授课方式、课程时间安排、课程内容难度、课程培训效果和课程满意度等课程设置进行评价。结果:总共37位外科住院医师完成两阶段课程培训并完成调查问卷。对于课程设计安排的总体满意率为100%,认为一阶段课程显著提高临床水平的有32人(86.5%),认为二阶段课程对临床水平有显著提高的有35人(94.6%),认为一阶段课程对二阶段课程有显著帮助的有36人(97.3%)。结论:接受培训的外科住院医师课后对进阶整合二段式腹腔镜模拟培训课程的认可度高,该课程整体设计合理且可行,对于外科住院医师具有吸引力。

互联网+微格教学法结合复盘教学方式在外科腹腔镜技能培训中的应用

目的:探讨互联网+微格教学法结合复盘教学方式在外科腹腔镜技能培训的应用效果。方法:选取在本院普通外科进行住院医师规范化培训且既往未受过其他腹腔镜培训的2020级学员30名,随机分为对照组及试验组,每组15人。对照组依照传统培训方式进行技能培训,试验组采用互联网+微格教学法结合复盘教学方式进行培训。分别于培训初始时,培训第8周对两组学员进行操作考核,所有培训结束后对两组学员进行满意度调查。分析两组学员的考核成绩以及教学满意度调查结果。结果:每个模块的考核成绩试验组均明显优于对照组(P<0.001);满意度方面,试验组在培训的教学方式、培训内容的兴趣程度、课程氛围、提升腔镜技能水平、学习成就感层面结果优于对照组(P<0.05)。结论:互联网+微格教学法结合复盘教学方式可以有效地提高学员腹腔镜技能操作水平,提升学员的学习兴趣,培养其主动学习能力,是值得应用的教学方法。

基于磁牵引术野暴露系统与真实脏器腔镜训练系统的梯度化腹腔镜手术教学体系建立与实践

腹腔镜手术教学一直是外科教学中的薄弱环节,而腔镜外科的迅猛发展使得构建真实、高效、医师职业生涯全覆盖的梯度化腹腔镜手术教学体系迫在眉睫。西安交通大学第一附属医院肝胆外科针对青年医师腔镜技术的培养与提高,联合真实脏器腔镜训练系统、磁牵引术野暴露系统的研发、转化单位,共同构建了基于磁牵引术野暴露系统与真实脏器腔镜训练系统的梯度化腹腔镜手术教学体系。该教学体系共包含6个阶段,能够满足青年医师从新手到主刀全过程的培训需求,符合由浅入深、由易到难的教学原则。借助该梯度化腹腔镜手术教学体系,已有48名医师完成腹腔镜技术的培训与进阶,获得了良好教学效果,并得到临床专家的好评。

腹腔镜手术视频教学在妇产科住院医师规范化培训中的应用效果

目的探讨腹腔镜手术视频教学在妇产科住院医师规范化培训(简称“住培”)中的作用,以提高教学质量和效果。方法选取2023年7—12月在苏州大学附属第一医院妇产科专业在院参加住培的住院医师42名,以双盲随机抽签的方法纳入传统教学组(n=20)和视频教学组(n=22),分别采用PPT教学结合典型临床病例的方式和手术视频结合典型临床病例的方式进行教学。对两组进行理论考核和临床实践考核,同时进行教学效果满意度调查。结果视频教学组学员在基本技能操作、专科技能操作、辅助检查结果判读、报告分析和临床思维与决策能力方面的成绩均高于传统教学组,差异有统计学意义(P<0.05);两组理论成绩、接诊和医疗文书书写成绩比较,差异无统计学意义(P>0.05)。视频教学组学员对教学过程的满意度为100.00%,高于传统教学组的90.00%,差异有统计学意义(P<0.05)。结论腹腔镜手术视频教学方法能够使住培医师的基本技能操作、专科技能操作、辅助检查结果判读、报告分析和临床思维与决策方面的能力得到提升,并提高了妇产科住培教学过程的满意度,值得进一步探索与推广。

早期康复训练对泌尿外科腹腔镜手术后患者的应用价值

目的 探讨泌尿外科腹腔镜手术后患者实施早期康复训练的效果。方法 72例接受泌尿外科腹腔镜手术治疗的患者,随机分为对照组和观察组,每组36例。对照组给予常规护理,观察组在此基础上给予早期康复训练。比较两组患者术后时间指标、并发症发生情况、满意度。结果 观察组患者的术后排气时间、进食时间、下床时间和住院时间分别为(22.42±3.75)h、(29.33±4.87)h、(20.17±6.44)h、(7.62±1.14)d,均显著短于对照组的(28.61±4.31)h、(36.52±5.23)h、(28.25±5.66)h、(9.82±1.35)d,差异有统计学意义(P<0.05)。观察组患者的并发症发生率为5.56%,显著低于对照组的22.22%,差异有统计学意义(P<0.05)。观察组患者的满意度为97.22%,显著高于对照组的80.56%,差异有统计学意义(P<0.05)。结论 对泌尿外科腹腔镜手术后患者实施早期康复训练,可以加快术后康复速度,减少并发症的发生,提升满意度,是一种具有较高临床价值的方法。