Polyglactin 910 Meshes Coated with Sustained-Release Cannabigerol Varnish Inhibit Staphylococcus aureus Biofilm Formation and Macrophage Cytokine Secretion: An In Vitro Study.

Synthetic surgical meshes are commonly used in abdominal wall reconstruction surgeries to strengthen a weak abdominal wall. Common mesh-related complications include local infection and inflammatory processes. Because cannabigerol (CBG) has both antibacterial and anti-inflammatory properties, we proposed that coating VICRYL (polyglactin 910) mesh with a sustained-release varnish (SRV) containing CBG would prevent these complications. We used an in vitro infection model with Staphylococcus aureus and an in vitro inflammation model of lipopolysaccharide (LPS)-stimulated macrophages. Meshes coated with either SRV-placebo or SRV-CBG were exposed daily to S. aureus in tryptic soy medium (TSB) or macrophage Dulbecco's modified eagle medium (DMEM). Bacterial growth and biofilm formation in the environment and on the meshes were assessed by changes in optical density, bacterial ATP content, metabolic activity, crystal violet staining, spinning disk confocal microscopy (SDCM), and high-resolution scanning electron microscopy (HR-SEM). The anti-inflammatory effect of the culture medium that was exposed daily to the coated meshes was analyzed by measuring the release of the cytokines IL-6 and IL-10 from LPS-stimulated RAW 264.7 macrophages with appropriate ELISA kits. Additionally, a cytotoxicity assay was performed on Vero epithelial cell lines. We observed that compared with SRV-placebo, the segments coated with SRV-CBG inhibited the bacterial growth of S. aureus in the mesh environment for 9 days by 86 ± 4% and prevented biofilm formation and metabolic activity in the surroundings for 9 days, with respective 70 ± 2% and 95 ± 0.2% reductions. The culture medium that was incubated with the SRV-CBG-coated mesh inhibited LPS-induced secretion of IL-6 and IL-10 from the RAW 264.7 macrophages for up to 6 days without affecting macrophage viability. A partial anti-inflammatory effect was also observed with SRV-placebo. The conditioned culture medium was not toxic to Vero epithelial cells, which had an IC50 of 25 µg/mL for CBG. In conclusion, our data indicate a potential role of coating VICRYL mesh with SRV-CBG in preventing infection and inflammation in the initial period after surgery.

Role of industry in development of surgical simulation centres: a medical education perspective.

The concept of simulation in medicine is derived from the industry. The industry plays an important role in the development production and assimilation of this technology throughout the medical profession however, it is up to the end-user to decide its' needs. Close interaction and cooperation between health care and industry professionals is imperative for successful dissemination of simulation in medicine.

Laparoscopic colectomy is associated with decreased postoperative gastrointestinal dysfunction.

BACKGROUND: Major abdominal surgery is associated with early postoperative gastrointestinal dysfunction, which may lead to abdominal distention and vomiting, requiring nasogastric (NGT) tube insertion. This study aimed to compare the rates of early postoperative NGT insertion after open and laparoscopic colorectal surgery. METHODS: A retrospective chart review was performed for patients who underwent colorectal surgery with removal of the NGT at completion of surgery. Patients who required reinsertion of the NGT in the early postoperative course were identified. The reinsertion rate for patients who underwent laparoscopic surgery was compared with that for the open group. RESULTS: There were 103 patients in the open group and 227 in the laparoscopic group. In the laparoscopic group, 42 patients underwent conversion to open surgery. Reinsertion of the NGT was required for 18.4% of the patients in the open group, compared with 8.6% of the patients for whom the procedure was completed laparoscopically (p = 0.02). Conversion to open surgery resulted in a reinsertion rate of 17%. CONCLUSION: Laparoscopic colorectal surgery is associated with decreased postoperative gastrointestinal dysfunction, resulting in a significantly lower NGT reinsertion rate.

Omega-loop gastric bypass is more effective for weight loss but negatively impacts liver enzymes: a registry-based comprehensive first-year analysis.

