Development, validation, and implementation of a cost-effective intermediate-level proficiency-based knot-tying and suturing curriculum for surgery residents.

BACKGROUND: The purpose of this study was to develop an intermediate-level proficiency-based knot-tying and suturing curriculum, evaluate construct validity, determine feasibility, document educational benefit, and quantify cost-effectiveness of implementation within a surgery residency program. METHODS: Six tasks with standardized metrics were developed using commercially available bench models; 39 PGY-1 surgery residents were enrolled in a 2-month curriculum (orientation/pre-test, self-practice, and a proctored post-test). Baseline trainee and expert performance were compared to assess construct validity. RESULTS: Baseline trainee and expert performance were significantly different (451 ± 83 vs 644 ± 10, p < 0.001), supporting construct validity. All trainees achieved proficiency during self-practice, completing 30 ± 17 repetitions over 3.4 ± 3.8 hours. Significant differences were detected between baseline and final trainee composite scores (451 ± 83 vs 607 ± 34, p < 0.001). CONCLUSIONS: Implementation of this curriculum was feasible and cost-effective. Construct validity and educational benefit in terms of skill acquisition were demonstrated. The purpose of this study was to develop an intermediate-level proficiency-based knot-tying and suturing curriculum, evaluate construct validity, determine feasibility, document educational benefit, and quantify cost-effectiveness of implementation within a robust surgery residency training program.

Developing a comprehensive, proficiency-based training program for robotic surgery.

INTRODUCTION: Robotically assisted surgery has become very popular for numerous surgical disciplines, yet training practices remain variable with little to no validation. The purpose of this study was to develop a comprehensive, proficiency-based robotic training program. METHODS: A skill deconstruction list was generated by observation of robotic operations and interviews with experts. Available resources were used, and other components were developed as needed to develop a comprehensive, proficiency-based curriculum to teach all deconstructed skills. Preliminary construct and content validity and curriculum feasibility were evaluated. RESULTS: The skill deconstruction list contained 23 items. Curricular components included an online tutorial, a half-day interactive session, and 9 inanimate exercises with objective metrics. Novice (546 ± 26) and expert (923 ± 60) inanimate composite scores were different (P < .001), supporting construct validity, and substantial pre-test to post-test improvement was noted after successful training completion. All 23 deconstructed skills were rated as highly relevant (4.9 ± 0.5; 5-point scale), and no skills were absent from the curriculum, supporting content validity. CONCLUSION: These data suggest that this proficiency-based training curriculum comprehensively addresses the skills necessary to perform robotic operations with early construct and content validity and feasibility demonstrated. Further validation is encouraged.

Magnetically anchored cautery dissector improves triangulation, depth perception, and workload during single-site laparoscopic cholecystectomy.

INTRODUCTION: This study evaluated operative outcomes and workload during single-site laparoscopy (SSL) using a magnetically anchored cautery dissector (MAGS) compared with a conventional laparoscopic hook cautery (LAP). METHODS: Each cautery was used to perform six SSL porcine cholecystectomies. For MAGS, the cautery device was inserted through the umbilical incision, magnetically coupled, and deployed; two graspers and a laparoscope were used. For LAP, two percutaneous retraction sutures, one grasper, a hook cautery dissector, and a laparoscope were used. Operative outcomes, surgeon ratings (scale, 1-5; 1 = superior), and workload (scale, 1-10; 1 = superior) were evaluated. RESULTS: No significant differences were detected for operative outcomes and surgeon ratings, however, trends were detected favoring MAGS. Surgeon workload ratings were significantly better for MAGS (2.6 ± 0.2) vs. LAP (5.6 ± 1.1; p < 0.05). For MAGS, depth perception and triangulation were excellent and the safe handling protocol was followed with no complications. For LAP, the parallelism of instruments and lack of triangulation hindered depth perception, caused instrument conflicts, and resulted in two minor complications (one superficial liver laceration and one inadvertent burn to the diaphragm). CONCLUSION: These data suggest that using the MAGS device for SSL cholecystectomy results in equivalent (or better) operative outcomes and less workload compared with LAP.

Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy.

