Looking forward.

With the rapid acceleration of technology, fundamental changes in the science of surgery are emerging within the lifetime of a surgeon's practice. This review includes the technologies of information systems, robotics, virtual reality, simulation and training, directed-energy surgical instruments, photonics, and brain chips, as well as their impact on the practice of surgery. Also considered are those technologies that may replace surgery, such as genetic engineering, tissue engineering, suspended animation, and nanotechnology. The evidence for each of these technologies is presented as preliminary reports of their success in research laboratories.

The nature of surgical error: a cautionary tale and a call to reason.

Errors and "patient safety" have taken on monumental importance for surgery. Like all things new, there is an initial over-reaction before a return to a balanced perspective. The current response to the global interest in error has been to seize on the latest reports that are focusing on the "systemic nature" of errors, which is also being referred to as "the new look." There has been an unintentional ignoring of the actual error, referred to as the coface error, that the surgeon commits. It is time to put the approach to errors into perspective and redefine errors within the context of the surgical community, which can result in a balance of the surgeon's position in regard to systemic and personal responsibility.

Analysis of errors in laparoscopic surgical procedures.

BACKGROUND: The determination of laparoscopic surgeon ability is essential to training error avoidance. The present study describes a practical method of surgical error analysis. METHODS: After review of practice videotapes of the excisional phase of laparoscopic cholecystectomy, consensus on the identification of eight errors was achieved. Interrater agreement at the end of this phase was 84-96%. Fourteen study videotapes of gallbladder excision were then observed independently by expert reviewers blinded to surgical team identity. Procedures were assessed using a scoring matrix of 1-min segments with each error reported each minute. RESULTS: Interrater agreement was 84-100% for all error categories. CONCLUSIONS: The present study demonstrates that excellent interrater agreement of procedural errors can be achieved by carefully defining and training recognition of targeted events. Extension of this simple and reliable analysis tool to other procedures should be feasible to define behaviors leading to adverse clinical outcomes.

Discriminative validity of the Minimally Invasive Surgical Trainer in Virtual Reality (MIST-VR) using criteria levels based on expert performance.

BACKGROUND: Increasing constraints on the time and resources needed to train surgeons have led to a new emphasis on finding innovative ways to teach surgical skills outside the operating room. Virtual reality training has been proposed as a method to both instruct surgical students and evaluate the psychomotor components of minimally invasive surgery ex vivo. METHODS: The performance of 100 laparoscopic novices was compared to that of 12 experienced (>50 minimally invasive procedures) and 12 inexperienced (<10 minimally invasive procedures) laparoscopic surgeons. The values of the experienced surgeons' performance were used as benchmark comparators (or criterion measures). Each subject completed six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) three times. The outcome measures were time to complete the task, number of errors, economy of instrument movement, and economy of diathermy. RESULTS: After three trials, the mean performance of the medical students approached that of the experienced surgeons. However, 7-27% of the scores of the students fell more than two SD below the mean scores of the experienced surgeons (the criterion level). CONCLUSIONS: The MIST-VR system is capable of evaluating the psychomotor skills necessary in laparoscopic surgery and discriminating between experts and novices. Furthermore, although some novices improved their skills quickly, a subset had difficulty acquiring the psychomotor skills. The MIST-VR may be useful in identifying that subset of novices.

Disruptive visions: surgical education.

Technological change, decreased financial support for medical education, and social oversight (in the form of the "To Err Is Human" report, HIPPA, and reduced work hours) are forcing a rethinking of the traditional model of surgical education to improve patient safety. New approaches to evaluating surgical competence, such as objective assessment, in combination with new technologies, such as the Internet and surgical simulators, provide the tools to effect a revolution in surgical education and training. Competency based upon quantifiable criteria measures must replace the traditional subjective assessment. The implementation requires accurately defining the elements of training, establishing new quantifiable metrics, stringently measuring performance against criterion, and reporting outcomes throughout the career of a surgeon.

Disruptive visions: a robot is not a machine...systems integration for surgeons.

