Training Tools and Methods for Laparoscopic Surgery

Ueda Y¹, Shiraishi N¹*, Hirashita T¹ and Inomata M²

¹Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Japan

²Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Japan

*Corresponding author: Shiraishi N, Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Oita, Japan

Received: October 02, 2018; Accepted: October 29, 2018; Published: November 01, 2018

Abstract

Background: Laparoscopic surgery has been rapidly advancing and is being disseminated worldwide. Therefore, laparoscopic surgeons have to further their efforts to acquire basic and advanced technical skills in laparoscopic surgery through training. Presently, numerous training tools and methods of training in laparoscopic surgery, such as box trainers, virtual reality simulators, animal models and human cadavers, have been developed.

Methods: We reviewed the reports published in the English-language literature to evaluate the training tools and training methods available for laparoscopic surgery.

Results: Numerous studies have evaluated each of the various training tools and methods and have reported their positive impact on the teaching of laparoscopic technical skills. Among them, the most popular studies compared the educational effectiveness of training using the box trainer versus the VR simulator for laparoscopic surgical trainees. However, it might be difficult to determine which of these two training tools is superior for trainees. Recently, the usefulness of educational programs that combine various training methods to acquire basic laparoscopic surgical skills has been reported, and these combination methods may become a new trend.

Conclusion: In the future, the impacts of multimodal educational programs or those combining training methods should be evaluated by assessing patient outcomes after laparoscopic surgery performed by the laparoscopic surgical trainees.

Keywords: Laparoscopic surgery; Training tools; Training methods

Introduction

Since the late 1990s, minimally invasive laparoscopic surgery has become the standard treatment for not only benign but also for malignant disease because of the quicker postoperative recovery compared with that of conventional open surgery. However, laparoscopic procedures sometimes require more advanced surgical techniques than do open abdominal procedures. As well, much time and work must be invested to acquire laparoscopic surgical skills that have a prolonged learning curve in the clinical setting. Furthermore, patient safety concerns have made it more difficult for trainees to learn laparoscopic technical skills on real patients. The 100-yearold Halstedian surgical mantra of “see one, do one, teach one” [1] is now unacceptable for the practice of laparoscopic skills by trainees in the operating room because it exposes patients to potential risks. Additionally, previous studies reported that many surgeons with little or no advanced laparoscopic skills might have higher rates of postoperative complications and procedure failure [2-4]. Therefore, an appropriate and safe training method is essential for trainees to learn basic to advanced laparoscopic procedures with shortened learning curves and to reduce postoperative complications. Therefore, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recommended incorporating educational programs for laparoscopic surgery into the training of general surgical residents [5].

In this article, we review the reports published in the Englishlanguage literature that have evaluated individual training tools and educational programs for the acquisition of laparoscopic surgical skills.

Development of training tools for laparoscopic surgery

In the past, various training tools for laparoscopic surgery were developed outside of the operating room [6]. Simulator training using classical box trainers was first proven to be a useful teaching method in the field of anesthesiology [7,8]. These trainers are being used to acquire basic surgical skills in laparoscopic surgery because of their low cost, portability, and time efficiency. They provide tactile feedback and practice through repetition for multiple trainees [9]. However, trainees require more realistic simulations to learn complex skills as they progress to advanced laparoscopic procedures. Therefore, other training tools, such as virtual reality (VR) simulators, animal and human cadavers, and live animal models, have been used to improve the trainees’ skills. Recently, a number of studies have shown that well-designed training methods for trainees have a significant impact on the clinical setting in laparoscopic surgery [10].