BACKGROUND: The impact of omega-loop gastric bypass (OLGB) on weight loss and liver enzymes remains inconclusive. OBJECTIVE: The aim of this study was to compare the impact of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and OLGB on weight loss and liver enzyme levels. SETTING: National Bariatric Surgery Registry. METHODS: The study included 10,675 cases of SG, 1590 cases of RYGB, and 469 cases of OLGB that had available baseline and 1-year (12 ± 2 mo) follow-up data. RESULTS: The highest percentage of excess weight loss was achieved by the OLGB group (84.5% ± 26.7%), followed by the SG (78.5% ± 26.0%) and RYGB (72.0% ± 26.5%) groups (P<.05). The data show that 10% of OLGB cases, 5.2% of RYGB cases, and 1.9% of SG cases (P<.001) had increases in alanine aminotransferase levels, from a normal baseline mean of 23.9 ± 7.5 U/L to an abnormal mean of 64.8.7 ± 66.0 U/L, at follow-up. Similar trends were observed for aspartate aminotransferase and alkaline phosphatase. A regression analysis showed that OLGB was a predictive risk factor for normal baseline alanine aminotransferase levels becoming abnormal postoperatively compared with SG (odds ratio [OR] = 5.65) or RYGB (OR = 2.08) (P<.001). Similarly, OLGB was a predictive risk factor for baseline aspartate aminotransferase and alkaline phosphatase levels becoming abnormal postoperatively. Female sex was the only other meaningful predictive risk of alanine aminotransferase (OR = 2.45) and aspartate aminotransferase (OR = 1.82) becoming abnormal postoperatively. CONCLUSION: This study confirmed the strengths of OLGB weight loss outcomes but also demonstrated its negative impact on liver enzymes. Thus, patients and caregivers should be informed of the risks, and close follow-up is warranted.

Low incidence of adhesion-related bowel obstruction after laparoscopic colorectal surgery.

BACKGROUND: Postoperative adhesions are a major cause of morbidity, accounting for approximately 5% of the readmissions of surgical patients. Bowel obstruction is attributed to adhesions in more than half of the cases, many of which are following colon and rectal surgery. Laparoscopic surgery has the potential advantage of reduced adhesion formation owing to attenuated surgical trauma, less tissue handling, and smaller scars. However, the translation of these advantages to a reduced rate of bowel obstruction has not been sufficiently demonstrated. The aim of this study was to assess the rate of adhesion-related bowel obstruction after laparoscopic colon and rectal surgery. METHODS: Data regarding all cases of laparoscopic colon and rectal surgery were prospectively collected. Information relative to demographics, surgical procedures, and follow-up was analyzed, and patients who were readmitted for bowel obstruction were identified. RESULTS: Over a period of 8 years, 306 patients, at a mean age of 63 years, had a laparoscopic colon and rectal operation in our department-122 for benign conditions and 184 for malignant disease. The mean length of follow-up was 38 months. Six cases (2%) of bowel obstruction, which were unrelated to hernia or advanced cancer, were identified. Two patients had a history of open surgery, in addition to the laparoscopic procedure, so adhesions could be attributed solely to the laparoscopic procedure in 4 patients, which consisted of 1.3% of the total study group. Obstruction occurred within 2 weeks of surgery in 2 patients, and one early reoperation was required. CONCLUSIONS: The incidence of adhesion ileus after laparoscopic colon and rectal surgery appears to be very low. This long-term benefit of laparoscopic surgery should be considered when comparing this technique to its open counterpart.

[Laparoscopic colon and rectal surgery--after ten years and 350 operations].

