Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review.

BACKGROUND: There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula. METHODS: A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias. RESULTS: Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent. CONCLUSIONS: Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

BACKGROUND: Robotic surgery is increasingly used worldwide to treat many different diseases. The robot is controlled by a surgeon, which may give them greater precision and better outcomes for patients. However, surgeons' robotic skills should be assessed properly, to make sure patients are safe, to improve feedback and for exam assessments for certification to indicate competency. This should be done by experts, using assessment tools that have been agreed upon and proven to work. AIM: This review's aim was to find and explain which training and examination tools are best for assessing surgeons' robotic skills and to find out what gaps remain requiring future research. METHOD: This review searched for all available studies looking at assessment tools in robotic surgery and summarized their findings using several different methods. FINDINGS AND CONCLUSION: Two hundred and forty-seven studies were looked at, finding many assessment tools. Further research is needed for operation-specific and automatic assessment tools before they should be used in the clinical setting.

Extravert Surgical Resident Applicants Get Higher 360-Degree Evaluations From Coworkers.

INTRODUCTION: 360-degree evaluations are used as an assessment in order to identify strengths and weaknesses of, or as a continuous evaluation for, residents. The aim of this study was to investigate the relationship between personality and ratings on 360-degree evaluations among surgical residency applicants. A secondary aim was to describe the personality profile of applicants for a surgical residency position. METHODS: Doctors interviewed for a residency or locum position in general, urology, or pediatric surgery were included. Participants rated their personality on the Neutralized Big Five Inventory. A 360-degree assessment was conducted. Scores from two laparoscopic simulators were used as a measure of technical ability. Univariate analyses were used to assess the results. Student's t-test was used to compare personality and Pearson correlations between 360-degree assessment and personality. RESULTS: Fifty doctors participated: data were complete for 38. Personality profiles showed higher emotional stability, agreeableness, conscientiousness and openness ratings than the norm. Correlations revealed a significant relationship between extraversion and higher scores on the 360-degree assessments. Significant univariate correlations were found between extraversion and the 360-degree assessments, and two of the correlations held up after adjustment for multiple tests. No correlations with performance when using laparoscopic simulators were found. CONCLUSIONS: Applicants for surgical residency rated significantly higher than the norm in four personality domains. Extraversion correlated with overall higher scores in 360-degree assessments by coworkers. Higher scores were not related to objective measures of technical skill, highlighting the importance of using objective measures for assessment.

Training and assessment for colorectal surgery and appendicectomy- a systematic review.

AIM: There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach. METHOD: A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported. RESULTS: Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery. CONCLUSION: This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

No difference between using short and long intervals for distributed proficiency-based laparoscopy simulator training: a randomized trial.

BACKGROUND: Simulation-based training is increasingly used to acquire basic laparoscopic skills. Multiple factors can influence training, e.g., distributed practice is superior to massed practice in terms of efficiency. However, the optimal interval between training sessions is unclear. The objective of this trial was to investigate if shorter intervals between sessions are more efficient than longer intervals during proficiency-based laparoscopy simulator training. METHODS: A randomized simulation-based trial where medical students (n = 39) were randomized to proficiency-based training with either 1-2 days (intervention group) or 6-8 days (control group) between training sessions. Both groups practiced a series of basic tasks and a procedural module until proficiency level on the LapSim® simulator. Both groups were given instructor feedback upon request. After reaching proficiency, participants were invited back for a retention test 3-5 weeks later and practiced the same tasks to proficiency again. RESULTS: The mean time to reach proficiency during training was 291 (SD 89) and 299 (SD 89) min in the intervention and control group, respectively (p = 0.81). During the retention test, the mean time to reach proficiency was 94 (SD 53) and 96 (SD 39) minutes in the intervention and control groups, respectively (p = 0.91). CONCLUSION: We found no difference whether practicing with shorter intervals or longer intervals between training sessions when examining time to proficiency or retention.

Evaluation of a novel home-based laparoscopic and core surgical skills programme (Monash Online Surgical Training).

