3D visualization systems improve operator efficiency during difficult laparoscopic cholecystectomy: a retrospective blinded review of surgical videos.

BACKGROUND: 3D visualization systems in laparoscopic surgery have been proposed to improve manual task handling compared to 2D, however, few studies have compared the intra-operative efficacy in laparoscopic cholecystectomy (LC). The aim of this study is to determine if there is a benefit in intra-operative efficiency when using a 3D visualization system in difficult LC compared to traditional 2D visualization systems. METHODS: Retrospective analysis of 'difficult' LCs (Grades 3 or 4) was completed. The assessor was blinded as all cases were recorded and viewed in 2D only. Variables collected included time to complete steps, missed hook diathermy attempts, failed grasp attempts, missed clip attempts and preparation steps for intra-operative cholangiogram (IOC). Multiple linear regression was undertaken for time variables, Poisson regression or negative binomial regression was completed for continuous variables. RESULTS: Fifty-two operative videos of 'difficult' LC were reviewed. 3D systems were associated with reduced operative times, although this was not statistically significant (CI: -2.93-14.93, P-value = 0.183). Dissection of the anterior fold to achieve the critical view of safety was significantly faster by 3.55 min (CI: 1.215-9.206, P-value = 0.002), and with considerably fewer errors when using 3D systems. Fewer IOC preparation errors were observed with a 3D system compared with a 2D system. CONCLUSIONS: 3D systems appear to enhance operator efficiency, allowing faster completion of critical steps with fewer errors. This pilot study underscores the utility of video annotation for intra-operative assessment and suggests that, in larger multi-centre studies, 3D systems may demonstrate superior intra-operative efficiency over 2D systems during a 'difficult' LC.

Laparoscopic common bile duct exploration: what factors determine success?

BACKGROUNDS: Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. METHODS: All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified. RESULTS: Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. CONCLUSION: LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Validation and reliability testing of a rating scale for objective assessment of performance in laparoscopic appendicectomy surgery.

BACKGROUNDS: To achieve a competency-based training paradigm, the ability to obtain reliable and valid quantitative assessments of intraoperative performance is required. Through this, weaknesses can be identified and practiced, and competency assessed. This study aimed to determine the validity and reliability an objective evaluation tool for assessment of performance in laparoscopic appendicectomy (LA). METHODS: A prospective single-blinded observational study design was used. Videos of inexperienced (performed <10 LAs) and experienced (performed >100 LAs) surgeons performing LA surgery were collected. Surgical performance during each recording was rated by two independent, blinded expert surgeons using the LA Rating Scale (LARS) and the modified Objective Structured Assessment of Technical Skill (OSATS) scale. RESULTS: The intraclass correlation coefficient (ICC) for LARS was 0.95 (95%CI 0.83-0.98). The ICC for each step ranged from 0.48 to 0.90, and the test-retest ICC for LARS was 0.91 (95%CI 0.69-0.98). Significant differences (P < 0.001) between median performance scores as rated by LARS were observed between the inexperienced and experienced surgeons. A Spearman's correlation coefficient of 0.87 (P < 0.001) was observed between LARS performance scores and modified OSATS scores. CONCLUSION: LARS demonstrated excellent inter-rater and test-retest reliability, and construct and concurrent validity and can be used to quantitatively evaluate performance during LA. This can potentially allow specific weaknesses to be identified and improved upon through deliberate practice. Progress can be tracked through re-evaluation and scores of expert surgeons can be used as performance goals for credentialing in LA.

Development of a rating scale for objective assessment of performance in laparoscopic appendicectomy surgery.

BACKGROUNDS: Laparoscopic appendicectomy (LA) is the most common index procedure for junior surgical trainees. Despite the shift towards competency-based training, there is no method of quantitatively assessing performance during LA. This study aimed to obtain expert consensus regarding the items required to create a LA Rating Scale (LARS). METHODS: A list of steps required for LA surgery, as well as descriptors of "poor", "average" and "excellent" performance for each of these steps were created for potential inclusion into an objective assessment tool for LA surgery. Using a Delphi method, 20 experts from multiple institutions rated on a Likert scale from 1 to 5 the suitability of these steps and descriptors of performance. Responses were obtained until consensus (Cronbach's α > 0.8) was achieved. RESULTS: Fifteen experts participated in the study. Consensus was achieved for all items during the first iteration of the Delphi with a Cronbach's α of 0.96. The Cronbach's α for the steps was 0.87 and 0.92 for the descriptors of performance. Steps and descriptors of performance that >80% of experts rated as ≥4 were used to create the final LARS tool. CONCLUSION: Multi-institutional expert consensus was obtained regarding the steps and, for the first time, descriptors of performance for LA, demonstrating their face and content validity, as well as generalisability. Subsequently, the LARS tool was created that can be used to quantitatively assess intra-operative performance. This instrument can be used to identify weaknesses in performance and facilitate deliberate practice, thus shifting training in LA to a competency-based approach.

