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Introduction: Three-dimensional (3D), high-definition (HD), and ultra-high-definition (4K HD) are recent additions over regular HD technology for laparoscopic surgery. The aim of this study was to ...

Background: We are currently in the era of laparoscopic surgery. It has gained popularity in the last few decades because of its well- known advantages. Laparoscopy requires different skills from those of open surgery. In a paradigm shift, learning basic surgical skills is now performed more in the skills laboratory than in the operation theater. However, there is a lack of reliable training and assessment tools for laparoscopic surgical skills. This study aimed to objectively assess the effect of bench laparoscopic training in novices. Methods: This prospective study was conducted at the Clinical Skills Centre of Bangalore Medical College and Research Institute (BMCRI) in Bangalore, India. Sixty interns with no previous experience in laparoscopy were included. They underwent supervised training on the box trainer for 3 days, 2 hours a day, in basic surgical tasks, including pointing dots, joining straight lines, joining curved lines, picking objects, peg transfer, and circle cut. All participants were assessed objectively in a virtual reality (VR) simulator before and after training. The objective outcomes measured were time taken, distance traveled, and error scores given by the VR simulator metrics. Results: The novices showed statistically significant improvement in all the tasks after the training compared with their skill levels before the training. Conclusion: Structured short-term training significantly improves basic laparoscopic surgery skills.

Background This study aims to investigate if a smartphone laparoscopy simulator, SimuSurg, is effective in improving laparoscopic skills in surgically inexperienced medical students. Methods This is a single-blinded randomized controlled trial featuring 30 preclinical medical students without prior laparoscopic simulation experience. The students were randomly allocated to a control or intervention group (n = 15 each) and 28 students completed the study (n = 14 each). All participants performed three validated exercises in a laparoscopic box trainer and repeated them after 1 week. The intervention group spent the intervening time completing all levels in SimuSurg, whereas the control group refrained from any laparoscopic activity. A prestudy questionnaire was used to collect data on age, sex, handedness, and experience with gaming. Results The total score improved significantly between the two testing sessions for the intervention group (n = 14, median change [MC] = 182.00, P = 0.009) but not for the control group (n = 14, MC = 161.50, P = 0.08). Scores for the nondominant hand improved significantly in the intervention group (MC = 66.50, P = 0.008) but not in the control group (MC = 9.00, P = 0.98). There was no improvement in dominant hand scores for either the intervention (MC = 62.00, P = 0.08) or control (MC = 26.00, P = 0.32) groups. Interest in surgery (β = −234.30, P = 0.02) was positively correlated with the baseline total scores; however, age, sex, and experience with video games were not. Conclusions The results suggest that smartphone applications improve laparoscopic skills in medical students, especially for the nondominant hand. These simulators may be a cost-effective and accessible adjunct for laparoscopic training among surgically inexperienced students and clinicians.

Background. Laparoscopic surgery has gained popularity in the last few decades replacing open standard techniques in several procedures. While its use and scope expand, a standardized method of training and assessment in laparoscopic skills is lacking. Aim. To assess the effect of virtual reality (VR) training on laparoscopic surgical skills. Materials and Methods. It is a prospective, controlled study conducted at Sagar Hospital’s skill lab and Shanthi Hospital and Research Centre (SHRC). We included 27 post graduates in general surgery. They were divided into two groups. One group underwent training in VR Simulator for one week, 30 minutes each day. The second group received no training. Their proficiency while mobilizing the Gallbladder from its liver bed was assessed using a validated scale by a single blinded observer. Results. The statistical analysis was done using a non-parametric test (Mann-Whitney U test). Residents who underwent training in VR simulator got better scores in Overall rating and also in individual parameters when compared with the control group (P =

Background The transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training. Methods With the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts. Results This training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent). Conclusions We present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.

Background: Virtual reality laparoscopic simulators were introduced to provide an optimal and safe learning environment for surgical trainees. The simulators had been validated and proven to be beneficial. Materials and Methods: The aim of this study is to assess the performance of the local surgical trainees using a validated simulator and help in the development of a training program using the simulator. Prospective repeated measures study in a single center using a validated virtual reality simulator was performed. Years 1 and 2 local postgraduate surgical trainees with limited laparoscopic cholecystectomy experience were included in the study. The trainees underwent a proposed training module, and the simulator evaluated each performance. Comparison was made between the performance before and after the training module. Results: Nine surgical trainees (eight males, median age: 33 years old) with a median of 5 years of surgical experience after graduation were included in the study. The time to complete each basic laparoscopic skill improved between 26.5% and 64.3% (P < 0.05) while the time taken to complete each of the cholecystectomy procedural task improved between 43.2% and 73.8% (P < 0.05). The time taken to complete a full cholecystectomy procedure improved from 873s to 512s (P = 0.008), and the efficiency of cauterization improved by 15.3% (P = 0.008). Analysis of the various learning curve showed the improvement plateaued between the third and tenth sessions. Conclusion: Virtual reality laparoscopic training should be implemented as part of training as it improves certain skill sets.

Background: Laparoscopic colorectal surgery (LCRS) was first described in 1991, and its safety, efficacy and patient benefit were adequately documented in literature. However, its penetration and acceptability is poor in most countries, due to its long learning curve and lack of surgeons training and confidence. A Minimal Access Surgery (MAS) Training Center in Mumbai has over the last 7 years trained more than 8000 surgeons in various MAS specialities. The centre has initiated courses for LCRS training. Materials and Methods: The anatomy of the pig colon is very different from human anatomy. The pig colon anatomy is altered to mimic human colon anatomy in the porcine abdomen, permitting hands-on practice on most laparoscopic colorectal surgical procedures, as part of the LCRS training course, under mentorship of expert faculty, who simultaneously assess participants performance. Results: Each participant performs and assists for at least three procedures and is evaluated at each step of the procedure by a structured format. The overall evaluation by Faculty which though subjective, is detailed and favourable. Feedback of each participant is good and acceptable as a very helpful course. Conclusion: This porcine model is ideal for hands-on training for LCRS. Participants achieve a good degree of skill level and confidence in performing LCRS procedures on fresh bleeding porcine cadaver models. The centre is factual and pragmatic and stresses that it needs more than a course to make a safe surgeon; operation room mentorship is the finishing school.