INTRODUCTION: Limitations to surgical education access were exacerbated during the COVID-19 Pandemic. In response, we created a national home-based comprehensive surgical skills course: Monash Online Surgical Training (MOST). Our aim was to evaluate the educational impact of this approach. METHODS: A remote, 6-week course was designed with learning objectives aligned to the national surgical training. Participants received a personal laparoscopic bench trainer, instrument tracking software, live webinars, access to an online theoretical learning platform, and individualised feedback by system-generated or expert surgeons' assessments. Mixed method analysis of instrument tracking metrics, pre- and post-course questionnaires (11 core surgical domains) and participant comments was utilised. Data were analysed using the Mann-Whitney U test, and a p-value of < 0.05 was considered statistically significant. RESULTS: A total of 54 participants with varied levels of experience (1 to > 6 years post-graduate level) completed MOST. All 11 learning-outcome domains demonstrated statistically significant improvement including core laparoscopic skills (1.4/5 vs 2.8/5, p < 0.0001) and handling laparoscopic instruments (1.5/5 vs 2.8/5, p < 0.0001). A total of 3460 tasks were completed reflecting 158.2 h (9492 min) of practice, 394 were submitted for formal feedback. Participants rated the course (mean 8.5/10, SD 1.6), live webinars (mean 8.9/10, SD 1.6) and instrument tracking software (mean 8.6, SD 1.7) highly. Qualitative analysis revealed a paradigm shift including the benefits of a safe learning environment and self-paced, self-directed learning. CONCLUSION: The MOST course demonstrates the successful implementation of a fully remote laparoscopic simulation course which participants found to be an effective tool to acquire core surgical skills.

Variable practice is superior to self-directed training for laparoscopic simulator training: a randomized trial.

BACKGROUND: Mastering laparoscopy is challenging-it requires specific psychomotor skills which are difficult to obtain in the operating room without potentially compromising patient safety. Proficiency-based training programs using virtual reality simulators allow novices to practice and develop their skills in a patient-safe learning environment. Variable practice leads to stronger retention and skills transfer in a non-surgical setting. The objective of this trial was to investigate if variable practice was superior to self-directed training. METHODS: A randomized trial where participants (n = 36) were randomized to proficiency-based laparoscopic simulator training of basic skills using either variable practice or self-directed training, followed by a transfer test with proficiency-based training on a procedural task (a salpingectomy). All participants returned after a period of 3-5 weeks to perform a retention test. RESULTS: The mean time to proficiency for the basic skills tasks were 119 min (SD: 93) for the variable practice group versus 182 min (SD: 46) for the self-directed training group (p = 0.015). The time to reach proficiency during the transfer test was 103 min (SD: 57) versus 183 min (SD: 64) for the variable practice group versus the self-directed training group, respectively (p < 0.001). The mean time to proficiency for the retention test was 51 min (SD: 26) and 109 min (SD: 53) for the variable practice group and self-directed training group, respectively (p < 0.001). CONCLUSION: Variable practice is superior to self-directed training for proficiency-based laparoscopic training. With variable time to practice proficiency is reduced, there is higher transfer to a procedural task, and retention is improved.

The influence of musical experience on laparoscopic surgical skill performance: an original investigation and literature review.

BACKGROUND: As the needs and curricula of surgical residencies evolve, recent studies have focused on identifying factors that may be related to faster and more efficient surgical skill acquisition, such as experience with playing video games, sports, and other dexterous activities. The aim of this study was to elucidate the relationship between instrumental musical experience and laparoscopic surgical skill performance as well as to provide an overview of the available literature on this topic. METHODS: A query from database inception to January 2023 of the PubMed database for literature discussing the association of musical experience and surgical skills was conducted. One hundred and twelve publications were sorted for relevance, yielding 16 included studies. The details of these studies were organized in a table and further analyzed. Study participants answered several questions regarding their personal instrumental musical experience and rotated through two minimally invasive surgery (MIS) skills stations. Participants received a score for each station based on level of performance. Descriptive statistics as well as non-parametric analyses and Spearman's correlations were calculated when appropriate to determine any associations between musical experience and laparoscopic surgical skill performance. RESULTS: One hundred individuals participated in the study. Fifty-one of the participants indicated that they played at least one musical instrument, and twelve (9.0%) of these individuals played more than one instrument. There was no statistically significant difference or correlation in scores between individuals that played an instrument and those that did not (p > 0.05). Playing a greater number of instruments did not significantly correlate with increased performance (p > 0.05). There was also no statistically significant difference or correlation in scores within the group that played instruments based on instrument type or number of years playing an instrument (p > 0.05). CONCLUSIONS: Experience playing musical instruments did not confer an advantage in MIS skills tested in the present study.