Implementation of a Surgical Simulation Care Pathway Approach to Training in Emergency Abdominal Surgery.

BACKGROUND: Simulation-based care pathway approach (CPA) training is a novel approach in surgical education. The objective of the present study was to determine whether CPA was feasible for training surgical residents and could improve efficiency in patients' management. A common disease was chosen: acute appendicitis. METHODS: All five junior residents of our department were trained in CPA: preoperative CPA consisted in virtual patients (VPs) presenting with acute right iliac fossa pain; intraoperative CPA involved a virtual competency-based curriculum for laparoscopic appendectomy (LAPP); finally, post-operative VP were reviewed after LAPP. Thirty-eight patients undergoing appendectomy were prospectively included before (n = 21) and after (n = 17) the training. All demographic and perioperative data were prospectively collected from their medical records, and time taken from admission to management was measured. RESULTS: All residents had performed less than 10 LAPP as primary operator. Pre- and intraoperative data were comparable between pretraining and post-training patients. Times to liquid and solid diet were significantly reduced after training [7 h (2-20) vs. 4 (4-6); P = 0.004, and 17 h (4-48) vs. 6 (4-24); P = 0.005] without changing post-operative morbidity [4 (19%) vs. 0 (0); P = 0.11] and length of stay [48 h (30-264) vs. 44 (21-145); P = 0.22]. CONCLUSIONS: CPA training is feasible in abdominal surgery. In the current study, it improved patients' management in terms of earlier oral intake.

Development of a proficiency-based virtual reality simulation training curriculum for laparoscopic appendicectomy.

BACKGROUND: Proficiency-based virtual reality (VR) training curricula improve intraoperative performance, but have not been developed for laparoscopic appendicectomy (LA). This study aimed to develop an evidence-based training curriculum for LA. METHODS: A total of 10 experienced (>50 LAs), eight intermediate (10-30 LAs) and 20 inexperienced (<10 LAs) operators performed guided and unguided LA tasks on a high-fidelity VR simulator using internationally relevant techniques. The ability to differentiate levels of experience (construct validity) was measured using simulator-derived metrics. Learning curves were analysed. Proficiency benchmarks were defined by the performance of the experienced group. Intermediate and experienced participants completed a questionnaire to evaluate the realism (face validity) and relevance (content validity). RESULTS: Of 18 surgeons, 16 (89%) considered the VR model to be visually realistic and 17 (95%) believed that it was representative of actual practice. All 'guided' modules demonstrated construct validity (P < 0.05), with learning curves that plateaued between sessions 6 and 9 (P < 0.01). When comparing inexperienced to intermediates to experienced, the 'unguided' LA module demonstrated construct validity for economy of motion (5.00 versus 7.17 versus 7.84, respectively; P < 0.01) and task time (864.5 s versus 477.2 s versus 352.1 s, respectively, P < 0.01). Construct validity was also confirmed for number of movements, path length and idle time. Validated modules were used for curriculum construction, with proficiency benchmarks used as performance goals. CONCLUSION: A VR LA model was realistic and representative of actual practice and was validated as a training and assessment tool. Consequently, the first evidence-based internationally applicable training curriculum for LA was constructed, which facilitates skill acquisition to proficiency.

Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance.

BACKGROUND: This study investigated whether deliberate practice leads to an increase in surgical quality in virtual reality (VR) laparoscopic cholecystectomies (LC). Previous research has suggested that sustained DP is effective in surgical training. METHODS: Fourteen residents were randomized into deliberate practice (n = 7) or control training (n = 7). Both groups performed ten sessions of two VR LCs. Each session, the DP group was assigned 30 min of DP activities in between LCs while the control group viewed educational videos or read journal articles. Performance was assessed on speed and dexterity; quality was rated with global (GRS) and procedure-specific (PSRS) rating scales. All participants then performed five porcine LCs. RESULTS: Both groups improved over 20 VR LCs in time, dexterity, and global rating scales (all p < 0.05). After 20 LCs, there were no differences in speed or dexterity between groups. The DP group achieved higher quality of VR surgical performance than control for GRS (26 vs. 20, p = 0.001) and PSRS (18 vs. 15, p = 0.001). For VR cases, DP subjects plateaued at GRS = 25 after ten cases and control group at GRS = 20 after five cases. At completion of VR training, 100 % of the DP group reached target quality of performance (GRS ≥ 21) compared with 30 % in the control group. There were no significant differences for improvements in time or dexterity over five porcine LCs. CONCLUSION: This study suggests that DP leads to higher quality performance in VR LC than standard training alone. Standard training may leave individuals in a state of "arrested development" compared with DP.

