Impact of Super Monkey Ball and Underground video games on basic and advanced laparoscopic skill training.

OBJECTIVE: This abstract profiles the comparison of correlations between previously validated Super Monkey Ball (SMB) and recently introduced Underground (U) video game on the Nintendo Wii U to multiple validated tasks used for developing basic and advanced laparoscopic skills. METHODS: Sixty-eight participants, 53 residents and 15 attending surgeons, performed the Top Gun Pea Drop, FLS Peg Pass, intracorporeal suturing, and two video games (SMB and U). SMB is an over-the-counter game, and U was formulated for laparoscopic skill training. RESULTS: Spearman's rank correlations were performed looking at performance comparing the three validated laparoscopic training tasks, and SMB/U. The SMB score had a moderate correlation with intracorporeal suturing (ρ = 0.39, p < 0.01), and the final score involving all three tasks (ρ = 0.39, p < 0.01), but low correlations with Pea Drop Drill and FLS Peg Transfer (ρ = 0.11, 0.18, p < 0.01). The U score had a small correlation with intracorporeal suturing and final score (ρ = 0.09, 0.13, p < 0.01). However, there were correlations between U score and Pea Drop Drill, and FLS Peg Transfer (ρ = 0.24, 0.27, p < 0.01, respectively). CONCLUSION: In this study, SMB had a very significant correlation with intracorporeal suturing. U demonstrated more of a correlation with basic skills. At this point, our conclusion would be that both are effective for laparoscopic skill training, and they should be used in tandem rather than alone.

The predictive value of aptitude assessment in laparoscopic surgery: a meta-analysis.

CONTEXT: Current methods of assessing candidates for medical specialties that involve laparoscopic skills suffer from a lack of instruments to assess the ability to work in a minimally invasive surgery environment. OBJECTIVES: A meta-analysis was conducted to investigate whether aptitude assessment can be used to predict variability in the acquisition and performance of laparoscopic skills. METHODS: PubMed, PsycINFO and Google Scholar were searched to November 2014 for published and unpublished studies reporting the measurement of a form of aptitude for laparoscopic skills. The quality of studies was assessed with QUADAS-2. Summary correlations were calculated using a random-effects model. RESULTS: Thirty-four studies were found to be eligible for inclusion; six of these studies used an operating room performance measurement. Laparoscopic skills correlated significantly with visual-spatial ability (r = 0.32, 95% confidence interval [CI] 0.25-0.39; p < 0.001), perceptual ability (r = 0.31, 95% CI 0.22-0.39; p < 0.001), psychomotor ability (r = 0.26, 95% CI 0.10-0.40; p = 0.003) and simulator-based assessment of aptitude (r = 0.64, 95% CI 0.52-0.73; p < 0.001). Three-dimensional dynamic visual-spatial ability showed a significantly higher correlation than intrinsic static visual-spatial ability (p = 0.024). CONCLUSIONS: In general, aptitude assessments are associated with laparoscopic skill level. Simulator-based assessment of aptitude appears to have the potential to represent a job sample and to enable the assessment of all forms of aptitude for laparoscopic surgery at once. A laparoscopy aptitude test can be a valuable additional tool in the assessment of candidates for medical specialties that require laparoscopic skills.

Thirty-seven patients treated with the C-seal: protection of stapled colorectal anastomoses with a biodegradable sheath.

PURPOSE: The present study was performed to get a better insight in the incidence of anastomotic leakage leading to reintervention when using the C-seal: a biodegradable sheath that protects the stapled colorectal anastomosis from leakage. METHODS: The C-seal is a thin walled tube-like sheath that forms a protective sheath within the bowel lumen. Thirty-seven patients undergoing surgery with creation of a stapled colorectal anastomosis with C-seal were analyzed. Follow-up was completed until 3 months after surgery. RESULTS: One patient (3%) developed anastomotic leakage leading to reintervention. None of the 37 anastomoses was dismantled. One patient was diagnosed with a rectovaginal fistula. In three patients (8%), a perianastomotic abscess spontaneously drained. CONCLUSION: The incidence of anastomotic leakage leading to reintervention when using the C-seal (3%) is lower than expected based on the literature (11%). We have currently set-up a multicenter randomized trial to confirm the efficiency of the C-seal (www.csealtrial.nl).

Kumar versus Olsen cannulation technique for intraoperative cholangiography: a randomized trial.