Evaluation of individual training tools for laparoscopic surgery

Box Trainer: The box trainer has been used to learn basic laparoscopic skills for trainees around the world for well over a decade, and this training method has been applied in many firstyear surgical residency programs. The generically manufactured box trainer contains an opaque box that approximates the size of the human abdominal cavity, video monitor, camera, and laparoscope. Various targets are manipulated inside the box based on visual information. One of the important attributes of the box trainer is the sensory feedback, also called haptics, that it provides [9]. Haptics is physical sensory feedback conferred via the box trainer that is on par with that of real laparoscopic operations. An additional attribute of this trainer is its lower acquisition cost. These reasons make the box trainer the most widely expanding training method in the world. A recent systematic literature review on box trainers showed evidence that surgical training using a box trainer appears to improve the basic laparoscopic skills of trainees without previous laparoscopic experience compared with limited prior laparoscopic experience [11]. Therefore, training box of the fundamentals of laparoscopic surgery (FLS) that was developed by the SAGES is already accessible to surgical trainees to hone their laparoscopic skills [12]. However, the problems about FLS skills test are still remain. One of the problems is high cost [13]. And the other is the most appropriate time when do they should perform for trainees [14].

VR simulators: Training using VR simulators is currently the most evolutionally advanced simulation training method in the area of laparoscopic surgery. VR simulators can assess various laparoscopic skills, such as camera navigation, object manipulation, insular dissection, and extracorporeal suturing [15]. VR simulators make many kinds of surgical training more believable for trainees than those using traditional box trainers do because the situation is made to be as real as possible [16]. Using the latest computer software, these training systems can be set up to record and save data for teaching the advanced skills required for laparoscopic surgery. These data make it possible for the educators to evaluate the trainees’ performance of various laparoscopic tasks, to track the progress of individual trainees, and to compare the trainees’ results [17,18]. In addition, several VR simulators, such as hybrid simulators, can provide the tactile feedback that is lacking in most simulators. VR training with haptic feedback is at least as effective as box trainers are and resulted in shorter operating times, less distance travelled, and fewer unnecessary movements when compared to VR training without haptic feedback [19]. Although these VR simulators are largely used for learning and practicing skills, they are rarely used as an assessment tool [20]. These training systems are relatively more expensive than box trainers, but their incorporation into laparoscopic surgical training programs may be increasingly encouraged if the price of these systems can be lowered. In recent years, low-cost laparoscopic simulators is regarded as being the most equitable solution to allow basic skills practice for junior surgical trainees [21].

Animal model training: Animal models, such as the anesthetized porcine model, are used to learn surgical skills for laparoscopic surgery because they have been shown to be a substitute for human tissues. Especially, the abdomen of the porcine model is sufficiently similar to the adult human in size and in intraabdominal anatomy [22]. Animal models are the only models in a non-patient environment for laparoscopic training that can simulate intraoperative bleeding and complications that can occur in a live patient. Therefore, animal models are frequently used for training together as a team before an operation [23]. It was recently reported that porcine-based training is useful in pediatric minimally invasive surgery [24], and a new animal model of calculous cholecystitis was created [25]. However, these training methods are prohibitive because of the substantial costs involved in providing appropriate staff and facilities. In addition, there are still some problems related to moral, ethical, and infection concerns with this particular training method [26].

Cadaver training: Cadaver training models that include animal and human cadavers have been useful in learning surgical anatomy and in performing tissue dissection, surgical handling, and complex laparoscopic procedures. Many reports have stressed the importance of cadaver training in the acquisition of laparoscopic skills. Fresh frozen cadavers have been recommended for wider use in a realistic laparoscopic operative training experience because of the perfect anatomy, normal colors, and consistency of the tissues [27,28]. Some authors have also recommended a training method using human cadavers embalmed by the Thiel method because this method provides better tissue flexibility and colors [29,30]. However, this embalming process is very complex and expensive, and it results in shorter conservation times [31]. The disadvantages of these cadaver-training methods are the limited availability of specialized environments and the high cost of their maintenance [32]. The limited supply of cadavers also constricts the wide use of cadaver training methods around the world.