Systematic review of learning curves for minimally invasive abdominal surgery: a review of the methodology of data collection, depiction of outcomes, and statistical analysis.

OBJECTIVE: To determine how minimally invasive surgical learning curves are assessed and define an ideal framework for this assessment. BACKGROUND: Learning curves have implications for training and adoption of new procedures and devices. In 2000, a review of the learning curve literature was done by Ramsay et al and it called for improved reporting and statistical evaluation of learning curves. Since then, a body of literature is emerging on learning curves but the presentation and analysis vary. METHODS: A systematic search was performed of MEDLINE, EMBASE, ISI Web of Science, ERIC, and the Cochrane Library from 1985 to August 2012. The inclusion criteria are minimally invasive abdominal surgery formally analyzing the learning curve and English language. 592 (11.1%) of the identified studies met the selection criteria. RESULTS: Time is the most commonly used proxy for the learning curve (508, 86%). Intraoperative outcomes were used in 316 (53%) of the articles, postoperative outcomes in 306 (52%), technical skills in 102 (17%), and patient-oriented outcomes in 38 (6%) articles. Over time, there was evidence of an increase in the relative amount of laparoscopic and robotic studies (P < 0.001) without statistical evidence of a change in the complexity of analysis (P = 0.121). CONCLUSIONS: Assessment of learning curves is needed to inform surgical training and evaluate new clinical procedures. An ideal analysis would account for the degree of complexity of individual cases and the inherent differences between surgeons. There is no single proxy that best represents the success of surgery, and hence multiple outcomes should be collected.

Emotional intelligence and stress in medical students performing surgical tasks.

PURPOSE: Poor stress management skills can compromise performance in the operating room, particularly in inexperienced trainees. Little is known about individual differences in managing stress. This study aimed to explore the relationship between trait emotional intelligence (EI) and objective and subjective measures of stress in medical students faced with unfamiliar surgical tasks. METHOD: Seventeen medical undergraduates completed an unfamiliar laparoscopic task on a simulator during January to April 2008. Subjective stress before, during (retrospectively), and after the task was measured using the self-report State-Trait Anxiety Inventory. Objective stress was measured using continuous heart rate (HR) monitoring. Participants also completed the Trait Emotional Intelligence Questionnaire short form (TEIQue-SF). The authors computed scores for global trait EI and the TEIQue-SF four factors and carried out descriptive and correlational analyses. RESULTS: The highest levels of subjective stress were reported during the task and correlated positively with trait EI as well as with the trait EI factors of well-being and emotionality. Objective stress (mean HR) during the task was positively related to the sociability factor of trait EI. Higher trait EI scores were also associated with better after-task recovery from stress experienced during the task. CONCLUSIONS: Students with higher trait EI are more likely to experience stress during unfamiliar surgical scenarios but are also more likely to recover better compared with their lower-trait-EI peers. Trait EI has implications for the design of effective stress management training tailored to individual needs and potential applications to surgical trainee selection and development.

Mental practice: effective stress management training for novice surgeons.

BACKGROUND: Surgeons are often subject to excessive levels of acute stress that can impair their performance. Mental practice (MP) is a strategy used in other high-performance industries to alleviate anxiety. This study investigated if MP reduces stress in novice surgeons. STUDY DESIGN: A prospective, randomized controlled design was used with 20 novice surgeons recruited by random sampling. After baseline testing, participants underwent training on an evidence-based virtual reality (VR) curriculum. They then performed 5 VR laparoscopic cholecystectomies (LC) after being randomized to MP or control groups. The MP group performed 30 minutes of MP using a validated MP training protocol before each LC; control participants conducted an unrelated activity. Stress was assessed subjectively using the validated State-Trait Anxiety-Inventory (STAI) questionnaire and objectively with a continuous heart rate (HR) monitor and salivary cortisol. Mental imagery was assessed using the validated mental imagery questionnaire. RESULTS: Eighteen participants completed the study. There were no intergroup differences in baseline stress, imagery, or technical ability. Comparing the MP group with controls, subjective stress (STAI) was lower for the MP group (median 8.40 vs 11.31, p < 0.01). Objective stress was also significantly reduced for the MP group in terms of the average HR (median 72 vs 88 beats/minute, p < 0.0001), maximum HR (median 102 vs 119 beats/minute, p < 0.01), and cortisol (median 2.26 vs 3.85 nmol/L, p < 0.05). Significant negative correlations were obtained between stress and imagery, indicating that improved imagery was associated with lower stress (p < 0.05). CONCLUSIONS: A short period of MP reduces the subjective, cardiovascular, and neuroendocrine response to stress on a VR simulator. Additional research should determine whether this effect extends beyond novice surgeons and transfers to the operating room.

Mental practice enhances surgical technical skills: a randomized controlled study.