BACKGROUND: There is resistance to routine intraoperative cholangiography (IOC) during cholecystectomy because it prolongs surgery and may be experienced as cumbersome. An alternative instrument may help to reduce these drawbacks and lower the threshold for IOC. This trial compared the Kumar cannulation technique to the more commonly used Olsen clamp for IOC (KOALA trial; Dutch Trial Register NTR2582). METHODS: Patients undergoing elective laparoscopic cholecystectomy were randomized between IOC using the Kumar clamp and the Olsen clamp. Primary end points were the time that the IOC procedure took and its perceived ease as measured on a visual analog scale from 0 (impossible) to 10 (effortless). To detect a difference of 33 % in IOC time, a total sample size of 40 patients was required. RESULTS: Fifty-nine patients were randomized. Nine were excluded because of conversion to open cholecystectomy before the IOC procedure. Twenty-eight patients underwent IOC with the Kumar clamp and 22 with the Olsen clamp. The success rate was 23 (82.1 %) of 28 for the Kumar clamp and 19 (86.4 %) of 22 for the Olsen clamp (p > 0.999). The mean IOC time was 10 min 27 s ± 6 min 17 s using the Kumar clamp and 11 min 34 s ± 7 min 27 s using the Olsen clamp (p = 0.537). Surgeons graded the ease of the Kumar clamp as 6.8 ± 2.7 and the Olsen clamp as 6.8 ± 2.1 (p = 0.977). CONCLUSIONS: IOC using the Kumar clamp was neither faster nor easier than using the Olsen clamp. Both clamps facilitated IOC in just over 10 min. Individual surgeon preference should dictate which clamp is used.

Face validity of a Wii U video game for training basic laparoscopic skills.

BACKGROUND: Although the positive effects of playing video games on basic laparoscopic skills have been studied for several years, no games are actually used in surgical training. This article discusses the face validity of the first video game and custom-made hardware, which takes advantage of these effects. METHODS: Participants were recruited at the Chirurgendagen 2013 and the Society of American Gastrointestinal and Endoscopic Surgeons 2014 annual meeting. In total, 72 laparoscopic surgeons completed a demo of the game and filled in a questionnaire. RESULTS: On a 1-to-10 scale, the mean score for hardware realism was 7.2 and the mean score for usefulness as a training tool was 8.4. Participants did not mind the fact that the workspace does not look like an abdominal cavity, but do have some trouble with the absence of tactile feedback. CONCLUSION: We obtained face validity for both the hardware and the usefulness of Underground, a video game made for training basic laparoscopic skills.

Training basic laparoscopic skills using a custom-made video game.

Video games are accepted and used for a wide variety of applications. In the medical world, research on the positive effects of playing games on basic laparoscopic skills is rapidly increasing. Although these benefits have been proven several times, no institution actually uses video games for surgical training. This Short Communication describes some of the theoretical backgrounds, development and underlying educational foundations of a specifically designed video game and custom-made hardware that takes advantage of the positive effects of games on basic laparoscopic skills.

Nintendo related injuries and other problems: review.

OBJECTIVE: To identify all reported cases of injury and other problems caused by using a Nintendo video gaming system. DESIGN: Review. DATA SOURCES AND REVIEW METHODS: Search of PubMed and Embase in June 2014 for reports on injuries and other problems caused by using a Nintendo gaming system. RESULTS: Most of the 38 articles identified were case reports or case series. Injuries and problems ranged from neurological and psychological to surgical. Traditional controllers with buttons were associated with tendinitis of the extensor of the thumb. The joystick on the Nintendo 64 controller was linked to palmar ulceration. The motion sensitive Wii remote was associated with musculoskeletal problems and various traumas. CONCLUSIONS: Most problems are mild and prevalence is low. The described injuries were related to the way the games are controlled, which varies according to the video game console.

Development of a standardized training course for laparoscopic procedures using Delphi methodology.

BACKGROUND: Content, evaluation, and certification of laparoscopic skills and procedure training lack uniformity among different hospitals in The Netherlands. Within the process of developing a new regional laparoscopic training curriculum, a uniform and transferrable curriculum was constructed for a series of laparoscopic procedures. The aim of this study was to determine regional expert consensus regarding the key steps for laparoscopic appendectomy and cholecystectomy using Delphi methodology. METHODS: Lists of suggested key steps for laparoscopic appendectomy and cholecystectomy were created using surgical textbooks, available guidelines, and local practice. A total of 22 experts, working for teaching hospitals throughout the region, were asked to rate the suggested key steps for both procedures on a Likert scale from 1-5. Consensus was reached with Crohnbach's α ≥ 0.90. RESULTS: Of the 22 experts, 21 completed and returned the survey (95%). Data analysis already showed consensus after the first round of Delphi on the key steps for laparoscopic appendectomy (Crohnbach's α = 0.92) and laparoscopic cholecystectomy (Crohnbach's α = 0.90). After the second round, 15 proposed key steps for laparoscopic appendectomy and 30 proposed key steps for laparoscopic cholecystectomy were rated as important (≥4 by at least 80% of the expert panel). These key steps were used for the further development of the training curriculum. CONCLUSION: By using the Delphi methodology, regional consensus was reached on the key steps for laparoscopic appendectomy and cholecystectomy. These key steps are going to be used for standardized training and evaluation purposes in a new regional laparoscopic curriculum.

