Development and validation of a simulator for teaching minimally invasive thoracic surgery in Brazil

ABSTRACT Purpose To develop and validate a chest cavity simulator for teaching video-assited thoracic surgery (VATS). Methods The first phase of the study consisted of developing a chest cavity simulator. A quasi-experimental study was performed in the second phase, and 25 surgeons and residents participated in a three-stage pulmonary suture experiment. The videos were recorded and timed. Generalized linear regression models for repeated measures were used to analyze the outcome change over time. Results The chest cavity simulator consists of a console simulating the left hemithorax. Among the participants, 96% rated the design, visual aspect, positioning ergonomics, and triangulation of the portals as very good or excellent (face validity). There was a decrease in suturing time in step 1 from 435.7 ± 105 to 355.6 ± 76.8 seconds compared to step 3 (p = 0.001). The evaluation of the simulation effectiveness and performance (content validity) was rated as very good or excellent by 96% ofparticipants. The most experienced surgeon showed significant reduction in procedure time (p = 0.021) (construct validity). Conclusions The thoracic cavity simulator is realistic, showing content and construct validity, and can be used in VATS training. The simulation model allowed skill gain in the endoscopic suture.

Simulated training model of ureteropyelic anastomosis in laparoscopic pyeloplasty

Purpose: To develop a model for simulated training of ureteropyelic anastomosis in laparoscopicpyeloplasty. Methods: Longitudinal and experimental study, with 16 participants. A synthetic instrument was produced to simulate the renal pelvis and the proximal portion of the ureter positioned on a platform within laparoscopic simulators, thereby resulting in the realistic simulation of the ureteropelvic anastomosis. A step-by-step guide was also developed for the accomplishment of the ureteropelvic anastomosis training model. Results: In the evaluation of all participants suture training, a decrease was found in the time needed to perform the anastomosis, with a median of 17.83 min in the 1st step and 14.21 min in the last one (p = 0.01). Regarding the knots, in the 1st step, 5% of them were considered firm, with an evolution to 30% in the last step (p = 0.011). Conclusion: We noticed improvement in the ability to perform the ureteropelvic anastomosis by participants with no experience with it. Therefore, even unexperienced participants can improve their skills with this training. Moreover, we observed the effectiveness of the model use, confirmed by the participants opinion and its validation by expert surgeons.(AU)

Evaluation tool for a gastroenterostomy simulated training

Purpose:To create a checklist to evaluate the performance and systematize the gastroenterostomy simulated training.Methods:Experimental longitudinal study of a quantitative character. The sample consisted of twelve general surgery residents. The training was divided into 5 sessions and consisted of participation in 20 gastroenterostomys in synthetic organs. The training was accompanied by an experienced surgeon who was responsible for the feedback and the anastomoses evaluation. The anastomoses evaluated were the first, fourth, sixth, eighth and tenth. A 10 item checklist and the time to evaluate performance were used.Results:Residents showed a reduction in operative time and evolution in the surgical technique statistically significant (p<0.01). The correlation index of 0.545 and 0,295 showed a high linear correlation between time variables and Checklist. The average Checklist score went from 6.8 to 9 points.Conclusion:The proposed checklist can be used to evaluate the performance and systematization of a simulated training aimed at configuring a gastroenterostomy.(AU)

Effects of omega-6/3 and omega-9/6 nutraceuticals on pain and fertility in peritoneal endometriosis in rats

Purpose: To evaluate the effects of the nutraceuticals omega-6/3 and omega-9/6 on endometriosis-associated infertility and pain. Methods: Controlled experimental study, with each group composed of eight female rats. Fertility groups: sham-operated control (0.9% saline solution); control with endometriosis (0.9% saline); omega-6/3 (1.2 g/kg/day); omega-9/6 (1.2 g/kg/day); and meloxicam (0.8 mg/kg/day). Pain groups: sham-operated control (0.9% saline); control with endometriosis (0.9% saline); omega-6/3 (1.2 g/kg/day); omega-9/6 (1.2 g/kg/day); medroxyprogesterone acetate (5 mg/kg/every 3 days); and meloxicam (0.8 mg/kg/day). Peritoneal endometriosis was surgically induced. Pain was evaluated with the writhing test. Fertility was evaluated by counting the number of embryos in the left hemi-uterus. Results: The mean number of writhings was as follows: sham-operated, 11.1 ± 2.9; control with endometriosis, 49.3 ± 4.4; omega-6/3, 31.5 ± 2.7; omega-9/6, 34.1 ± 4.5; medroxyprogesterone acetate, 2.1 ± 0.8; meloxicam, 1 ± 0.3. There was a significant difference between both controls and all drugs used for treatment. Regarding fertility, the mean values were as follows: sham-operated, 6.8 ± 0.6; control with endometriosis, 4.2 ± 0.7; omega-6/3, 4.7 ± 1; omega-9/6, 3.8 ± 0.9; and meloxicam, 1.8 ± 0.9. Conclusions: The omega-6/3 and omega-9/6 nutraceuticals decreased pain compared to the controls. There was no improvement in fertility in any of the tested groups.(AU)