BACKGROUND: Within a decade since laparoscopy was used in cholecystectomy it has become the preferred approach in many abdominal procedures. Laparoscopic colon and rectal surgery has not yet been adopted by the majority of surgeons, due to technical complexity and reservation regarding its oncological safety. As data and experience accumulate, this attitude is gradually changing. We present our experience with laparoscopic surgery of the large bowel over the last ten years. AIM: To assess the short and intermediate term results after laparoscopic colon and rectal surgery, and to summarize the long term results after curative colectomy for malignancy. METHODS: Data regarding all patients undergoing laparoscopic colon and rectal surgery was prospectively entered into a computerized database, including demographics, surgical technique and perioperative course. Follow-up information was gathered at outpatient clinic visits, and using telephone interviews in selected cases. Data analysis was performed using a statistical software package. RESULTS: Over a period of ten years, 350 various laparoscopic colon and rectal procedures were performed, for both benign and malignant conditions. Sixty percent of the operations were for treatment of colorectal cancer. In 14.5% of cases conversion to open laparotomy was required. Post-operative complications included surgical site infection in 17.4%, anastomotic leak in 6.9%, and a mortality rate of 2.8%. Long term follow-up revealed cancer recurrence locally in 2.3% and systemically in 8.2%. Five year survival was 56% after resection of colorectal cancer regardless of the stage, and 63% after resection with curative intent. CONCLUSIONS: The laparoscopic approach to large bowel surgery enables short and long term results comparable with those achieved by open technique, regarding perioperative complication rate and long term oncologic outcome. The advantages of laparoscopy, related to reduced abdominal wall trauma, justify the adoption of this technique as a legitimate alternative to the open approach.

The Israel Center for Medical Simulation: a paradigm for cultural change in medical education.

Simulation-based medical education (SBME) is a rapidly growing field, as is illustrated by the increased development of simulation centers worldwide. SBME is becoming a powerful force in addressing the need to increase patient safety through quality-care training. Recognizing the benefits of SBME, increasing numbers of bodies involved in medical and health care education and training are establishing simulation centers worldwide. The general model of most facilities focuses on a single simulation modality or a specific branch of medicine or health care, limiting their overall impact on patient safety and quality of care across the health care systems. MSR, the Israel Center for Medical Simulation, is a comprehensive, national, multimodality, multidisciplinary medical simulation center dedicated to enhancing hands-on medical education, performance assessment, patient safety, and quality of care by improving clinical and communication skills. The center uses an "error-driven" educational approach, which recognizes that errors provide an opportunity to create a unique beneficial learning experience. The authors present the Israeli experience as an alternative model, and describe the impact of the MSR model on the Israeli medical community during four years of activity. They also describe the opportunities this model has opened towards changing the culture of medical education and patient safety within Israel Although this model may require modification when implemented in other medical systems, it highlights important lessons regarding the power of SBME in triggering and bringing about cultural changes in traditional medical education.

Self-assessment of performance among surgical trainees during simulated procedures in a simulated operating theater.

BACKGROUND: The ability of surgeons to assess their own performance is essential for training and self-regulation. The latter is based on the premise that they recognize their weaknesses and seek remedial action accordingly. METHODS: Twenty-seven surgical trainees performed a simulated saphenofemoral high-tie on a synthetic model in a simulated operating theater. The performance assessment consisted of blinded rating of technical skills and a global rating of team skills by a human factors expert and a trained surgical research fellow. Subjects also were asked to assess their own performance using the same methods. Spearman's rho was used for data analysis. RESULTS: There was a strong correlation between the experts rating of technical skills and self-assessment (rho = .64). However, the correlation improved with increasing experience. It was .24 for junior trainees, .43 for those with intermediate experience, and .52 for senior trainees. There was a low correlation between the self-assessment and the expert scores for human factors skills (rho = .31). The correlation was higher for the 2 junior groups compared with the senior trainees. CONCLUSIONS: Unlike other studies on self-assessment, this study found that senior surgical trainees are accurate in their self-assessment of technical skills. However, this was not true in the case of human factors skills.

Synchronized video and motion analysis for the assessment of procedures in the operating theater.

HYPOTHESIS: Objective assessment of surgical skill has recently been shown to be possible through the use of dexterity-based and video analysis systems. The aim of this study was to synchronize these 2 modalities to produce a comprehensive surgical assessment tool. DESIGN: The Imperial College Surgical Assessment Device is a dexterity-based motion analysis device that has been developed in the Department of Surgical Oncology and Technology by the Surgical Computing and Imaging Research Group. Further advances to this system have been made to enable synchronized acquisition of hand kinematics and video from real procedures, and their concurrent analysis. To test the feasibility of the system, 10 laparoscopic cholecystectomies performed by 5 different surgeons on consenting patients were recorded. Analysis focused on the entire procedure and also on specific parts of the operation such as the clipping and cutting of the cystic duct and artery. RESULTS: Dexterity analysis was performed using the objective measures of time, path length, number of movements, velocities, and trajectories. Comparative analysis of a surgeon's dexterity was carried out on the whole procedure and by using the synchronized zoom facility in the software. Kinematic signals revealed rapid changes in velocity caused by alternating between different instruments or occurring after complications such as bleeding. CONCLUSION: This new motion analysis system has been shown to be an effective tool for the comprehensive assessment of operative procedures.