The effects of video games on laparoscopic simulator skills.

BACKGROUND: Recently, there has been a growth in studies supporting the hypothesis that video games have positive effects on basic laparoscopic skills. This review discusses all studies directly related to these effects. DATA SOURCES: A search in the PubMed and EMBASE databases was performed using synonymous terms for video games and laparoscopy. All available articles concerning video games and their effects on skills on any laparoscopic simulator (box trainer, virtual reality, and animal models) were selected. CONCLUSIONS: Video game experience has been related to higher baseline laparoscopic skills in different studies. There is currently, however, no standardized method to assess video game experience, making it difficult to compare these studies. Several controlled experiments have, nevertheless, shown that video games cannot only be used to improve laparoscopic basic skills in surgical novices, but are also used as a temporary warming-up before laparoscopic surgery.

[C-seal for prevention of anastomotic leakage following colorectal anastomosis]. / C-seal tegen naadlekkage bij colorectale anastomosen.

The C-seal is a new product for prevention of anastomotic leakage following colorectal anastomosis. Anastomotic leakage is a much-feared complication of colorectal surgery, with an incidence of around 11%. The C-seal is a biodegradable sheath that is attached to the inner surface of the bowel, just above the colorectal anastomosis, with a circular stapler. Intestinal contents drain from the body via the C-seal. The C-seal can be used in stapled anastomoses at up to 15 cm from the anus and is compatible with all circular staplers. To date, 50 patients have been treated with a C-seal. Results are encouraging and therefore the C-seal is soon to be investigated under randomized study conditions.

Protection of stapled colorectal anastomoses with a biodegradable device: the C-Seal feasibility study.

BACKGROUND: A colorectal anastomotic leak can be life-threatening. We have assessed the feasibility of a new intraluminal biodegradable bypass device that we designed to avoid anastomotic leakage and the necessity of a temporary stoma. METHODS: Fifteen patients underwent colorectal surgery. Before performing the anastomosis in a standard way, the C-Seal (Polyganics BV, Groningen, The Netherlands) was glued to the anvil of the circular stapler. Consequently, the bypass was fixated in the staple row just proximal of the simultaneously made anastomosis. A water-soluble contrast enema was performed after 1 week. RESULTS: The sheath was well compatible with the standard stapler device and easy to use. All donuts remained intact. No radiologic or clinical leaks were observed after surgery. CONCLUSIONS: This pilot study shows that the C-Seal can be applied successfully in colorectal surgery. Further investigation with large numbers of patients is now necessary to assess the efficacy of the C-Seal as a protective device.

The C-seal: a biofragmentable drain protecting the stapled colorectal anastomosis from leakage.

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates. The incidence of AL varies between 2.5 and 20%. Over the years, many strategies aimed at lowering the incidence of anastomotic leakage have been examined. The cause of AL is probably multifactorial. Etiological factors include insufficient arterial blood supply, tension on the anastomosis, hematoma and/or infection at the anastomotic site, and co-morbid factors of the patient as diabetes and atherosclerosis. Furthermore, some anastomoses may be insufficient from the start due to technical failure. Currently a new device is developed in our institute aimed at protecting the colorectal anastomosis and lowering the incidence of AL. This so called C-seal is a biofragmentable drain, which is stapled to the anastomosis with the circular stapler. It covers the luminal side of the colorectal anastomosis thereby preventing leakage. The C-seal is a thin-walled tube-like drain, with an approximate diameter of 4 cm and an approximate length of 25 cm. It is a tubular device composed of biodegradable polyurethane. Two flaps with adhesive tape are found at one end of the tube. These flaps are used to attach the C-seal to the anvil of the circular stapler, so that after the anastomosis is made the C-seal can be pulled through the anus. The C-seal remains in situ for at least 10 days. Thereafter it will lose strength and will degrade to be secreted from the body together with the gastrointestinal natural contents. The C-seal does not prevent the formation of dehiscences. However, it prevents extravasation of faeces into the peritoneal cavity. This means that a gap at the anastomotic site does not lead to leakage. Currently, a phase II study testing the C-seal in 35 patients undergoing (colo-)rectal resection with stapled anastomosis is recruiting. The C-seal can be used in both open procedures as well as laparoscopic procedures. The C-seal is only applied in stapled anastomoses within 15 cm from the anal verge. In the video, application of the C-seal is shown in an open extended sigmoid resection in a patient suffering from diverticular disease with a stenotic colon.