BACKGROUND: This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques. METHODS: Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1 = superior), workload (1-10 scale; 1 = superior), and global impressions (1-10 scale; 10 = superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant. RESULTS: The operative outcomes were similar except for significantly higher blood loss with SSL (16.3 ± 10.3) versus LAP (2.8 ± 1.5; p < 0.05) but not with MAGS/PSS (4.8 ± 3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3 ± 2.8 mm) and SSL (29.3 ± 2.5 mm) than with LAP (48.0 ± 3.6 mm; p < 0.05). Compared with SSL (3.6 ± 0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8 ± 0.4) and LAP (1.7 ± 0.2; p < 0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3 ± 1.0 and 3.8 ± 0.5, respectively) versus LAP (1.5 ± 0.6 and 2.0 ± 0.8, respectively; p < 0.05) but not with MAGS/PSS (2.5 ± 1.0 and 3.0 ± 0.8, respectively). Both MAGS/PSS (4.5 ± 0.5) and SSL (4.8 ± 1.0) were associated with a significantly greater workload than LAP (2.5 ± 0.6; p < 0.05). Global impression ratings were significantly higher for LAP (8.7 ± 1.3) versus SSL (5.8 ± 2.0; p < 0.05) but not for MAGS/PSS (7.1 ± 1.8). Cosmesis was significantly better with MAGS/PSS (9.5 ± 0.6) versus LAP (6.5 ± 2.4; p < 0.05) but not with SSL (8.8 ± 1.3). CONCLUSION: The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.

Comprehensive proficiency-based inanimate training for robotic surgery: reliability, feasibility, and educational benefit.

BACKGROUND: We previously developed a comprehensive proficiency-based robotic training curriculum demonstrating construct, content, and face validity. This study aimed to assess reliability, feasibility, and educational benefit associated with curricular implementation. METHODS: Over an 11-month period, 55 residents, fellows, and faculty (robotic novices) from general surgery, urology, and gynecology were enrolled in a 2-month curriculum: online didactics, half-day hands-on tutorial, and self-practice using nine inanimate exercises. Each trainee completed a questionnaire and performed a single proctored repetition of each task before (pretest) and after (post-test) training. Tasks were scored for time and errors using modified FLS metrics. For inter-rater reliability (IRR), three trainees were scored by two raters and analyzed using intraclass correlation coefficients (ICC). Data from eight experts were analyzed using ICC and Cronbach's α to determine test-retest reliability and internal consistency, respectively. Educational benefit was assessed by comparing baseline (pretest) and final (post-test) trainee performance; comparisons used Wilcoxon signed-rank test. RESULTS: Of the 55 trainees that pretested, 53 (96 %) completed all curricular components in 9-17 h and reached proficiency after completing an average of 72 ± 28 repetitions over 5 ± 1 h. Trainees indicated minimal prior robotic experience and "poor comfort" with robotic skills at baseline (1.8 ± 0.9) compared to final testing (3.1 ± 0.8, p < 0.001). IRR data for the composite score revealed an ICC of 0.96 (p < 0.001). Test-retest reliability was 0.91 (p < 0.001) and internal consistency was 0.81. Performance improved significantly after training for all nine tasks and according to composite scores (548 ± 176 vs. 914 ± 81, p < 0.001), demonstrating educational benefit. CONCLUSION: This curriculum is associated with high reliability measures, demonstrated feasibility for a large cohort of trainees, and yielded significant educational benefit. Further studies and adoption of this curriculum are encouraged.

Proficiency-based training for robotic surgery: construct validity, workload, and expert levels for nine inanimate exercises.