Impact of dehydration on laparoscopic performance: a prospective, open-label, randomized cross-over trial.

INTRODUCTION: During laparoscopic surgery, surgeons may experience prolonged periods without fluid intake, which might impact surgical performance, yet there are no objective data investigating this issue. Therefore, the aim of this study was to elucidate the effect of prolonged dehydration on laparoscopic surgical performance and tissue handling. METHODS: A total of 51 laparoscopic novices participated in a single-center, open-label, prospective randomized cross-over trial. All participants were trained to proficiency using a standardized laparoscopic training curriculum. Afterward, all participants performed four different laparoscopic tasks twice, once after 6 h without liquid intake (dehydrated group) and once without any restrictions (control group). Primary endpoints were tissue handling defined by force exertion, task time, and error rate. The real hydration status was assessed by biological parameters, like heart rate, blood pressure, and blood gas analysis. RESULTS: 51 laparoscopic novices finished the curriculum and completed the tasks under both hydrated and dehydrated conditions. There were no significant differences in mean non-zero and peak force between the groups. However, dehydrated participants showed significantly slower task times in the Peg transfer task (hydrated: 139.2 s vs. dehydrated: 147.9 s, p = 0.034) and more errors regarding the precision in the laparoscopic suture and knot task (hydrated: 15.7% accuracy rate vs. dehydrated: 41.2% accuracy rate, p < 0.001). CONCLUSION: Prolonged periods of dehydration do not appear to have a substantial effect on the fundamental tissue handling skills in terms of force exertion among surgical novices. Nevertheless, the observed impact on speed and precision warrants attention.

A synopsis of the SAGES ADOPT course for foregut surgery and its positive impact on surgeons' confidence levels.

BACKGROUND: The Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program was established by SAGES to develop and expand individual surgeon's comfort with specific, complex operations using hands-on teaching and longitudinal mentoring. The 2022-2023 Foregut (Dominating the Hiatus) section of the course focused on hiatal hernia dissection and gastric fundoplication techniques. Our aim was to describe the experience of surgeons who participated in the course. METHODS: The hands-on component occurred in March 2022 at the SAGES annual meeting. Each expert mentor was matched to two participants. The mentors guided the surgeons through steps of a laparoscopic paraesophageal (PEH) hernia repair and fundoplication using a cadaveric model. Afterwards, monthly group webinars occurred and participants could receive individual coaching from their assigned mentor for a year. Each participant was given a pre-course survey with 3 and 12-month follow-up questionnaires. RESULTS: The majority of the 16 participants were employed in non-academic settings (87.5%). Years in practice ranged from 1 to 26, and 69% completed a fellowship. 100% completed the pre-course survey, and 53.8% responded to the 12-month post-course survey. Participant-reported effectiveness in performing a PEH hernia repair with fundoplication increased from 37.5% pre-course to 85.7% by the conclusion of the course. Confidence levels for the six core steps of the operation also increased: pre-course only 56-75% were confident with each step, this improved to 100% in four out of six steps. 85.7% said the course has changed their practice. DISCUSSION: Since inception, the ADOPT program has aimed to provide expert instruction for practicing surgeons to learn new techniques or improve their confidence in performing operations. The data for the 2022 ADOPT Foregut course shows that 1 year of participation made a positive impact on these surgeons' practices. This helps to fill in the learning gap that occurs after formal surgical training ends.

Satisfaction of surgeons with the current state of training in minimally invasive surgery: a survey among German surgeons.