WOS:000587591000008 PubMed: 32966206 Objective: This study aimed to evaluate the opinions of urologists from different countries about urooncology education, fellowship programs, and approaches to different urological malignancies at different stages using a questionnaire. Material and methods: A total of 207 urologists from 22 countries were sent a questionnaire containing 18 items by email. The questions were related to urologic oncology training provided during residency, acceptance of uro-oncology as a sub-branch, the necessity of certification for treatment and follow-up, fellowship program preferences, adequateness of the programs, and approach differences to the different stages of urological malignancies among the urologists from different countries. Results: In total, Ill (53.62%) urologists who completed the questionnaire were enrolled in the study, and 40.54% of the urologists reported that the uro-oncology training during the residency period was not sufficient. Furthermore, 79.27% of the urologists reported opinions about acceptance of uro-oncology as a sub-branch. The ratio of urologists who undertake the treatment of patients with muscle-invasive bladder cancer (radical surgery and urinary diversion) and prostate cancer (radical prostatectomy, definitive radiation therapy, experimental local treatment, and hormonal therapy) is 27.92% and 37.83%, respectively. The urologists reported that they perform nephron-sparing surgery (NSS), radical nephrectomy (RN), and laparoscopic NSS/RN treatments in patients with localized renal cancer at the rates of 61.26%, 47.74%, and 25.22%, respectively. Conclusion: Uro-oncology training during the residency period seems to be inadequate in most of the countries, and a high number of the urologists tend to avoid high-volume operations and systemic treatments of uro-oncologic malignancies.

Background Laparoscopy has reduced tactile and visual feedback compared to open surgery. There is increasing evidence that visual and haptic information converge to form a more robust mental representation of an object. We investigated whether tactile exploration of an object prior to executing a laparoscopic action on it improves performance. Methods A prospective cohort study with 20 medical students randomized in two different groups was conducted. A silicone ileocecal model, on which a laparoscopic action had to be performed, was used inside an outside a ForceSense box trainer. During the pre-test, students either did a combined manual and visual exploration or only visual exploration of the caecum model. To track performance during the trials of the study we used force, motion and time parameters as representatives of technical skills development. The final trial data were used for statistical comparison between groups. Results All included time and motion parameters did not show any clear differences between groups. However, the force parameters Mean force non-zero (p = 004), Maximal force (p = 0.01) Maximal impulse (p = 0.02), Force volume (p = 0.02) and SD force (p = 0.01) showed significant lower values in favour of the tactile exploration group for the final trials. Conclusions By adding haptic sensation to the existing visual information during training of laparoscopic tasks on life-like models, tissue manipulation skills improve during training.

The study involves the testing of a novel laparoscopic training model by surgeons of various levels of experience.There has been an increasing requirement for low-cost simulation. Our aim was to evaluate the construct validity of a low-cost model for teaching core laparoscopic skills.The Double-Glove model was made from 2 latex gloves, one placed in the other. The inner glove was filled with water and 3 ovals were drawn on the outer glove. Participants were required to dissect the middle oval out without perforating the inner glove or leaving the line border of the middle oval. The task was assessed using a previously validated scoring system (minimum -120; maximum 80).Ninety-five participants completed the task: 40 novices, 45 intermediates, and 10 experts. The model revealed statistical significance between the three groups. Experts scored higher than novices (58/80 vs 11.7/80; p 0.0001) and intermediates (58/80 vs 29.1/80; p = 0.0004), and intermediates scored higher than novices (29.1/80 vs 11.7/80; p = 0.014). Novices took more time to complete the task compared to intermediates (10 min vs 7.87 min; p 0.0001) and experts (10 min vs 6.98 min; p 0.0001). No correlation between time taken and score obtained was seen (r = -0.06, r = 0.01, r = -0.2 for novice, intermediate, and expert groups).By differentiating between groups of variable experience, the model demonstrated construct validity. It offers an inexpensive model that can be utilized in low-cost laparoscopic simulation.Study of a diagnostic test.II.

BACKGROUND Total laparoscopic distal gastrectomy (TLDG) is increasing due to some advantages over open surgery, which has generated interest in gastrointestinal surgeons. However, TLDG is technically demanding especially for lymphadenectomy and gastrointestinal reconstruction. During the course of training, trainee surgeons have less chances to perform open gastrectomy compared with that of senior surgeons. AIM To evaluate an appropriate, efficient and safe laparoscopic training procedures suitable for trainee surgeons. METHODS Ninety-two consecutive patients with gastric cancer who underwent TLDG plus Billroth I reconstruction using an augmented rectangle technique and involving trainees were reviewed. The trainees were taught a laparoscopic view of surgical anatomy, standard operative procedures and practiced essential laparoscopic skills. The TLDG procedure was divided into regional lymph node dissections and gastrointestinal reconstruction for analyzing trainee skills. Early surgical outcomes were compared between trainees and trainers to clarify the feasibility and safety of TLDG performed by trainees. Learning curves were used to assess the utility of our training system. RESULTS Five trainees performed a total of 52 TLDGs (56.5%), while 40 TLDGs were conducted by two trainers (43.5%). Except for depth of invasion and pathologic stage, there were no differences in clinicopathological characteristics. Trainers performed more D2 gastrectomies than trainees. The total operation time was significantly longer in the trainee group. The time spent during the lesser curvature lymph node dissection and the Billroth I reconstruction were similar between the two groups. No difference was found in postoperative complications between the two groups. The learning curve of the trainees plateaued after five TLDG cases. CONCLUSION Preparing trainees with a laparoscopic view of surgical anatomy, standard operative procedures and practice in essential laparoscopic skills enabled trainees to perform TLDG safely and feasibly.

Stereoscopic (3D) imaging can be used to facilitate the learning of basic laparoscopic tasks. Its advantages over traditional endoscopic (2D) imaging include better depth perception and spatial orientation. However, the transition between 3D and 2D imaging systems has not been previously studied. This study compares the acquisition of basic laparoscopic skills in a laparoscopic-naïve population using both imaging systems, and explores the possibility of a secondary learning curve in the transition between systems.26 novice learners were randomly allocated into two arms and taught to perform two basic laparoscopic tasks adopted from the fundamentals of laparoscopic surgery (FLS) curriculum, peg transfer (T1) and pattern cutting (T2) using either 2D or 3D imaging systems. These tasks were repeated until proficiency was achieved. Participants in each arm then repeated the tasks in the other viewing system (2D/3D vs 3D/2D). The parameters measured were: (a) time taken to complete the task and (b) number of attempts to achieve proficiency.There was a significant shortening of time required to achieve proficiency in T2 using a 3D system (mean difference-in-differences = - 65.4, 95% CI - 103.6 to - 27.2, t(24) = - 3.5, p value = 0.002) but no difference between 2D and 3D imaging systems for T1, a simpler task. Sub-group analysis of T1 and T2 between the 2D/3D and 3D/2D arms showed the presence of a secondary learning curve in the 2D/3D arm for both tasks, (T1: β-estimate - 2.68, 95% CI - 3.68 to - 1.68, p value = 0.0003; T2: β-estimate - 2.45, 95% CI - 3.75 to - 1.14, p value 0.004), but in the 3D/2D arm there was a secondary learning curve only for T2. (β-estimate 2.60, 95% CI 1.45-3.76, p value 0.001) CONCLUSION: 3D imaging can be an effective tool to speed the acquisition of proficiency in basic laparoscopic tasks for novice learners, especially in more complex tasks such as pattern cutting. The skills learned in 3D imaging can translate into 2D, albeit with a secondary learning curve.