Assessment of psychomotor skills acquisition during laparoscopic cholecystectomy courses.

BACKGROUND: Standardized short courses in laparoscopic cholecystectomy aim to teach laparoscopic skills to surgical trainees, although end-of-course assessments of performance remain subjective. The current study aims to objectively assess psychomotor skills acquisition of trainees attending laparoscopic cholecystectomy courses. METHODS: Thirty-seven junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate 2-day courses (A, B, and C), all with identical format. Assessments were comprised of a standardized simulated laparoscopic task, with performance measured using a valid electromagnetic hand-motion tracking device. RESULTS: Overall, trainees made significant improvements in path length (P=.006), number of movements (P<.001), and time taken (P<.001). Analyzing the 3 courses separately, only trainees attending courses A and C made significant improvements. DISCUSSION: Objective validated methods can be used to assess learning of psychomotor skills on courses. In addition to providing participants with an insight into their skills, these data can be used to demonstrate course efficacy.

The reliability of multiple objective measures of surgery and the role of human performance.

BACKGROUND: There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings. METHODS: Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics. RESULTS: On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94. CONCLUSION: The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged.

Objective assessment of technical skills in cardiac surgery.

OBJECTIVE: Reduced training time combined with no rigorous assessment for technical skills makes it difficult for trainees to monitor their competence. We have developed an objective bench-top assessment of technical skills at a level commensurate with a junior registrar in cardiac surgery. METHODS: Forty cardiothoracic surgeons were recruited for the study, consisting of 12 junior trainees (year 1-3), 15 senior trainees (year 4-6) and 13 consultants. The assessment consisted of four key tasks on standardised bench-top models: aortic root cannulation, vein-graft to aorta anastomosis, vein-graft to Left Anterior Descending (LAD) anastomosis and femoral triangle dissection. An expert surgeon was present at each station to provide passive assistance and rate performance on a validated global rating scale giving rise to a total possible score of 40. Three expert surgeons repeated the ratings retrospectively, using blinded video recordings. Data analysis employed non-parametric tests. RESULTS: Both live and video scores differentiated significantly between performances of all groups of surgeons for all four stations (P < 0.01) (median live and video score for LAD; Junior 19,17; Senior 29,22; Consultant 36,28). Correlations between live and blinded rating were high (r = 0.67-0.84; P < 0.001) as was inter-rater reliability between the three expert video raters (alpha = 0.81). CONCLUSIONS: The use of bench-top tasks to differentiate between cardiac surgeons of differing technical abilities has been validated for the first time. Furthermore, it is unnecessary to perform post-hoc video rating to obtain objective data. These measures can provide formative feedback for surgeons-in-training and lead to the development of a competency-based technical skills curriculum.

Ceiling effect in technical skills of surgical residents.

BACKGROUND: Objective evaluation of technical skills is now possible. The aim of this study was to evaluate whether a previously validated assessment tool can discriminate between junior and senior higher surgical trainees (HST) with regard to their technical skills. METHODS: Fifteen junior trainees (years 1 to 3) and 15 senior (years 4 to 6) were asked to perform a series of bench-model tasks, which included knot-tie at depth, vertical mattress suturing, sebaceous cyst excision, small bowel anastomosis, and saphenofemoral junction dissection. Analysis of performance included the Imperial College Surgical Assessment Device, which analyzed positional data such as total number of movements, total distance traveled, and time taken, and video-based qualitative evaluation of performance using global rating scales. In addition, all participants were asked to complete a self-assessment using exactly the same scoring system used by the observers. Statistical analysis included nonparametric tests and Cronbach's alpha was used for interrater reliability (IRR) A P value less than 0.05 was deemed significant. RESULTS: There were no significant differences in performance between junior and senior trainees for most of the tasks (IRR was 0.8 to 0.9). However, significant differences in performance were noted, in favor of the junior group, for knot-tie at depth, for two of the three parameters measured (total number of movements, P = 0.004; time taken, P = 0.01). CONCLUSIONS: In the absence of any significant differences between the groups, we can conclude that there is a ceiling effect (years 3 to 4) in performance beyond which pure technical skills, as measured by this tool, can no longer discriminate between levels of experience. Increasing the sensitivity of future assessment tools is necessary for better evaluation of performance levels. This finding also may imply that for the evaluation of senior trainees, other aspects of surgical competence should be assessed.