BACKGROUND: Minimally invasive surgery (MIS) requires intense education and training with structured supervision and feedback. However, a standardized training structure is lacking in Germany. This nationwide survey aimed to assess the current state of minimally invasive surgery (MIS) training and factors impacting surgeons' satisfaction. METHODS: Between July and October 2021, an online survey was conducted among general, abdominal, and thoracic surgeons in Germany. The survey collected data on department size, individual operative experience, availability of MIS training equipment and curricula, and individual satisfaction with training. A linear regression analysis was conducted to investigate factors influencing the surgeons' satisfaction with the MIS training. RESULTS: A total of 1008 surgeons participated in the survey, including residents (26.1%), fellows (14.6%), attendings (43.8%), and heads of departments (15.2%). Of the respondents, 57.4% reported having access to MIS training equipment, 29.8% and 26% had a curriculum for skills lab MIS training and intraoperative MIS training, respectively. In multivariate linear regression analysis, strongest predictors for surgeons' satisfaction with skills lab MIS training and intraoperative training were the availability of respective training curricula (skills lab: ß 12.572; p < 0.001 & intraoperative: ß 16.541; p < 0.001), and equipment (ß 5.246; p = 0.012 & ß 4.295; p = 0.037), and experience as a first surgeon in laparoscopy (ß 12.572; p < 0.001 & ß 3.748; p = 0.007). Additionally, trainees and teachers differed in their satisfaction factors. CONCLUSION: Germany lacks standardized training curricula and sufficient access to MIS training equipment. Trainees and teachers have distinct factors influencing their satisfaction with MIS training. Standardized curricula, equipment accessibility, and surgical experience are crucial for improving surgeons' satisfaction with training.

Artificial intelligence automated surgical phases recognition in intraoperative videos of laparoscopic pancreatoduodenectomy.

BACKGROUND: Laparoscopic pancreatoduodenectomy (LPD) is one of the most challenging operations and has a long learning curve. Artificial intelligence (AI) automated surgical phase recognition in intraoperative videos has many potential applications in surgical education, helping shorten the learning curve, but no study has made this breakthrough in LPD. Herein, we aimed to build AI models to recognize the surgical phase in LPD and explore the performance characteristics of AI models. METHODS: Among 69 LPD videos from a single surgical team, we used 42 in the building group to establish the models and used the remaining 27 videos in the analysis group to assess the models' performance characteristics. We annotated 13 surgical phases of LPD, including 4 key phases and 9 necessary phases. Two minimal invasive pancreatic surgeons annotated all the videos. We built two AI models for the key phase and necessary phase recognition, based on convolutional neural networks. The overall performance of the AI models was determined mainly by mean average precision (mAP). RESULTS: Overall mAPs of the AI models in the test set of the building group were 89.7% and 84.7% for key phases and necessary phases, respectively. In the 27-video analysis group, overall mAPs were 86.8% and 71.2%, with maximum mAPs of 98.1% and 93.9%. We found commonalities between the error of model recognition and the differences of surgeon annotation, and the AI model exhibited bad performance in cases with anatomic variation or lesion involvement with adjacent organs. CONCLUSIONS: AI automated surgical phase recognition can be achieved in LPD, with outstanding performance in selective cases. This breakthrough may be the first step toward AI- and video-based surgical education in more complex surgeries.

Can you feel the force just right? Tactile force feedback for training of minimally invasive surgery-evaluation of vibration feedback for adequate force application.