The purpose of this study was to evaluate the effect of 3D visualization applied to laparoscopic appendectomy (LA) performed by young surgeons (YS). We considered both operative features and clinical outcomes, aiming to highlight the benefits that this technology could bring to novice surgeons and their laparoscopic training. All the surgical procedures were performed by residents who had performed less than 20 appendectomies prior to the beginning of the study under the supervision of an expert surgeon. At the time of enrolment patients were randomized into two arms: Experimental arm (EA): laparoscopic appendectomy performed with laparoscopic 3D vision technology. Control arm (CA): laparoscopic appendectomy performed with the "standard" 2D technology. The primary endpoint was to find any statistically significant difference in operative time between the two arms. Differences in conversion rate, intra-operative complications, post-operative complications and surgeons’ operative comfort were considered as secondary endpoints. We randomized 135 patients into the two study arms. The two groups were homogeneous for demographic characteristics, BMI and ASA scores. The characteristics of clinical presentation and anatomical position showed no significant difference. The operative time was longer in the CA (57.5 vs. 49.6 min, p = 0.048, 95% CI). In the subgroup of complicated appendicitis, this trend toward inferior operative time was confirmed without reaching statistical significance (2D = 60 min, 3D = 49.5 min, p = 0.082 95% CI). No intra-operative complications were observed in either group. The conversion rate was 5.6% (4 patients) in the 2D group and 4.6% (3 patients) in 3D group. The utilization of 3D laparoscopy was associated with reduction in operative time without influencing other parameters, in particular without altering the safety profile of the procedure.

Contains fulltext : 225446.pdf (Publisher’s version ) (Open Access) BACKGROUND: Little is known about the relation between impulsiveness and surgical performance even though research in similar high-risk/high-skills shows evidence of more hazardous behavior by impulsive professionals. We investigated the impact of impulsiveness on laparoscopic simulator performance. METHODS: Eighty-three subjects participated in a four-session laparoscopic training course. Based on the Eysenck Personality test, we created equal sized high- and low impulsiveness groups and compared task duration and errors on tasks for two laparoscopic simulators. RESULTS: The low impulsiveness group outperformed the high impulsiveness group on damage on the LapSim virtual reality trainer (U = 459, p

INTRODUCTION To determine whether training laparoscopic nephrectomy (LN) with a virtual reality (VR) simulator improves the performance of porcine LN. METHODS Twelve urological residents were assigned to two groups: a training and a non-training group. All participants performed baseline assessments of LN skills and time on the LapPASS® simulator. The training group received preoperative LapPASS® training. Both groups then performed LN using a porcine model. The operations were videotaped and evaluated using the Global Operative Assessment of Laparoscopic Skills (GOALS) system. After porcine LN, the training group performed a final LN with the LapPASS® simulator. RESULTS There was no significant difference in the operation time required for porcine LN. There were no significant differences in the total A (autonomy), B (bimanual dexterity), D (depth perception), or T (tissue handling) GOALS scores. However, the total E (efficiency) score in the training group was higher than that in the non-training group (P = .030). The final LN score with LapPASS® was significantly higher than the baseline (P = .004). CONCLUSIONS The results of this study demonstrated that VR LN training improved performance in an actual operation. VR-based procedural simulation could become a vital part of the laparoscopic training program for residents.

Background: A major concern about the Laparoscopy Approach to Cervical Cancer trial is the disparities in laparoscopic radical hysterectomy experience between the participating centers and the potential effects of the learning curve of minimally invasive surgery on the oncologic outcomes of patients. Thus, it is necessary to assess the survival of cervical cancer patients undergoing laparoscopy in a minimally invasive gynecology center.Methods: A consecutive series of patients undergoing first laparoscopic radical hysterectomy (LRH) for cervical cancer from May 2008 to December 2017 at a national laparoscopic training center were retrospectively analyzed. The overall survival (OS) and progression-free survival (PFS) were compared between groups.Results: In total, 1316 women with FIGO (2009) stage IA-IIB cervical cancer received LRH. Among them, 1114 (84.7%) were followed-up for 3 months or longer; the median follow-up period was 48 months (range, 3-144 months). In patients with stage IA, IB1 (≤ 2 cm), IB1 (> 2 cm), IB2, IIA1 and IIA2-IIB tumors, the 4-year PFS rates were 98.6%, 94.5%, 87.4%, 65.6%, 80.0% and 67.4%, respectively, and the 4-year OS rates were 98.6%, 96.8%, 91.1%, 77.4%, 85.6% and 76.2%, respectively. The 4-year PFS and OS were as high as 96.2% and 97.5%, respectively, in patients with squamous cell carcinoma of 2 cm or smaller in diameter. A stable high 4-year OS and PFS was achieved after completing 100 LRHs. In patients operated on by the same surgeon, an improvement in survival was observed after 40 LRHs. Conclusion: Favorable oncologic outcomes can be achieved in patients with IA-IB1 cervical cancer after LRH in a center with a high surgery volume.

IntroductionEfficient training methods are required for laparoscopic surgical skills training to reduce the time needed for proficiency. Transcranial direct current stimulation (tDCS) is widely used to enhance motor skill acquisition and can be used to supplement the training of laparoscopic surgical skill acquisition. The aim of this study was to investigate the effect of anodal tDCS over the primary motor cortex (M1) on the performance of a unimanual variant of the laparoscopic peg-transfer task.MethodsFifteen healthy subjects participated in this randomized, double-blinded crossover study involving an anodal tDCS and a sham tDCS intervention separated by 48 hours. On each intervention day, subjects performed a unimanual variant of laparoscopic peg-transfer task in three sessions (baseline, tDCS, post-tDCS). The tDCS session consisted of 10 minutes of offline tDCS followed by 10 minutes of online tDCS. The scores based on the task completion time and the number of errors in each session were used as a primary outcome measure. A linear mixed-effects model was used for the analysis.ResultsWe found that the scores increased over sessions (pConclusionThis study suggests that irrespective of the type of current stimulation (anodal and sham) over M1, there was an improvement in the performance of the unimanual peg-transfer task, implying that there was motor learning over time. The results would be useful in designing efficient training paradigms and further investigating the effects of tDCS on laparoscopic peg-transfer tasks.