OBJECTIVE: To assess the effects of mental practice on surgical performance. BACKGROUND: Increasing concerns for patient safety have highlighted a need for alternative training strategies outside the operating room. Mental practice (MP), "the cognitive rehearsal of a task before performance," has been successful in sport and music to enhance skill. This study investigates whether MP enhances performance in laparoscopic surgery. METHODS: After baseline skills testing, 20 novice surgeons underwent training on an evidence-based virtual reality curriculum. After randomization using the closed envelope technique, all participants performed 5 Virtual Reality (VR) laparoscopic cholecystectomies (LC). Mental practice participants performed 30 minutes of MP before each LC; control participants viewed an online lecture. Technical performance was assessed using video Objective Structured Assessment of Technical Skills-based global ratings scale (scored from 7 to 35). Mental imagery was assessed using a previously validated Mental Imagery Questionnaire. RESULTS: Eighteen participants completed the study. There were no intergroup differences in baseline technical ability. Learning curves were demonstrated for both MP and control groups. Mental practice was superior to control (global ratings) for the first LC (median 20 vs 15, P = 0.005), second LC (20.5 vs 13.5, P = 0.001), third LC (24 vs 15.5, P < 0.001), fourth LC (25.5 vs 15.5, P < 0.001) and the fifth LC (27.5 vs 19.5, P = 0.00). The imagery for the MP group was also significantly superior to the control group across all sessions (P < 0.05). Improved imagery significantly correlated with better quality of performance (ρ 0.51­0.62, Ps < 0.05). CONCLUSIONS: This is the first randomized controlled study to show that MP enhances the quality of performance based on VR laparoscopic cholecystectomy. This may be a time- and cost-effective strategy to augment traditional training in the OR thus potentially improving patient care.

Stress impairs psychomotor performance in novice laparoscopic surgeons.

BACKGROUND: Little is known about acute stress in surgery although it is recognized to impair human performance in safety-critical industries. This study aimed to establish a direct empirical link between stress and psychomotor performance of novice surgeons. METHODS: Eighteen participants completed this cross-sectional study. Participants carried out laparoscopic tasks on a MIST-VR simulator. Validated dexterity parameters were obtained from MIST-VR (path length, time taken, number of errors). Stress was assessed using the validated Imperial Stress Assessment Tool (ISAT). This captured stress subjectively using the State Trait Anxiety Inventory (STAI) questionnaire and objectively using salivary cortisol and mean and maximum heart rate. RESULTS: Regarding technical performance, median values obtained were 55.12 s (range = 22.9-99.8) for time taken, 4.83 (range = 3-7) for economy of motion, and 88.0 (range = 35-175) for number of errors made. Subjective stress (STAI) correlated with economy of motion (r = 0.53, p = 0.042) and number of errors (r = 0.51, p = 0.034). Objective stress (mean and maximum heart rate) correlated with time taken (r = 0.62, p = 0.004), economy of motion (r = 0.55, p = 0.048), and number of errors (r = 0.67, p = 0.012). CONCLUSION: This is the first study to demonstrate through direct correlation that stress impairs surgical performance on a simulator. Training in managing stress may be required to minimize these deleterious consequences and improve patient care.

Development and validation of mental practice as a training strategy for laparoscopic surgery.

BACKGROUND: Concerns for patient safety have accelerated the need for alternative training strategies outside the operating room. Mental practice (MP: the use of mental imagery to rehearse a task symbolically before performance) has been used successfully in sports and music to enhance skill. This study aimed to develop and validate a MP training strategy for laparoscopic surgery. METHODS: A cognitive "walk through" was conducted for a laparoscopic cholecystectomy (LC) to identify key visual, cognitive, and kinesthetic cues for the procedure. This was used to develop a MP training protocol featuring an "MP script" to enhance mental imagery of a LC. The script was validated by asking each subject to rehearse mentally a LC within 30 min. Ability to practice this procedure mentally was assessed before and after MP training with a modified version of a validated questionnaire (minimum score, 8; maximum score, 56). RESULTS: The study was completed by 20 subjects (10 experienced surgeons >100 LCs, 10 novice surgeons <10 LCs). Reliability testing of the questionnaire gave it a Cronbach alpha of 0.984 (n = 20) before MP training and 0.879 (n = 20) after MP training, indicating internal consistency. The construct validity of the questionnaire is supported by the fact that the experienced surgeons scored higher on all the questions than the novices both before and after training. Significant improvement in global imagery score after MP was shown by both experienced (48 before MP vs. 53 after MP; p = 0.007) and novice (15 before MP vs. 42 after MP; p = 0.005) surgeons, suggesting both face and content validity. CONCLUSIONS: This is the first study to develop and validate MP as a novel training approach for laparoscopic surgery. Mental practice may be a time- and cost-effective strategy that improves surgeons' ability to visualize themselves performing a LC, increasing both their knowledge and confidence.