BACKGROUND: Tissue handling is a crucial skill for surgeons and is challenging to learn. The aim of this study was to develop laparoscopic instruments with different integrated tactile vibration feedback by varying different tactile modalities and assess its effect on tissue handling skills. METHODS: Standard laparoscopic instruments were equipped with a vibration effector, which was controlled by a microcomputer attached to a force sensor platform. One of three different vibration feedbacks (F1: double vibration > 2 N; F2: increasing vibration relative to force; F3: one vibration > 1.5 N and double vibration > 2 N) was applied to the instruments. In this multicenter crossover trial, surgical novices and expert surgeons performed two laparoscopic tasks (Peg transfer, laparoscopic suture, and knot) each with all the three vibration feedback modalities and once without any feedback, in a randomized order. The primary endpoint was force exertion. RESULTS: A total of 57 subjects (15 surgeons, 42 surgical novices) were included in the trial. In the Peg transfer task, there were no differences between the tactile feedback modalities in terms of force application. However, in subgroup analysis, the use of F2 resulted in a significantly lower mean-force application (p-value = 0.02) among the student group. In the laparoscopic suture and knot task, all participants exerted significantly lower mean and peak forces using F2 (p-value < 0.01). These findings remained significant after subgroup analysis for both, the student and surgeon groups individually. The condition without tactile feedback led to the highest mean and peak force exertion compared to the three other feedback modalities. CONCLUSION: Continuous tactile vibration feedback decreases the mean and peak force applied during laparoscopic training tasks. This effect is more pronounced in demanding tasks such as laparoscopic suturing and knot tying and might be more beneficial for students. Laparoscopic tasks without feedback lead to increased force application.

A needs assessment for simulation in African surgical education.

INTRODUCTION: There is a critical need for comprehensive surgical training in African countries given the unmet surgical burden of disease in this region. Collaborative and progressive initiatives in global surgical education will have the greatest impact on trainees. Little is known about surgical education needs from the perspective of practicing surgeons and trainees in low-middle-income countries (LMICs). Even less is known about the potential role for simulation to augment training. METHODS: A modified Delphi methodology with 2 rounds of responses was employed to survey program directors (PD) and associate program directors (APD) of Pan-African Association of Christian Surgeons (PAACS) general surgery residency programs across eight low-middle-income countries in Africa. 3 PD/APDs and 2 surgical residents participated in semi-structured interviews centered around the role of simulation in training. Descriptive analysis was performed to elicit key themes and illustrative examples. RESULTS: The survey of program directors revealed that teaching residents the psychomotor skills need to perform intracorporeal suturing was both high priority and desired in multiple training sites. Other high priority skills were laparoscopic camera driving and medial visceral rotation. The interviews revealed a specific desire to perform laparoscopic surgery and a need for a simulation curriculum to familiarize staff and trainees with laparoscopic techniques. Several barriers to laparoscopic surgery exist, such as lack of staff familiarity with the equipment, lack of public buy in, and lack of generalizable and adaptable educational modules. Trainees saw utility in the use of simulation to optimize time in the operating room and sought opportunities to improve their laparoscopic skills. CONCLUSION: Faculty and surgical trainees in LMICs have interest in learning advanced surgical techniques, such as laparoscopy. Developing a simulation curriculum tailored to the trainees' local context has the potential to fill this need.

Internal and external factors affecting the performance score of surgical trainees doing laparoscopic appendectomy: a prospective, observational cohort study in a structured training programme.

BACKGROUND: Laparoscopic appendectomy is a common procedure and introduced early in general surgical training. How internal (i.e. surgeon's experience) or external (i.e. disease severity) may affect procedure performance is not well-studied. The aim of this study was to evaluate factors that may have an influence on the performance scores for surgical trainees. METHODS: A prospective, observational cohort study of laparoscopic appendectomies performed by surgical trainees (experience < 4 years) operating under supervision. Trainers evaluated trainees' overall performance on a 6-point scale for proficiency. Perioperative data were recorded, including appendicitis severity, operating time and the overall difficulty of the procedure as assessed by the trainer. A "Challenging" procedure was defined as a combination of either/or "perforation" and "difficult". Trainees who had performed > 30 appendectomies were defined as "experienced". The trainees were asked if they had used simulation or web-based tools the week prior to surgery. RESULTS: 142 procedure evaluation forms were included of which 19 (13%) were "perforated", 14 (10%) "difficult" and 24 (17%) "Challenging". Perforated appendicitis was strongly associated with procedure difficulty (OR 21.2, 95% CI 6.0-75.6). Experienced trainees performed "proficient" more often than non-experienced (OR 34.5, 95% CI 6.8-176.5). "Difficult" procedures were inversely associated with proficiency (OR 0.1, 95% CI 0.0-0.9). In "Challenging" procedures, identifying the appendix had lowest proficiency (OR 0.4, 95% CI 0.1-0.9). The procedures assessed as "difficult" had significantly longer operating time with a median (IQR) of 90 (75-100) min compared to 59 (25-120) min for the non-difficult (p < 0.001). CONCLUSION: Both internal and external factors contribute to the performance score. Perforated appendicitis, technical difficult procedures and trainee experience all play a role, but a "difficult" procedure had most overall impact on proficiency evaluation.