Objective: To evaluate whether or not prior laparoscopic training improves performance during robotic surgery utilising DaVinci robotic skills simulator. Methods: The cross-sectional study was conducted at the Civil Hospital, Karachi, from May 4 to November 11, 2018, and comprised first year residents in Group A with no laparoscopic skills and fourth year residents doing laparoscopic cholecystectomy independently and surgical faculty members in Group B who had laparoscopic skills. Both the groups had no previous exposure to robotic surgery and skills simulator. There were 4 exercises which were repeated three times by each participant. Scoring was done using the the DaVinci robotic skills simulator software. Data was analysed using SPSS 22. Results: Of the 30 surgeons, there were 15(50%) in Group A with a mean age of 26±0.56 years, and 15(50%) in Group B with a mean age of 32 years± 9.16 (p0.05). Group B fared better in the individual scoring of Suture sponge 2 (p>0.05). Conclusion: Laparoscopic skills apparently did not confer any benefit while performing exercises on the DaVinci skills simulator. Key Words: DaVinci Si, DaVinci skills simulator, dVSSS, Robotic surgery curriculum, Robotic surgery simulation. Continuous...

Background: The eoSim® laparoscopic augmented reality (AR) simulator has instrument tracking capabilities that may be suitable for implementation in laparoscopic training. The objective is...

The advanced laparoscopic skills (ALS) curriculum was created to address the need for improved laparoscopic training for senior surgical trainees. It focuses on the domain of laparoscopic suturing and consists of 6 tasks with established proficiency benchmarks. Tasks are performed using a standard laparoscopic box trainer. This study examines whether practicing on the ALS curriculum could translate to improved clinical suturing.Surgery residents from four institutions participated in the study. Performance of the 6 ALS tasks and performance of a porcine gastrojejunostomy (GJ) and Nissen fundoplication were assessed before and after training. Video-recorded performance was de-identified and scored by three experts using both time and a previously published assessment instrument. Paired t-tests examined performance differences before and after the curriculum. Pearson correlations examined the relationship between performance on the porcine and ALS tasks.Twelve residents (PGY1-8) from 4 institutions completed the study. Average practice time on ALS tasks was 6.25 weeks (range 1-14 weeks) and 254 min (range 140-600min). Combined ALS task time decreased from 2748s ± 603s to 1756s ± 281s (p 0.001). Each of the 6 task times significantly improved (p 0.05). Total errors decreased from 5.8 ± 3.2 to 3.7 ± 1.9 (p 0.05). Average GJ times decreased from 1043s ± 698s to 643s ± 183s (p = 0.055). Average Nissen times decreased from 990s ± 531s to 685s ± 265s (p 0.05).Dedicated practice on the six ALS tasks led to decreased suturing time and fewer errors when completing both GJ and Nissen suturing in a porcine model. Further studies will be undertaken to determine the optimal application of the ALS task set in advanced laparoscopic training.

To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures. A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed. A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working ≤ 50 h per week, laparoscopic training and having laparoscopic training boxes. Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.

BACKGROUND The purpose of this study was to develop a remote-controlled injection device for T-tube cholangiography to avoid occupational exposure. MATERIAL AND METHODS The remote-controlled injection device has 3 major components: an injection pump, a pressure sensor, and a wireless remote-control panel. The feasibility and effectiveness of this device for T-tube cholangiography was evaluated in ex vivo porcine livers using a laparoscopic training platform and in in vivo canine experiments. RESULTS The contrast dye was successfully injected into the biliary tracts of the ex vivo porcine liver and canines by the designed device. The X-ray images clearly showed the anatomical structure of the bile ducts. No obvious adverse reaction was observed in the dogs during or after the procedure. All steps were controlled remotely, avoiding ionizing radiation exposure to the surgeons. CONCLUSIONS This novel remote-controlled injection device for T-tube cholangiography can assist operators in completing cholangiography remotely and protecting them from occupational exposure.

Introduction Spaced learning has been shown to be superior in complex motor skill acquisition like laparoscopic suturing and knot tying. By using a pre–post follow-up design, the aim of the study was to evaluate the long-term impact of implementation of the spaced learning concept in laparoscopic training. Materials and Methods To evaluate the effectiveness of spaced learning, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes—prior and after 3 hours of hands-on training. To examine the long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 12 months later as follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation. Results Twenty students were included in the study; after simple randomization, 10 were trained using the “spaced learning” concept and 10 via traditional methods. Both groups had comparable baseline characteristics and improved after training significantly, regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of speed (p = 0.021), knot quality (p = 0.008), and suture strength (p = 0.003). Additionally, spaced learning significantly decreased anxiety (p = 0.029) and probability of success (p = 0.005). Conclusion The spaced learning concept is very suitable for long-term complex motor skill acquisition, like laparoscopic suturing and knot tying. It is superior to conventional training regarding speed and, most importantly, knot quality and stability, resulting in improved confidence and motivation. Thus, we strongly recommend to incorporate the spaced learning concept into training courses and surgical programs.

Background:The practice of laparoscopy involves the use of training models that are different from conventional open surgery. These concepts are not captured in the traditional models of surgical residency training. Residency training in surgery has been seen as an ample opportunity for early introduction and training in laparoscopy.Objectives: This study aimed to assess the level of exposure and training experience of some surgical resident doctors in accredited training institutions in Nigeria on laparoscopy. Methodology:A cross-sectional survey was conducted among the resident doctors undergoing revision course in surgery at the National Orthopaedic Hospital, Igbobi, Lagos, and Lagos University Teaching Hospital, Lagos, in March 2018. Using the quantitative method of data collection, a pre-tested structured questionnaire was used to collect information on the demography and training exposure of the residents in laparoscopy.Results:A total of 54 of 96 residents surveyed returned the questionnaire, giving a response rate of 56%. There were 53 (98.1%) males and 1 (1.9%) female. The age range of the respondents was between 30 and 46 years, with a mean of 34.2 ± 3.96 years. Thirty-two (59.3%) respondents had spent at least 2 years training in surgery. Thirty-six (66.7%) respondents had not participated in more than four laparoscopic procedures during their rotation. Forty-six percent of respondents reported that their experience in laparoscopy was mainly by observation of the procedures. Forty-nine (90.7%) of respondents surveyed had not attended any training program in laparoscopy. Eighty-one (81.0%) of respondents had a strong motivation and desire for future practice of laparoscopy.Conclusion:This study revealed that few Nigerian postgraduate trainees sampled in the survey were exposed and had training experience in laparoscopy.