Robotic assisted rectopexy.

BACKGROUND: During the last 3 years, robotic surgery has had a considerable impact on minimally invasive surgery in a wide range of specialties. This study describes the surgical technique and preliminary results of our first 6 cases of robotic assisted suture rectopexy. METHODS: During a period of 13 months 6 patients with full thickness rectal prolapse were operated on with the da Vinci surgical system. All patients were considered suitable for a suture rectopexy. Setting-up time, procedure time, patient recovery, and hospital stay were recorded and compared with the current literature. RESULTS: All operations were completed successfully using the robotic system. There were no major complications and no deaths. Mean setting-up time was 28 minutes, mean operation time was 127 minutes, and mean hospital stay was 6 days. At 3 to 6 months of follow-up all patients are in good health, with no signs of recurrence and no reports of constipation. CONCLUSIONS: Robotic assisted suture rectopexy is feasible and safe and apparently meets accepted standards of laparoscopic surgery.

Focused, minimally invasive radio-guided parathyroidectomy: a feasible and safe option for elderly patients with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism in elderly patients is usually associated with additional co-morbidity that increases operative risk, and thus many geriatric patients are denied the benefit of surgery for a single parathyroid adenoma. OBJECTIVES: To evaluate the safety and efficacy of accurate single photon emission computed tomography sestamibi scintigraphy, enabling precise localization of a single adenoma, in the geriatric population. METHODS: Twenty-two patients aged 70 years and over with biochemically proven PHPT and with a single parathyroid adenoma identified by localization studies (sestamibi SPECT scan and ultrasonography) underwent 23 operations over 29 months (out of a total of 140 patients operated upon during the same period). Immediate preoperative sestamibi scintigraphy and marking of focal adenoma uptake followed by intraoperative hand-held gamma probe were used for the removal of the parathyroid adenoma by unilateral minimal access surgery. Associated major co-morbid conditions and pre- and postoperative calcium, phosphorus and parathormone levels were recorded. Indications for surgery were listed and operative and postoperative complications were noted. The patients were followed for a mean period of 17.7 months using the same parameters. RESULTS: The 22 patients with PHPT had a mean age of 76.3 +/- 5.9 years (range 70-88 years) and a female to male ratio of 13:9. Associated co-morbidity included ischemic heart disease (n = 15), hypertension (n = 22), non-insulin-dependent diabetes mellitus (n = 9), chronic obstructive pulmonary disease (n = 3), and previous neck surgery (n = 3). Mean preoperative serum calcium, phosphorous and PTH were 11.7 +/- 1.3 mg/dl, 2.5 +/- 0.5 mg/dl and 160.9 +/- 75.4 pg/ml respectively. In 20 of the 22 patients, surgery was successful in curing PHPT (91%). One patient had persistent hypercalcemia due to a missed adenoma, and repeat operation (by focused minimal accesss surgery) was successfully performed 2 weeks later. There were no complications and no morbidity postoperatively. Mean postoperative serum calcium, phosphorous and PTH were 9.6 +/- 1.2 mg/dl, 3.0 +/- 0.5 mg/dl and 35.2 +/- 24 pg/ml respectively. In all patients, serum calcium levels remained normal (9.7 +/- 1.3 mg/ml) after long-term follow-up (mean 17.7 +/- 9.6 months). CONCLUSIONS: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is a safe and effective method to cure hyperparathyroidism in the elderly. Success of surgery is directly related to the surgeon's experience and to the precise localization marking provided by sestamibi scintigraphic SPECT localization and concurrent sonographic findings.