An artificial intelligence-based nerve recognition model is useful as surgical support technology and as an educational tool in laparoscopic and robot-assisted rectal cancer surgery.

BACKGROUND: Artificial intelligence (AI) has the potential to enhance surgical practice by predicting anatomical structures within the surgical field, thereby supporting surgeons' experiences and cognitive skills. Preserving and utilising nerves as critical guiding structures is paramount in rectal cancer surgery. Hence, we developed a deep learning model based on U-Net to automatically segment nerves. METHODS: The model performance was evaluated using 60 randomly selected frames, and the Dice and Intersection over Union (IoU) scores were quantitatively assessed by comparing them with ground truth data. Additionally, a questionnaire was administered to five colorectal surgeons to gauge the extent of underdetection, overdetection, and the practical utility of the model in rectal cancer surgery. Furthermore, we conducted an educational assessment of non-colorectal surgeons, trainees, physicians, and medical students. We evaluated their ability to recognise nerves in mesorectal dissection scenes, scored them on a 12-point scale, and examined the score changes before and after exposure to the AI analysis videos. RESULTS: The mean Dice and IoU scores for the 60 test frames were 0.442 (range 0.0465-0.639) and 0.292 (range 0.0238-0.469), respectively. The colorectal surgeons revealed an under-detection score of 0.80 (± 0.47), an over-detection score of 0.58 (± 0.41), and a usefulness evaluation score of 3.38 (± 0.43). The nerve recognition scores of non-colorectal surgeons, rotating residents, and medical students significantly improved by simply watching the AI nerve recognition videos for 1 min. Notably, medical students showed a more substantial increase in nerve recognition scores when exposed to AI nerve analysis videos than when exposed to traditional lectures on nerves. CONCLUSIONS: In laparoscopic and robot-assisted rectal cancer surgeries, the AI-based nerve recognition model achieved satisfactory recognition levels for expert surgeons and demonstrated effectiveness in educating junior surgeons and medical students on nerve recognition.

Current status of resident simulation training curricula: pearls and pitfalls.

BACKGROUND: Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation. MATERIALS AND METHODS: Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected. RESULTS: Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding. CONCLUSIONS: While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

Be prepared! Impact of structured video-assisted coaching on performance in a simulated bleeding exercise during laparoscopic surgery.

BACKGROUND: Bleeding during laparoscopic surgery is stressful and requires immediate efficient management. Skills for complication management are rarely trained. This study aims to investigate the impact of video-assisted coaching on laparoscopic skills acquisition and performance in emergency bleeding situations. METHODS: Participants faced simulated emergency scenarios during laparoscopy involving bleeding management in porcine aorta/kidney specimens. Four sequences were conducted over two days, with a structured video-assisted coaching provided between sequences. Performance was assessed using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. The study involved 27 participants attending the advanced colorectal surgery module at the 40th Annual Davos Course in 2023. RESULTS: 54 video sequences were analyzed. Structured video-assisted coaching improved the GOALS sum score by 0.36 (95%CI: 0.21-0.50, P < 0.001) in contrast to simple repetition (0.05 with 95%CI: -0.43 to 0.53, P = 0.826). This association was observed for depth of perception (P < 0.001), bimanual dexterity (P < 0.001), tissue handling (P < 0.001), overall performance (P < 0.001), and efficiency (P < 0.001). Autonomy did not significantly improve (P = 0.55). Findings were consistent regardless of age, gender, and overall laparoscopic experience of the participants. However, a weaker effect of structured video-assisted coaching was observed in participants with experience in laparoscopic surgery. CONCLUSION: Structured video-assisted coaching improved performance in laparoscopic skills in complex and stress-inducing bleeding scenarios. The findings of this study support the incorporation of video-assisted coaching and complication management exercises into surgical training curricula.