Ursodeoxycholic acid in the prevention of gallstones in patients subjected to Roux-en-Y gastric bypass

Purpose:To evaluate the contribution of ursodeoxycholic acid (UDCA) in the first 12 months after Roux-en-Y gastric bypass in the prevention of gallstone formation.Methods:A community-based clinical trial was conducted. A total of 137 patients were included in the study; 69 were treated with UDCA, starting 30 days after the surgery, at a dose of 150 mg twice daily (300 mg/day) over a period of 5 consecutive months (GROUP A), and 68 were control patients (GROUP B). The patients were followed-up, and ultrasonography was performed to determine the presence of gallstones at various times during follow-up. Demographic, anthropometric and comorbid indicators were obtained. The data were subjected to normality tests and evaluated using appropriate tests.Results:Patients did not differ in their baseline characteristics. Of the 69 patients who used UDCA, only one patient developed cholelithiasis (1%), whereas 18 controls (26%) formed gallstones (OR = 24.4, p <0.001). Also, other factors were found not to influence the formation of calculi, such as pre-operative or postoperative hepatic steatosis or diabetes (p = 0.759, 0.468, 0.956).Conclusion:The results demonstrated that patients who did not use UDCA showed a 24.4-fold greater probability of developing cholelithiasis.(AU)

Abdominal cavity simulator for skill progression in videolaparoscopic sutures in Brazil

Purpose: To develop and test a model of teaching by means of an abdominal cavity simulator. Methods: This study had two stages: development of a teaching model and an experimental prospective study that aimed to evaluate the residents competence. The participants were divided into 3 groups: first-year resident, second-year resident, and senior surgeon. The two groups of resident physicians received training in the simulator, under instructor supervision for skill acquisition, according to the model proposed in first stage. The surgeons did not receive this intervention. The correlations and associations were verified through simple and multiple linear regressions. The learning curves were analysed using Cox regression models. The impact of the epidemiological characteristics was tested.Results: All residents reached the maximum score at the end of 16 steps and were comparable to the experimental (p<0.001). Conclusion: Residents who underwent training using the methodology of the proposed teaching model, which is based on realistic simulation, acquired proficiency in the accomplishment of endosutures in up to 16 hours of training in the laboratory.(AU)

Hepatic retractor in an ex vivo model

Purpose:To discuss the use of models of hepatic retraction by laparoscopy, to present a new Hepatic Retractor (HR) and to evaluate its practicality, efficacy and safety in Esophageal Hiatus Exposure (EHE).Methods:Experimental cross - sectional study with a quantitative character. It was carried out in the Laboratory of Health Training of Christus University Center. The sample consisted of 12 livers of adult pigs weighing between 30 and 45 kg. A circular-shaped HR, 5 cm diameter and deformable materials was developed with a polypropylene cloth, metallic guide wire, epidural needle plastic guide and nylon string. The practicality of HR management was measured by the time required to use the instrument, efficacy by exposure to the operative field and safety by macroscopic assessment of liver damage.Results:The average time to complete the procedure was 3.24 minutes and reached less than 2 minutes after 12 repetitions. In eight experiments the maximum degree of EHE was obtained. No macroscopic lesions were observed.Conclusion:The use of HR described can broaden the operative field, without causing macroscopic liver lesions and prolonging the surgical time.(AU)

Model for simulated training of laparoscopic gastroenterostomy

Purpose: To develop a model of gastroenterostomy and to analyze the acquisition of skills after training by simulation. Methods: Experimental longitudinal study and of a quantitative character. The sample consisted of twelve general surgery residents from four hospitals. The training consisted of making ten anastomoses divided equally into five sessions and it took place over a period of six weeks. The evaluation of the anastomoses considered the time and the analysis of the operative technique through the global evaluation scale Objective Structured Assessment of Technical Skills (OSATS). Results: Residents showed a reduction in operative time and evolution in the surgical technique statistically significant (p 0.01). The correlation index of 0.545 and 0.497 showed a high linear correlation between time variables and OSATS. Conclusion: The preparation of ten gastroenterostomies is an exercise capable of transferring basic and advanced skills in laparoscopy through a standardized training using synthetic organs and a simulator.(AU)