INTRODUCTION This study presents the first steps and results towards the development of a system for predicting the quality of surgical performance and workload in laparoscopic training. MATERIAL AND METHODS Surgeons wore a smartwatch which recorded their heart rate and hand motion during each laparoscopic procedure. Data was then correlated with both the Surgery Task Load Index (SURG-TLX) subjective questionnaire and the Global Operational Assessment of Laparoscopic Skills (GOALS) objective evaluation tool. Statistical analysis was conducted in order to study the relationship between parameters and to compare the results according to the surgeons’ level of experience. RESULTS Nine laparoscopic surgeons participated in this study, five gynecologists and four digestive surgeons. Gynecological surgeons showed a positive correlation between their level of experience, heart rate, hand motion, and GOALS score, except for bimanual dexterity. The reduction in the variability of hand accelerations led to improved tissue handling. Digestive surgeons showed a negative correlation between their level of experience and the reported temporal demand and complexity of the procedure. Novice digestive surgeons reported increased workload during surgery, mainly in mental, physical, and temporal workload. In both surgical specialties, it was observed that reduction in surgical workload was associated with improved GOALS score. CONCLUSIONS Preliminary results showed that bimanual dexterity is independent of the experience of gynecological surgeons. During laparoscopic surgical procedures, reduced variability in hand accelerations leads to better tissue manipulation. In addition, in gynecological and upper gastrointestinal procedures, reduced surgical workload is associated with improved surgical performance.

Supplemental Digital Content is available in the text., Background: Although methods to overcome difficulties associated with mirror-image conditions have been investigated, the ideal spatial relationship among the operator line of sight, monitor location, and camera location remains unclear. Moreover, the best training method for improving laparoscopic surgical skills under varying operator line of sight, camera, and monitor positions is unknown. We aimed to investigate the role of laparoscopic training under mirror-image conditions in improving surgical efficiency and whether prior surgical experience affects such training. Methods: This prospective study was conducted at the Department of Surgical Oncology, Tokyo University, Japan. Twenty-five surgeons participated. Novice (n=14), trained (n=7), and expert (n=4) participants performed the simulated task in a box trainer while varying the positional relationships among the surgeons, camera, and monitor. Five patterns were repeatedly performed 5 times per day for 4 days over 2 weeks. Results: The most significant differences in terms of the time required to complete the task under mirror-image conditions among the 3 groups were on day 1 (novices: 185.8 s, trained: 79.7 s, and experts: 46.5 s, P=0.009). However, after 4 days of training, the corresponding times did not differ among the 3 groups (26.0, 30.7, and 23.1 s, respectively; P=0.415). Laparoscopic training was sufficiently effective under mirror-image conditions. Conclusions: Mirror-image surgical conditions provided the most difficult setting, because surgeons and assistants often became disoriented, and task performance was most degraded. However, just 4 days of training was found to be sufficient to overcome the difficulties encountered while performing laparoscopic procedures under mirror-image conditions.

Background The availability of validated laparoscopic simulators has not resulted in sustainable high-volume training. We investigated whether the validated laparoscopic serious game Underground would increase voluntary training by residents. We hypothesized that by removing intrinsic barriers and extrinsic barriers, residents would spend more time on voluntary training with Underground compared to voluntary training with traditional simulators. Methods After 1 year, we compared amount of voluntary time spent on playing Underground to time spent on all other laparoscopic training modalities and to time spent on performing laparoscopic procedures in the OR for all surgical residents. These data were compared to resident’ time spent on laparoscopic activities over the prior year before the introduction of Underground. Results From March 2016 until March 2017, 63 residents spent on average 20 min on voluntary serious gaming, 17 min on voluntary simulator training, 2 h and 44 min on mandatory laparoscopic training courses, and 14 h and 49 min on laparoscopic procedures in the OR. Voluntary activities represented 3% of laparoscopic training activities which was similar in the prior year wherein fifty residents spent on average 33 min on voluntary simulator training, 3 h and 28 min on mandatory laparoscopic training courses, and 11 h and 19 min on laparoscopic procedures. Conclusion Serious gaming has not increased total voluntary training volume. Underground did not mitigate intrinsic and extrinsic barriers to voluntary training. Mandatory, scheduled training courses remain needed. Serious gaming is flexible and affordable and could be an important part of such training courses.

This study was conducted to evaluate the feasibility and therapeutic safety of laparoendoscopic single-site ovariectomy (LESS-OVE) and 3-portal laparoscopic ovariectomy (Lap-OVE) in dogs. Ten female mixed breed dogs were included in the study. Dogs were divided into group 1 (LESS-OVE; n = 5) and group 2 (Lap-OVE; n = 5). All procedures were performed by laparoscopic-skilled surgeons, and the anesthetic protocol was the same for all patients. In both groups, the ovarian vascular pedicle and ligaments were transected using a bipolar vessel sealer/divider device. The mean total surgical time was slightly longer in LESS-OVE (36.6 ± 3.5 min) than Lap-OVE (32.0 ± 3.0 min); however, the differences were not significant. Perioperative complications were not reported in any group. Both laparoscopic techniques were shown to be equally feasible and safe for patients. However, surgeons found LESS-OVE to require more skill than Lap-OVE. Therefore, additional studies should be conducted to evaluate this novel approach in clinical veterinary practice, and a proper laparoscopic training program for veterinary surgeons should be developed.

Laparoscopy is a cornerstone of modern surgical care. Despite clear advantages for the patients, it has been associated with inducing upper body musculoskeletal disorders amongst surgeons due to the propensity of non-neutral postures. Furthermore, there is a perception that patients with obesity exacerbate these factors. Therefore, novice, intermediate and expert surgeon upper body posture was objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess the subsequent postural data during laparoscopic training on patient models that simulated BMI’s of 20, 30, 40 and 50 kg/m2. In all experience groups, the posture of the upper body significantly worsened during simulated surgery on the BMI 50 kg/m2 model as compared to on the baseline BMI model of 20 kg/m2. These findings suggest that performing laparoscopic surgery on patients with severe obesity increases the prevalence of non-neutral upper body posture and may further increase the risk of musculoskeletal disorders in surgeons.