The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on adjustable gastric banding.

BACKGROUND: Bariatric surgery is one of the clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, and laparoscopic adjustable gastric banding (LAGB) is one of the three anchoring bariatric procedures. To improve surgeon lifelong learning, the Masters Program seeks to identify sentinel articles of each of the 3 bariatric anchoring procedures. In this article, we present the top 10 articles on LAGB. METHODS: A systematic literature search of papers on LAGB was completed, and publications with the most citations and citation index were selected and shared with SAGES Metabolic and Bariatric Surgery Committee members for review. The individual committee members then ranked these papers, and the top 10 papers were chosen based on the composite ranking. RESULTS: The top 10 sentinel publications on LAGB contributed substantially to the body of literature related to the procedure, whether for surgical technique, novel information, or outcome analysis. A summary of each paper including expert appraisal and commentary is presented here. CONCLUSION: These seminal articles have had significant contribution to our understanding and appreciation of the LAGB procedure. Bariatric surgeons should use this resource to enhance their continual education and acquisition of specialized skills.

Standardized porcine integrated robotic inguinal hernia training: the SPIRIT model.

BACKGROUND: Implementing a robotic system for minimally invasive surgical procedures necessitates a comprehensive training regimen. This involves not only mastering the technological aspects of the robotic system but also enhancing surgical proficiency in manipulating robotic instruments. Furthermore, procedural expertise in specific surgeries is critical. Minimally invasive inguinal hernia repair is particularly suitable as an initial procedure for human application. The development of a comprehensive training model for this type of repair is a crucial element of such an educational pathway. METHOD: Anatomical dissections were carried out on pigs to assess both the similarities and differences between pig and human anatomy. A structured minimally invasive inguinal hernia repair was performed to determine the suitability of the porcine inguinal region for training purposes. RESULTS: A detailed anatomical description of the porcine inguinal region is outlined, to provide a framework for assessing the critical view of the porcine myopectineal orifice. By integrating the human 'ten golden rules' for safe and effective minimally invasive inguinal hernia repair, the standardized porcine integrated robotic inguinal hernia training (SPIRIT) model describes a step-by-step approach to practice surgical techniques in a realistic setting. CONCLUSION: The SPIRIT model is designed to be a well-structured training model for minimally invasive inguinal hernia repair and incorporates the specific surgical steps as encountered in a human patient.

Skill assessment based on clutch use in cross-platform robot-assisted surgery.

BACKGROUND: Many studies have investigated the transfer of skills between laparoscopic and robot-assisted surgery (RAS). These studies have considered time, error, and clinical outcomes in the assessment of skill transfer. However, little is known about the specific operations of the surgeon. Clutch control use is an important skill in RAS. Therefore, the present study aimed to propose a novel objective algorithm based on computer vision that can automatically evaluate a surgeon's clutch use. Additionally, the study aimed to evaluate the correlation between clutch metrics and surgical skill on different surgical robot platforms. METHODS: The robotic surgery training center of Wuhan University trained 30 laparoscopic surgeons as the study group between 2023 and 2024. Laparoscopic surgeons were trained by combining robotic simulator exercises and RAS animal experiments. During the training, video and hand movement data were collected. Hand movements identified by a skin-color model were combined with labeling information to classify clutch use. The metrics were validated on different robotic platforms (dv-Trainer, EDGE MP1000, Toumai™ MT1000, and DaVinci Xi system) and among surgeons with different surgical skill levels. RESULTS: On the robotic simulator, clutch accuracy in the expert group was significantly higher than in the study group for all tasks. No significant differences were observed in the number of clutches between the expert and study groups. In the RAS experiment, the number of clutches decreased significantly for both study and expert groups. The accuracy was maintained at a high level in the expert group but decreased rapidly in the study group. CONCLUSIONS: We proposed a new objective assessment of surgical skills, clutch use metrics, in cross-platform RAS. Additionally, we verified that the metrics significantly correlated with the surgical skill levels of the surgeons.