The discipline of surgery has become even more complex with the rapid introduction of revolutionary technologies. Laparoscopic surgery is just the simplest and first of these new directions. Robotic surgery and image-guided therapy are the next generation. As biosurgery and other modalities are introduced, the complexity will increase exponentially. In order to understand and utilize the new technologies, surgeons need to be grounded in the science of systems integration. The pervasive influence of this new requirement, as well as the skills, education, training, and assessment needs, are defined.

Disruptive visions: predictive simulation--between scientific method and clinical trial is the role of modeling and simulation in scientific discovery and validation.

The foundations of surgery have rested upon the passing of knowledge from generation to generation by mentors and manuscripts. Until the 1900 s, the passage of knowledge was through tradition. Since then, it has changed from observation and experience to the scientific method to clinical trials. A new approach, derived from other scientific disciplines, is that of predicting results from modeling and simulation, which will allow for acceleration of the process of validation of discoveries and optimizing the implementation of clinical trials in order to more rapidly transfer trusted knowledge from generation to generation.

Robotic surgery: identifying the learning curve through objective measurement of skill.

BACKGROUND: The incorporation of new devices into surgical practice often requires that surgeons acquire and master new skills. We studied the learning curve for intracorporeal knot tying in robotic surgery. METHODS: We developed an objective scoring system to evaluate knot tying and tested eight attending surgeons during 3 weeks of training on a surgical robot. Each performed intracorporeal knot tying tasks both before and after robotic skills training. These performances were compared to their laparoscopic knots and analyzed to determine and define skill improvement. RESULTS: Baseline laparoscopic knot completion took 140 sec (range, 47-432), with a mean composite score of 77 (100 possible), whereas robotic knot tying took 390 sec, with a mean composite score of 40. After initial robotic training, times decreased by 65% to 139 sec and scores increased to 71. With more training, completion times and composite scores were improved and errors were reduced. CONCLUSION: Like any new technology, surgical robotics requires dedicated training to achieve mastery. Initially, even experienced laparoscopists may register an inferior performance. However, after adequate training, surgeons can exceed their laparoscopic performance, completing intracorporeal knots better and faster using robotics.

PicSOr: an objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopic performance.

BACKGROUND: Laparoscopic surgery requires surgeons to infer the shape of 3-D structures, such as the internal organs of patients, from 2-D displays on a video monitor. Recent evidence indicates that the issue is not resolved by the use of contemporary 3-D camera systems. It is therefore crucial to find ways of measuring differences in aptitude for recovering 3-D structure from 2-D images, and assessing its impact on performance. Our aim was to test empirically for a relationship between laparoscopic ability and the perceptual skill of recovering information about 3-D structures from 2-D monitor displays. METHODS: Participants in three studies completed a simulated laparoscopic cutting task as well as the Pictorial Surface Orientation (PicSOr)3 Test. In studies 1 (n = 48) and 2 (n = 32) both groups were laparoscopic novices, and in study 3 (n = 34) 18 of the participants were experienced laparoscopic surgeons. FINDINGS: All three studies showed that PicSOr consistently predicted the laparoscopic performance of participants on the laparoscopic cutting task (study 1, r = 0.5, p < 0.0003; study 2, r = 0.5, p < 0.004; and study 3, r = 0.42, p = 0.017). Furthermore, it was also a significant predictor of laparoscopic surgeons' performance (r = 0.54, p = 0.047). INTERPRETATIONS: This is the first objective perceptual psychometric test to reliably predict laparoscopic technical skills. PicSOr provides a tool for assessing which trainees have the potential to learn minimal access surgery.

Disruptive visions: biosurgery.