Real-time synchronization of kinematic and video data for the comprehensive assessment of surgical skills.

Surgical dexterity in operating theatres has traditionally been assessed subjectively. Electromagnetic (EM) motion tracking systems such as the Imperial College Surgical Assessment Device (ICSAD) have been shown to produce valid and accurate objective measures of surgical skill. To allow for video integration we have modified the data acquisition and built it within the ROVIMAS analysis software. We then used ActiveX 9.0 DirectShow video capturing and the system clock as a time stamp for the synchronized concurrent acquisition of kinematic data and video frames. Interactive video/motion data browsing was implemented to allow the user to concentrate on frames exhibiting certain kinematic properties that could result in operative errors. We exploited video-data synchronization to calculate the camera visual hull by identifying all 3D vertices using the ICSAD electromagnetic sensors. We also concentrated on high velocity peaks as a means of identifying potential erroneous movements to be confirmed by studying the corresponding video frames. The outcome of the study clearly shows that the kinematic data are precisely synchronized with the video frames and that the velocity peaks correspond to large and sudden excursions of the instrument tip. We validated the camera visual hull by both video and geometrical kinematic analysis and we observed that graphs containing fewer sudden velocity peaks are less likely to have erroneous movements. This work presented further developments to the well-established ICSAD dexterity analysis system. Synchronized real-time motion and video acquisition provides a comprehensive assessment solution by combining quantitative motion analysis tools and qualitative targeted video scoring.

A simple, low-cost platform for basic laparoscopic skills training.

Laparoscopic basic skills' training relies mainly on costly video trainers. The aim of this study was to evaluate a simple, low-cost devise for laparoscopic training. In all, 32 participants with varying levels of skill were recruited. A Simulab LapTrainer (Simulab, Seattle, Washington), using a simple plastic box, a webcam, and a Universal Serial Bus 2 card, was used together with standard operating tools. Participants performed 3 tasks (rope passing, peg transfer, and intracorporeal knot tying), which were video recorded and blindly assessed by 2 experts using error scores, checklists, and time. Statistical analysis included nonparametric tests and Cronbach alpha for inter-rater reliability. A P <.05 was deemed significant. Highly significant differences were noted between groups in all tasks and for all parameters (P = .001). Inter-rater reliability was 0.88. Simulator ratings were good: 63%, excellent: 28%, and only 9% rated it as average. The Simulab LapTrainer provides a valid alternative for skills training. Its simplicity, portability, and relatively low cost make it an attractive surgical training tool.

Training and assessment of trauma management: the role of simulation-based medical education.

Simulation-based medical education (SBME) offers a safe and "mistake-forgiving" environment to teach and train medical professionals. The diverse range of medical simulation modalities enables trainees to acquire and practice an array of tasks and skills. SBME offers the field of trauma training multiple opportunities to enhance the effectiveness of the education provided in this challenging domain. In this article, the authors describe the possible roles of simulated patients, skills trainers, computerized patient simulators, and web-based teaching in trauma training, and describe some practical aspects of using simulation for trauma training.

Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: objective assessment of the transfer of skill from virtual reality to reality.

BACKGROUND: Very few studies have addressed the transferability of skills from virtual reality (VR) to real life. The aim of this study was to assess the feasibility and effectiveness of teaching intracorporeal knot tying (ICKT) by VR simulation only. METHODS: Twenty novices underwent structured training of basic skills training on the Minimally Invasive Surgical Trainer simulator (Mentice AB, Gothenburg, Sweden) followed by knot tying training on the LapSim simulator (Surgical Science, Gothenburg, Sweden). They were assessed pre- and post-training on a video trainer. Assessment of performance included motion tracking and video-based checklist. Nonparametric statistical analysis was used, and P < .05 was deemed significant. RESULTS: All participants completed a correct knot as compared with only 25% before VR training. Time to completion was 66% faster and knot quality 45% better after VR training. Significant reduction in number of movements (P = .006) and distance traveled (P < .000) by both hands after VR training. CONCLUSIONS: Teaching ICKT by VR simulators only is feasible and effective. Furthermore, this study highlights the complementary use of different VR simulators within a structured curriculum.