Objective To analyze the applicability and efficiency of amulti-approach laparoscopic training in improving basic laparoscopic skills of obstetrics and gynecology (OBGYN) residents. Methods Cross-sectional, observational and descriptive study, developed at the Experimentation and Surgery Training Center (CETEC, in the Portuguese acronym) of the Hospital Israelita Albert Einstein with OBGYN residents. Theoretical and practical tests were applied to 24 OBGYN residents to assess their laparoscopic skills before and after their participation in an 8-week course. The course involved theoretical lectures and practical laparoscopic surgery exercises developed using rubber models, black boxes, virtual simulators and animal models (pigs). Results There was an overall improvement in the ability of the residents, with an increase in the number of correct answers in the theoretical evaluation and decrease in the time needed to perform practical tests (needle holder assembly and laparoscopic node). The course was evaluated by the students as highly relevant for both improving their surgical skills and motivating them to continue practicing. Conclusion Laparoscopic training using multiple approaches resulted in significant improvement of surgical skills with a high satisfaction level of the participants. Further studies are still needed to measure the long-term retention of these acquired skills. Resumo Objetivo Analisar a aplicabilidade e eficiência de um treinamento em laparoscopia com múltiplas abordagens, em melhorar as habilidades laparoscópicas básicas de residentes de ginecologia e obstetrícia (GO). Métodos Estudo transversal, observacional e descritivo, desenvolvido no Centro de Treinamento em Experimentação e Cirurgia (CETEC) do Instituto de Pesquisa do Hospital Albert Einstein com residentes de GO. Foram aplicadas avaliações teóricas e práticas a 24 residentes de GO com o objetivo de avaliar suas habilidades laparoscópicas antes e após sua participação em um curso de 8 semanas. O curso envolveu palestras teóricas e exercícios práticos de cirurgia laparoscópica através de modelos de borracha, caixas pretas, simuladores virtuais e modelos animais (porcos). Resultados Houve uma melhora geral na habilidade dos residentes, comaumento do número de respostas corretas na avaliação teórica e diminuição do tempo na execução dos testes práticos (montagem do porta-agulha e realização de nó laparoscópico). O curso foi avaliado pelos alunos como altamente relevante por melhorar suas habilidades cirúrgicas e motivá-los a continuar praticando. Conclusão O treinamento laparoscópico utilizando múltiplas abordagens resultou em melhora significativa das habilidades cirúrgicas atrelado a alto nível de satisfação dos participantes. Novos estudos ainda são necessários para mensurar a retenção destas habilidades adquiridas a longo prazo.

Resumen: Introducción: la enseñanza de la cirugía atraviesa un cambio de paradigma, siendo el entrenamiento en laparoscopía avanzada uno de sus mayores desafíos. El objetivo de este estudio es describir y evaluar la experiencia de un servicio de cirugía universitario con un modelo de entrenamiento simulado de anastomosis intestinal laparoscópica. Método: tres residentes de cirugía general completaron un programa de entrenamiento de cuatro semanas. Se utilizó un modelo biológico ex vivo en box trainer, evaluando objetivamente la realización de una anastomosis entero-entérica. Resultados: el tiempo de ejecución del procedimiento se redujo en una media de 15 minutos, con una mejoría significativa del desempeño según la escala OSATS. Discusión: la implementación de un programa validado y modificado de simulación en laparoscopía avanzada permitió obtener resultados positivos, utilizando para ello solo el 4% de la carga horaria semanal curricular. El modelo tiene una alta fidelidad, bajo costo y es fácilmente reproducible. Conclusiones: el entrenamiento simulado en laparoscopía es una herramienta obligatoria y beneficiosa durante la formación del cirujano general. Summary: Background: there is a changing paradigm in surgical education, being laparoscopic training one of its major challenges. The objective of this study is to describe and evaluate our experience with a simulated laparoscopic small bowel anastomosis training model at a universitary surgical center. Methods: a 4-week training program was conducted with participation of 3 general surgery residents. An ex vivo biological model in a box trainer was used to objectively evaluate a simulated entero-enterostomy. Results: final procedure time was reduced an average of 15 minutes, with better outcomes according to OSATS scale. Discussion: implementation of a modified, validated advanced laparoscopic skills training program showed positive results, taking only 4% of the weekly curricular schedule. The model has high fidelity, low cost and is easily reproducible. Conclusions: simulated laparoscopic training is both mandatory and beneficial in surgical education. Resumo: Introdução: o ensino da cirurgia atravessa um cambio de paradigma, sendo o treinamento em laparoscopia avançada um de sus maiores desafios. O objetivo deste estudo é descrever e avaliar a experiencia de um serviço universitário de cirurgia com um modelo de treinamento simulado de anastomose intestinal laparoscópica. Métodos: 3 residentes de cirurgia general completaram um programa de treinamento de 4 semanas. Foi empregado um modelo biológico ex vivo em simuladores de caixa, avaliando objetivamente a realização de uma anastomose entero-entérica. Resultados: o tempo de execução do procedimento foi reduzido em média 15 minutos, com una melhoria significativa do desempenho segundo a escala OSATS. Discussão: a implementação de um programa validado e modificado de simulação em laparoscopia avançada permitiu obter resultados positivos, utilizando somente 4% da carga horaria semanal curricular. O modelo tem alta fidelidade, baixo custo e é facilmente reproduzível. Conclusões: o treinamento simulado em laparoscopia é uma ferramenta obrigatória e benéfica durante a formação do cirurgião geral.

INTRODUCTION AND OBJECTIVE:There is limited data demonstrating the efficacy of laparoscopic training curricula, such as BLUS (Basic Laparoscopic Urologic Skills), in improving technical skills. Des...

Background: Simulation plays an important role in surgical training. We developed a simulator for laparoscopic ventral hernia repair (LVHR) surgery based on porcine tissue, characterized by low cost and high reality. Methods: Our LVHR model is based on porcine tissue mounted in a human mannequin. The anterior abdominal wall is constructed to allow laparoscopic training. Training sessions are conducted in a simulated operating room environment. Results: During preliminary tests, the LVHR simulator was found to be highly realistic in terms of tissue feedback, instrumentation usage, and performing the key steps of the LVHR procedure. The model was evaluated as a very useful tool for residents' training allowing to gain laparoscopic skills, learn the key steps of LVHR, and practice team work. Conclusions: Our simulator, based on porcine tissue mounted in a mannequin, offers a very realistic and cost-effective model for simulating LVHR surgery.

The objective of this study was to examine the impact of an intensive laparoscopic training course incorporating structured assessment and immediate feedback on residents' operative performance in animal lab.Surgical residents participated in a 2-day intensive laparoscopic training course. They performed the same procedures on two consecutive days on live pigs. Junior residents (PGY1-2) performed laparoscopic cholecystectomy and incisional hernia repair and the senior residents (PGY3-5) performed laparoscopic Nissen fundoplication, splenectomy, and low anterior colon resection. Assessment tools with proven validity evidence (global and procedure-specific rating tools for operative assessment of laparoscopic skills) were used to assess their operative performance. Faculty assessment and self-assessments were completed immediately after each procedure on both days. The Wilcoxon rank test was used to examine the effect of training on resident performance after one repetition.Forty surgical residents (20 junior and 20 senior residents) participated. There was a significant improvement in general laparoscopic skills during incisional hernia repair and Nissen fundoplication using global rating scales (p 0.05). Moreover, there was an improvement in their performance during cholecystectomy, incisional hernia repair, and low anterior colectomy when procedure-specific skills assessments were used (p 0.05). There was a positive correlation between residents' self-reported confidences and their operative performance CONCLUSION: Trainees showed significant improvements in performance in general and procedure-specific laparoscopic skills in a wide range of procedures after an intensive training course. This study demonstrates the benefit of a structured training curriculum in improving operative performance in basic and advanced laparoscopic skills in a simulated environment. Future studies are needed to examine the duration of training required to achieve skill retention and competency.

