Force-based learning curve tracking in fundamental laparoscopic skills training.

BACKGROUND: Within minimally invasive surgery (MIS), structural implementation of courses and structured assessment of skills are challenged by availability of trainers, time, and money. We aimed to establish and validate an objective measurement tool for preclinical skills acquisition in a basic laparoscopic at-home training program. METHODS: A mobile laparoscopic simulator was equipped with a state-of-the-art force, motion, and time tracking system (ForceSense, MediShield B.V., Delft, the Netherlands). These performance parameters respectively representing tissue manipulation and instrument handling were continuously tracked during every trial. Proficiency levels were set by clinical experts for six different training tasks. Resident's acquisition and development of fundamental skills were evaluated by comparing pre- and post-course assessment measurements and OSATS forms. A questionnaire was distributed to determine face and content validity. RESULTS: Out of 1842 captured attempts by novices, 1594 successful trials were evaluated. A decrease in maximum exerted absolute force was shown in comparison of four training tasks (p ≤ 0.023). Three of the six comparisons also showed lower mean forces during tissue manipulation (p ≤ 0.024). Lower instrument handling outcomes (i.e., time and motion parameters) were observed in five tasks (resp. (p ≤ 0.019) and (p ≤ 0.025)). Simultaneously, all OSATS scores increased (p ≤ 0.028). Proficiency levels for all tasks can be reached in 2 weeks of at home training. CONCLUSIONS: Monitoring force, motion, and time parameters during training showed to be effective in determining acquisition and development of basic laparoscopic tissue manipulation and instrument handling skills. Therefore, we were able to gain insight into the amount of training needed to reach certain levels of competence. Skills improved after sufficient amount of training at home. Questionnaire outcomes indicated that skills and self-confidence improved and that this training should therefore be part of the regular residency training program.

Assessing pre- and postoperative activity levels with an accelerometer: a proof of concept study.

BACKGROUND: Postoperative recovery after abdominal surgery is measured mostly based on subjective or self-reported data. In this article we aim to evaluate whether recovery of daily physical activity levels can be measured postoperatively with the use of an accelerometer. METHODS: In this multicenter, observational pilot study, 30 patients undergoing laparoscopic abdominal surgery (hysterectomy, adnexal surgery, cholecystectomy and hernia inguinal surgery) were included. Patients were instructed to wear an Actigraph wGT3X-BT accelerometer during one week before surgery (baseline) and during the first, third and fifth week after surgery. Wear time, steps taken and physical activity intensity levels (sedentary, light, moderate and vigorous) were measured. Patients were blinded for the accelerometer outcomes. Additionally, an activity diary comprising patients' self-reported time of being recovered and a list of 18 activities, in which the dates of resumption of these 18 activities were recorded after surgery, was completed by the patient. RESULTS: Five patients were excluded from analyses because of technical problems with the accelerometer (n = 1) and protocol non-adherence (n = 4). Light, moderate, vigorous, combined moderate and vigorous intensity physical activity (MVPA), and step counts showed a clear recovery curve after surgery. Patients who underwent minor surgery reached their baseline step count and MVPA three weeks after surgery. Patients who underwent intermediate surgery had not yet reached their baseline step count during the last measuring week (five weeks after surgery). The results of the activity diaries showed a fair agreement with the accelerometer results (Cohens Kappa range: 0.273-0.391). Wearing the accelerometer was well tolerated and not regarded as being burdensome by the patients. CONCLUSIONS: The accelerometer appeared to be a feasible way to measure recovery of postoperative physical activity levels in this study and was well tolerated by the patients. The agreement with self-reported physical recovery times was fair.

Ten-year outcomes of a randomised trial of laparoscopic versus open surgery for colon cancer.