There are a number of new therapeutic options generated by the biotechnology, bioengineering, and bioimaging revolutions in terms of organ-specific designer drugs, genetically engineered cells, cell-specific proteins and drugs, directed energy instruments, therapeutic microdevices, etc. Many of these new therapies need to be placed exactly on, within, or adjacent to an organ, and many others are delivered by endoluminal or endovascular approaches. The common requirements are (1) the accurate delivery of the modality and (2) the functional importance of targeting the biologic basis rather than the anatomic structure--hence the term biosurgery. As more of these therapies achieve clinical applicability and FDA approval, there will be the need for the precision of delivery to be at the micro- and nanoscale, which is well beyond human physical limitations. The surgeon of the future must be able to identify those therapeutic modalities that would benefit from such exact placement or implantation and acquire the skills, training, and equipment to use surgical expertise to deliver these new modalities. A review of some of the emerging opportunities is presented. Ignoring these challenges will relinquish these new procedures to other nonsurgical interventionalists, perhaps to the detriment of patient safety.

Metrics for objective Assessment.

As the need for improved methods of assessing surgical competence grows, it is imperative to establish the basic infrastructure to ensure the ability to communicate among educators, education researchers, responsible training bodies, and credentialing boards. A workshop was conducted to provide a foundation for communication and a standardization of definitions, measurements, and criteria. Future conferences and workshops will be needed to review and refine this initial framework.

Disruptive visions.

A number of concepts have been advocated for the next generation operating room based on some inadequacies of the current systems. Most have focused on removing excess tubes and wiring, others on information systems or robotics. An analysis of other industries, a projected direction of current technologies, a focus on the importance of integrated information systems, and a serious consideration of emerging basic technologies suggest a significantly different approach.

Disruptive visions.

Numerous advanced technologies, both medical and nonmedical, are emerging faster than their social, behavioral, political, moral, and ethical implications can be understood. Some of these technologies will fundamentally challenge the practice of surgery: human cloning, genetic engineering, tissue engineering, intelligent robotics, nanotechnology, suspended animation, regeneration, and species prolongation. Because of the rapidity of change, the current status of these emerging technologies with their specific moral and ethical issues must be addressed at this time by the new generation of surgeons, or we must all face the consequences of an uncontrolled and unprepared future.

Virtual reality as a metric for the assessment of laparoscopic psychomotor skills. Learning curves and reliability measures.

BACKGROUND: The objective assessment of the psychomotor skills of surgeons is now a priority; however, this is a difficult task because of measurement difficulties associated with the assessment of surgery in vivo. In this study, virtual reality (VR) was used to overcome these problems. METHODS: Twelve experienced (>50 minimal-access procedures), 12 inexperienced laparoscopic surgeons (<10 minimal-access procedures), and 12 laparoscopic novices participated in the study. Each subject completed 10 trials on the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR). RESULTS: Experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster, with less error, more economy in the movement of instruments and the use of diathermy, and with greater consistency in performance. The standardized coefficient alpha for performance measures ranged from a = 0.89 to 0.98, showing high internal measurement consistency. Test-retest reliability ranged from r = 0.96 to r = 0.5. CONCLUSION: VR is a useful tool for evaluating the psychomotor skills needed to perform laparoscopic surgery.

Evaluation of structured and quantitative training methods for teaching intracorporeal knot tying.

BACKGROUND: We evaluated the effectiveness of five training methods-four structured and one unstructured-for teaching intracorporeal knot tying. METHODS: Forty-three graduate students without prior laparoscopic experience were randomly assigned to one of five training groups, and their performance in 10 intracorporeal knot tying trials was evaluated, using time to complete a knot as the outcome measure. RESULTS: The average knot tying times for the four structured groups were significantly faster than the unstructured group (p < 0.0001). Among the four structured groups, the minimally invasive surgical trainer-virtually reality (MIST-VR) and the box trainer drills showed the most rapid improvements. The MIST-VR improved average suturing time from trial one to trial two (P = 0.05), the box trainer drills group improved from trial one to trial four (P = 0.01), and the other two groups showed slower improvements. Statistically significant correlations were observed between scores on MIST-VR tasks and average knottying times (R > 0.7, p < 0.05). CONCLUSION: Structured training can be useful for the development of laparoscopic skills. MIST-VR is a valuable part of this training, particularly in the objective evaluation of performance.