Background Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3–0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial. Methods Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor. Results Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding. Conclusions The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Abstract: Introduction and aim: Minimally invasive techniques are gaining popularity in pediatric surgery, confident knowledge in endoscopies is one of the main purposes of the training. This survey analyzed the laparoscopic training for pediatric surgeons. Method: We sent questionnaires to all trainees and pediatric surgeons specialized after 2012 by e-mail. The questionnaire focused on their opportunities for laparoscopy during the training and their subjective opinions. Results: 34 questionnaires were sent by email. 17 trainees and 11 specialists responded (82%). The rate of endoscopic surgeries is 15% in the clinical centers without trauma surgery, and 2–10% in other training centers. Routine laparoscopies are performed in all centers, and in 40–60% of the centers, advanced endoscopies are also applied. Half of the surgeons performed laparoscopy in the first 2 years of training. An average of 20 laparoscopies were carried out by trainees in the 3–6th year. 50% of the trainees had the opportunity to use pelvitrainer, however, video-watching (100%) is the most common preparation before endoscopies. The surgeons’ subjective opinion about having enough laparoscopic experience by the time of the specialty exam was yes: n = 6 (21%), sufficient: n = 12 (43%) and no: n = 10 (36%). The training could be more effective with more equipment, free courses on pelvitrainers or animal models, and with more patient and dedicated attitude of the instructors. Conclusion: Laparoscopy is in everyday practice in major centers, however, trainees do not have enough experience in terms of its confident use. Endoscopic training could be better with the regular use of pelvitrainers and more surgical practice. Revision of the operation list and the rise in the number of laparoscopies are necessary. Orv Hetil. 2018; 159(43): 1747–1753.

Laparoscopic surgery requires complex surgical skills; hence, surgeons require regular training to improve their surgical techniques. The quantitative assessment of a surgeon’s skills and the provision of feedback are important processes for conducting effective training. The aim of this study was to develop an inexpensive training system that provides automatic technique evaluation and feedback. We detected the instrument using image processing of commercial web camera images and calculated the motion analysis parameters (MAPs) of the instrument to quantify performance features. Upon receiving the results, we developed a method of evaluating the surgeon’s skill level. The feedback system was developed using MAPs-based radar charts and scores for determining the skill level. These methods were evaluated using the videos of 38 surgeons performing a suturing task. There were significant differences in MAPs among surgeons; therefore, MAPs can be effectively used to quantify a surgeon’s performance features. The results of skill evaluation and feedback differed greatly between skilled and unskilled surgeons, and it was possible to indicate points of improvement for the procedure performed in this study. Furthermore, the results obtained for certain novice surgeons were similar to those obtained for skilled surgeons. This system can be used to assess the skill level of surgeons, independent of the years of experience, and provide an understanding of the individual’s current surgical skill level effectively. We conclude that our system is useful as an inexpensive laparoscopic training system that might aid in skill improvement.

The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career. A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship. Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice. Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice.

Laparoscopy is used increasingly to treat malignant and benign colorectal surgical diseases. However, this practice is still not offered to all patients. Many barriers halt the widespread use of laparoscopic colorectal surgery. Both surgeon's and patient's factors contribute to limit a wider use of laparoscopy in colorectal surgery.We retrospectively analyzed 408 consecutive colorectal resections in a 4-year period, to find out if a selection bias exists in using laparotomy or laparoscopy for colorectal surgical diseases, and which factors are associated with a poor use of laparoscopy or to a preferred laparotomy.In our practice, advanced disease, American Society of Anesthesiologist class III and IV, and emergency status are all patient-related factors associated with laparotomy. Surgeon's age more than 52 years and lack of laparoscopic training are surgeon-related factors that negatively affect the chance of being operated on with the laparoscopic technique.An extensive laparoscopic colorectal training and a supporting environment, especially during the night shift, are needed to facilitate the use of laparoscopy in colorectal surgery avoiding a bias in selecting surgical candidates to one technique or another.

Background Recently to improve depth perception, the performance of three-dimensional (3D) laparoscopic surgeries has increased. However, the effects of laparoscopic training using 3D are still unclear. This study aimed to clarify the effects of using a 3D monitor among novices in the early phase of training. Methods Participants were 40 novices who had never performed laparoscopic surgery (20 medical students and 20 junior residents). Three laparoscopic phantom tasks (task 1: touching markers on a flat disk with a rod; task 2: straight rod transfer through a single loop; and task 3: curved rod transfer through two loops) in the training box were performed ten times, respectively. Performances were recorded by an optical position tracker. The participants were randomly divided into two groups: one group performed each task five times initially under a 2D system (2D start group), and the other group performed each task five times under a 3D system (3D start group). Both groups then performed the same task five times. After the trial, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and the learning curves for both groups. Results Scores for all tasks performed under the 3D system were significantly better than scores for tasks using the 2D system. Scores for each task in the 2D start group improved after switching to the 3D system. However, scores for each task in the 3D start group were worse after switching to the 2D system, especially scores related to technical errors. Conclusions The stereoscopic vision improved laparoscopic surgical techniques of novices from the early phase of training. However, the performance of novices trained only by 3D worsened by changing to the 2D environment.

Recent technological progress offers the opportunity to significantly transform conventional open surgical procedures in ways that allow minimally invasive surgery (MIS) to be accomplished by specific operative instruments’ entry into the body through key-sized holes rather than large incisions. Although MIS offers an opportunity for less trauma and quicker recovery, thereby reducing length of hospital stay and attendant costs, the complex nature of this procedure makes it difficult to master, not least because of the limited work area and constricted degree of freedom. Accordingly, this research seeks to design a Teach and Playback device that can aid surgical training by key-framing and then reproducing surgical motions. The result is an inexpensive and portable Teach and Playback laparoscopic training device that can record a trainer’s surgical motions and then play them back for trainees. Indeed, such a device could provide a training platform for surgical residents generally and would also be susceptible of many other applications for other robot-assisted tasks that might require complex motion training and control.