BACKGROUND: We previously developed nine inanimate training exercises as part of a comprehensive, proficiency-based robotic training curriculum that addressed 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to evaluate construct validity, workload, and expert levels for the nine exercises. METHODS: Expert robotic surgeons (n = 8, fellows and faculty) and novice trainees (n = 4, medical students) each performed three to five consecutive repetitions of nine previously reported exercises (five FLS models with or without modifications and four custom-made models). Each task was scored for time and accuracy using modified FLS metrics; task scores were normalized to a previously established (preliminary) proficiency level and a composite score equaled the sum of the nine normalized task scores. Questionnaires were administered regarding prior experience. After each exercise, participants completed a validated NASA-TLX Workload Scale to rate the mental, physical, temporal, performance, effort, and frustration levels of each task. RESULTS: Experts had performed 119 (range = 15-600) robotic operations; novices had observed ≤ 1 robotic operation. For all nine tasks and the composite score, experts achieved significantly better performance than novices (932 ± 67 vs. 618 ± 111, respectively; P < 0.001). No significant differences in workload between experts and novices were detected (32.9 ± 3.5 vs. 32.0 ± 9.1, respectively; n.s.). Importantly, frustration ratings were relatively low for both groups (4.0 ± 0.7 vs. 3.8 ± 1.6, n.s.). The mean performance of the eight experts was deemed suitable as a revised proficiency level for each task. CONCLUSION: Using objective performance metrics, all nine exercises demonstrated construct validity. Workload was similar between experts and novices and frustration was low for both groups. These data suggest that the nine structured exercises are suitable for proficiency-based robotic training.

Construct and face validity of the American College of Surgeons/Association of Program Directors in Surgery laparoscopic troubleshooting team training exercise.

BACKGROUND: Our aim was to develop an objective scoring system and evaluate construct and face validity for a laparoscopic troubleshooting team training exercise. METHODS: Surgery and gynecology novices (n = 14) and experts (n = 10) participated. Assessments included the following: time-out, scenario decision making (SDM) score (based on essential treatments rendered and completion time), operating room communication assessment (investigator developed), line operations safety audits (teamwork), and National Aeronautics and Space Administration-Task Load Index (workload). RESULTS: Significant differences were detected for SDM scores for scenarios 1 (192 vs 278; P = .01) and 3 (129 vs 225; P = .004), operating room communication assessment (67 vs 91; P = .002), and line operations safety audits (58 vs 87; P = .001), but not for time-out (46 vs 51) or scenario 2 SDM score (301 vs 322). Workload was similar for both groups and face validity (8.8 on a 10-point scale) was strongly supported. CONCLUSIONS: Objective decision-making scoring for 2 of 3 scenarios and communication and teamwork ratings showed construct validity. Face validity and participant feedback were excellent.

A randomized comparison of laparoscopic, magnetically anchored, and flexible endoscopic cameras in performance and workload between laparoscopic and single-incision surgery.

BACKGROUND: This study aimed to evaluate the surgeon performance and workload of a next-generation magnetically anchored camera compared with laparoscopic and flexible endoscopic imaging systems for laparoscopic and single-site laparoscopy (SSL) settings. METHODS: The cameras included a 5-mm 30° laparoscope (LAP), a magnetically anchored (MAGS) camera, and a flexible endoscope (ENDO). The three camera systems were evaluated using standardized optical characteristic tests. Each system was used in random order for visualization during performance of a standardized suturing task by four surgeons. Each participant performed three to five consecutive repetitions as a surgeon and also served as a camera driver for other surgeons. Ex vivo testing was conducted in a laparoscopic multiport and SSL layout using a box trainer. In vivo testing was performed only in the multiport configuration and used a previously validated live porcine Nissen model. RESULTS: Optical testing showed superior resolution for MAGS at 5 and 10 cm compared with LAP or ENDO. The field of view ranged from 39 to 99°. The depth of focus was almost three times greater for MAGS (6-270 mm) than for LAP (2-88 mm) or ENDO (1-93 mm). Both ex vivo and in vivo multiport combined surgeon performance was significantly better for LAP than for ENDO, but no significant differences were detected for MAGS. For multiport testing, workload ratings were significantly less ex vivo for LAP and MAGS than for ENDO and less in vivo for LAP than for MAGS or ENDO. For ex vivo SSL, no significant performance differences were detected, but camera drivers rated the workload significantly less for MAGS than for LAP or ENDO. CONCLUSION: The data suggest that the improved imaging element of the next-generation MAGS camera has optical and performance characteristics that meet or exceed those of the LAP or ENDO systems and that the MAGS camera may be especially useful for SSL. Further refinements of the MAGS camera are encouraged.