BACKGROUND: Laparoscopic surgery for colon cancer is associated with improved recovery and similar cancer outcomes at 3 and 5 years in comparison with open surgery. However, long-term survival rates have rarely been reported. Here, we present survival and recurrence rates of the Dutch patients included in the COlon cancer Laparoscopic or Open Resection (COLOR) trial at 10-year follow-up. METHODS: Between March 1997 and March 2003, patients with non-metastatic colon cancer were recruited by 29 hospitals in eight countries and randomised to either laparoscopic or open surgery. Main inclusion criterion for the COLOR trial was solitary adenocarcinoma of the left or right colon. The primary outcome was disease-free survival at 3 years, and secondary outcomes included overall survival and recurrence. The 10-year follow-up data of all Dutch patients were collected. Analysis was by intention-to-treat. The trial was registered at ClinicalTrials.gov (NCT00387842). RESULTS: In total, 1248 patients were randomised, of which 329 were Dutch. Fifty-eight Dutch patients were excluded and 15 were lost to follow-up, leaving 256 patients for 10-year analysis. Median follow-up was 112 months. Disease-free survival rates were 45.2 % in the laparoscopic group and 43.2 % in the open group (difference 2.0 %; 95 % confidence interval (CI) -10.3 to 14.3; p = 0.96). Overall survival rates were 48.4 and 46.7 %, respectively (difference 1.7 %; 95 % CI -10.6 to 14.0; p = 0.83). Stage-specific analysis revealed similar survival rates for both groups. Sixty-two patients were diagnosed with recurrent disease, accounting for 29.4 % in the laparoscopic group and 28.2 % in the open group (difference 1.2 %; 95 % CI -11.1 to 13.5; p = 0.73). Seven patients had port- or wound-site recurrences (laparoscopic n = 3 vs. open n = 4). CONCLUSIONS: Laparoscopic surgery for non-metastatic colon cancer is associated with similar rates of disease-free survival, overall survival and recurrences as open surgery at 10-year follow-up.

The interplay between partners' responsiveness and patients' need for emotional expression in couples coping with cancer.

The central aim of this longitudinal observational study was to test whether patients with a high need for emotional expression are especially sensitive to their partners' responsive behavior, and therefore at risk for depressive symptoms when responsiveness is withheld. Patients with colorectal cancer and their partners (n = 58) participated in a longitudinal study (3, 5 and 9 months after the diagnosis). Additionally to self-report measurements (i.e., patients' need for emotional expression, patients' depressive symptoms and patients' relationship satisfaction) couples were videotaped discussing cancer-related concerns. External observers coded partners' responsiveness (i.e., understanding, validation and caring) and patients' self-disclosures. Partner responsiveness predicted lower levels of depressive symptoms over time in patients who had a relatively high need for emotional expression above and beyond the effect of relationship satisfaction. We demonstrated that partners' understanding and validation are more important in explaining patients' depressive symptoms than partners' caring behavior. Our findings highlight the importance of the relational context in improving adaptation to cancer taking into account individual differences.

[Simulation-based training in minimally invasive surgery: the Advanced Suturing Course]. / Simulatieonderwijs in minimaal-invasieve chirurgie: de 'Advanced suturing course'.

OBJECTIVE: To investigate the additional value of the Advanced Suturing Course (ASC) in the basic laparoscopic skills training curriculum for residents. DESIGN: Prospective cohort study. METHOD: Laparoscopic skills of 162 participants attending one of 17 ASCs held during the period April 2008-December 2010, were assessed before and after the training. Subjective and objective evaluation was performed using the Objective Structured Assessment of Technical Skills (OSATS) list and Motion Analysis Parameters (MAPs), recorded with the Training in Endoscopy tracking system, respectively. Confidence of participants in various laparoscopic tasks was rated using a visual analogue scale. RESULTS: At the end of the first course day, mean OSATS-scores were significantly higher for open and laparoscopic knot-tying tasks than before the first course day. After 6 weeks of autonomous training, these scores were unaltered. Right hand MAPs were also unaltered after this training period. Confidence of participants in completing an open or a laparoscopic knot increased significantly during the entire course, as well as confidence in completing an open or laparoscopic intestinal anastomosis. CONCLUSION: Medical simulation-based skills training appears to be an efficient method to improve certain basic laparoscopic skills in a relatively short period. Regular practice, sufficient opportunities for evaluation and feedback, and skills assessment are hereby critical.

Relationship satisfaction in couples confronted with colorectal cancer: the interplay of past and current spousal support.

Based on attribution theory, this study hypthesized that past spousal supportiveness may act as a moderator of the link between one partner's current support behavior and the other partner's relationship satisfaction. A sample of 88 patients with colorectal cancer and their partners completed questionnaires approximately 3 and 9 months after diagnosis. The data were analyzed employing dyadic data analytic approaches. In the short-term, spousal active engagement--which involved discussing feelings and engaging in joint problem solving--was positively associated with relationship satisfaction in patients as well as in partners, but only when past spousal support was relatively low. Spousal protective buffering--which involved hiding worries and fears and avoiding talking about the disease--was negatively associated with relationship satisfaction in patients, again only when past spousal support was relatively low. If past spousal support was high, participants rated the quality of their relationship relatively high, regardless of their partner's current support behavior. Over time, past spousal supportiveness was not found to mitigate the negative association between spousal protective buffering and relationship satisfaction. Overall, our results indicate that relationship satisfaction can be maintained if past spousal supportiveness is high even if the partner is currently not very responsive to the individual's needs, at least in the short-term.