Study Objective To pilot a remote learning Fundamentals of Laparoscopic Surgery (FLS) elective to pre-clinical medical students. Design Due to COVID-19 restrictions, pre-clinical medical students were required to strictly quarantine for two weeks upon arrival to their clinical rotation sites, during which they would engage in an elective of their choice. Medical students enrolled in the Remote Learning FLS Elective received a laparoscopic training box (Task It) with supplies prior to traveling around the continental United States for clinical rotations. Students also received instructions to access publicly available FLS modules and videos to introduce instruments and tasks. Each learner engaged in self-guided practice with coaching available via a live-streaming platform to assist with refining their skills during the course. Setting While quarantined in three different locations (Bethesda MD, San Antonio TX, and San Diego CA) learners utilized space in their living quarters to set up the Task II trainer and computer. Patients or Participants Three pre-clinical medical students enrolled in a 2-week distance learning FLS elective. Interventions Learners participated in a 2-week distance learning elective that utilized self-directed learning and practice, use of available FLS modules and videos, and individual coaching sessions with instructor. Measurements and Main Results All learners were true novices with no prior FLS or laparoscopic experience, and minimal to no experience with surgical skills. Learners practiced individually and timed themselves practicing each skill. Each was able to attain facility with object transfer, depth perception. Conclusion All learners improved from their baseline skills level. Remote coaching of FLS with true novices is a viable alternative to traditional face to face learning with motivated learners.

Laparoscopy is a cornerstone of modern surgical care, with clear advantages for the patients. However, it has also been associated with inducing upper body musculoskeletal disorders amongst surgeons due to their propensity to assume non-neutral postures. Further, there is a perception that patients with high body mass indexes (BMI) exacerbate these factors. Therefore, surgeon upper body postures were objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess posture during laparoscopic training on patient models that simulated BMIs of 20, 30, 40 and 50 kg/m2. In all surgeons the posture of the upper body significantly worsened during simulated laparoscopic surgery on the BMI 50 kg/m2 model as compared to the baseline BMI model of 20 kg/m2. These findings suggest that performing laparoscopic surgery on patients with high BMIs increases the prevalence of non-neutral posture and may further increase the risk of musculoskeletal disorders in surgeons.

Background Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India. Methods A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated. Results Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers. Conclusion Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context., Highlights • Structured training in gasless laparoscopy is feasible for rural surgeons. • Demonstrates overall improvement in knowledge and skill acquisition. • The training environment is an essential component for rural surgeons. • Lower costs support wider adoption in LMIC.

Background: Laparoscopic appendicectomy has advantages over open surgery in terms of complications, postoperative pain and the length of hospital stay. It is considered as a preferred basic laparoscopic procedure for surgical trainees based on the studies performed at teaching hospitals. Objective: The aim of this study was to determine whether laparoscopic appendicectomy can safely be carried out by surgical trainees in peripheral hospitals. Methods: A retrospective analysis was conducted at a base hospital in Uva province of Sri Lanka including all laparoscopic appendicectomies performed from July 2018 to December 2018. Duration of procedure, complications, postoperative pain, and duration of hospital stay were compared between the surgeries performed by surgeon (group A) and by a supervised trainee (group B). Results: 53 laparoscopic appendicectomies, 15 (28.3%) were included in group A and 38 (71.7%) were included in group B. Demographics including age, intraoperative findings and histology were comparable between two groups. There were no significant differences observed between group A and B for the duration of procedure (34.67 min vs. 41.18 min, p = 0.30), deep surgical site infections (0 vs. 2.6%, p = 1.0), median postoperative pain score (1 vs 1, p = 0.23) and duration of hospital stay (2.27 days vs. 2.58 days, p = 0.11). However, group B had a higher conversion rate to open surgery compared to group A (5% vs. 0). Conclusion: Laparoscopic appendicectomy is a safe procedure for supervised trainees to perform in peripheral hospital setting.

To introduce a novel laparoscopic training system with a continuously perfused ex-vivo porcine liver for hepatobiliary surgery. Existing models for laparoscopic training, such as box trainers and virtual reality simulators, often fail to provide holistic training and real haptic feedback. We have formulated a new training system that addresses these problems. Real-Liver Laptrainer consists of a porcine liver, customized mannequin, ex-vivo machine perfusion system, and monitoring software. We made a detailed comparison of Real-Liver Laptrainer with the LapSim virtual reality simulator and the FLS Trainer Box systems. Five laparoscopic surgeons assessed the new system on multiple features. We assessed the performances of 43 trainees who used the new system to perform laparoscopic cholecystectomy (LC) three times. Real-Liver Laptrainer offered more functions and better tactile feedback than the FLS or LapSim system. All five surgeons graded the quality of the new system as realistic. The utility of the system for training was scored as 3.6 ± 1.1 on a scale of 1–5. Between the first and third attempts, the number of successfully performed LCs increased (9 vs 14 vs 23; P = .011), while the numbers of liver damage incidents (25 vs. 21 vs. 18, P = .303) and gallbladder perforations decreased (17 vs. 12 vs. 9, P = .163). The mean LC operation time significantly decreased (63 vs. 50 vs. 44, P

Background Laparoscopy is difficult to master, in part because surgeons operate in a three-dimensional (3D) space guided by two-dimensional (2D) images. This trial explores the effect of 3D vision during a laparoscopic training program, and examine whether it is possible to transfer skills acquired with 3D conditions to 2D conditions. Methods We designed a randomized controlled trial where residents (n = 34) were randomized to proficiency-based laparoscopic simulator training under either 3D or 2D conditions. Subsequently, participants completed a retention test under 2D conditions. Results Mean training time were reduced in the intervention group; 231 min versus 323 min; P = 0.012. There was no significant difference in the mean times to completion of the retention test; 92 min versus 95 min; P = 0.85. Conclusion 3D vision reduced time to proficiency on a virtual-reality laparoscopy simulator. Furthermore, skills learned with 3D vision can be transferred to 2D vision conditions. Clinicaltrials.gov ( NCT02361463 ).

Background Laparoscopic assistance is often entrusted to a less experienced resident, medical student, or operating room nurse. Data regarding laparoscopic training for operating room nurses are not available. Objectives The aim of the study was to analyse the initial performance level and learning curves of operating room nurses in basic laparoscopic surgery compared with medical students and surgical residents to determine their ability to assist with this type of procedure. Design The study was designed to compare the initial virtual reality performance level and learning curves of user groups to analyse competence in laparoscopic assistance. Participants The study subjects were operating room nurses, medical students, and first year residents. Methods Participants performed three validated tasks (camera navigation, peg transfer, fine dissection) on a virtual reality laparoscopic simulator three times in 3 consecutive days. Laparoscopic experts were enrolled as a control group. Participants filled out questionnaires before and after the course. Results Nurses and students were comparable in their initial performance (p > 0.05). Residents performed better in camera navigation than students and nurses and reached the expert level for this task. Residents, students, and nurses had comparable bimanual skills throughout the study; while, experts performed significantly better in bimanual manoeuvres at all times (p Conclusion The included user groups had comparable skills for bimanual tasks. Residents with limited experience reached the expert level in camera navigation. With training, nurses, students, and first year residents are equally capable of assisting in basic laparoscopic procedures.