Evaluations to establish well-designed educational programs for laparoscopic surgery

Application of training methods to educational programs: Box trainer and/or VR simulator (Table 1): Many studies have compared the effectiveness of training methods for laparoscopic surgery using the box trainer and the VR simulator. Most of these studies were performed as prospective randomized controlled trials, and the participants in most were novices, such as medical students and surgical interns. The assessments of each training method were based on the performance of several laparoscopic tasks or exercises on the box trainer, VR simulator, or in animal models. These tasks or exercises were scored for several parameters, such as time, movements, accuracy, and others. In these studies, the trained groups performed significantly better on most of the parameters than the control (no training) groups in learning laparoscopic skills. Most of these previous studies reported that VR simulator training was a more efficient method for trainees than the box trainer [33-36]. Youngblood et al. [34] reported that the mean Global ratings scores (1-5) of the VR training group was significantly better than both Box training and no training group (3.31 vs. 2.27 and 2.31, p=0.005). However, some studies reported that both the box trainers and VR simulators were equally effective means of teaching laparoscopic skills [8,37]. Reported that VR training was the more efficient training modality, whereas box training was the more cost-effective option [36]. Thus, from these randomized controlled trials, it remains controversial whether VR training or box training is more useful for laparoscopic surgical training.

Table 1: application of training methods to educational programs: box trainer and/or virtual reality simulator.




  
    Author
    Country
    Year
    Citation
    Study design
    Training
    
    Assessment
    
  
  
    Training method
    Training period
    Participents (n)
    Method
    Outcome assessment
    Results
  
  
    Minz Y [8]
    UK
    2004
    Surg Endosc 18, 485-494
    RCT
    VRS vs BT
    3 week lasting 30 min
    MS (24)
    Laproscopic task
    Motion analysis and error score
    No difference
  
  
    Debes AJ [29]
    Norway
    2010
    Am J Surg 199, 840-845
    RCT
    VRS vs BT
    
    MS (46)
    Crossover assessment of the other    method
    Time, movements, path length, and    total score
    VRS
  
  
    Mchammadi Y [35]
    USA
    2010
    JSLS 14, 205-212
    Prospective observational study
    BT+ VRS vs BT a lone
    
    MS (43)
    5 standard exercises
    Time, accuracy, and surveys
    BT + VRS
  
  
    Youngbbod PL [30]
    USA
    2005
    J Am Coll Surg 200, 546-551
    RCT
    VRS vs BT
    12 dys
    MS (46)
    3 laproscopic tasks on live    anesthetized pigs
    Time and accuracy scores
    VRS
  
  
    Madan AK [34]
    USA
    2007
    Surg Endosc 21, 209-213
    RCT
    VRS vs BT vs combination of both
    200 min
    MS (65)
    4 laproscopic tasks in a porcine    laboratory
    Time and error scores
    Combination of both
  
  
    Diesen DL [33]
    USA
    2011
    J surg Educ 68,289-299
    RCT
    VRS vs BT
    6 months
    MS (12) and surgical (11)
    5 laproscopic exercises in a live    porcine model
    Scoring system
    No difference
  
  
    Mulk M [31]
    UK
    2012
    J surg Educ 69, 190-195
    RCT
    BT vs BT + additional practice vs    VRS vs mental training
    1 week
    MS (41)
    Task on the VRS and on a BT
    Time, precision, accuracy, and    performance
    VRS
  
  
    Orzech N [32]
    Canada
    2012
    Am J Surg 255, 833-839
    RCT
    VRS vs BT
    
    Surgical residents (24)
    Laproscopic stiches during    operation on a patient
    Time, global rating score,    checklist score, and cost
    VRS (more efficient) BT    (cost-effective)
  
  
    RCT: Randomized Controlled Trails; VRS:    Virtual Reality Simulator; BT: Box Trainer; MS: Medical Students



Table 1: application of training methods to educational programs: box trainer and/or virtual reality simulator.

Some reports stressed that the combination of box trainer and VR simulator training methods was more useful to acquire laparoscopic surgical skills. Both Madan et al. [38] and Mohammadi et al. [39] found that the combination of both training methods led to better laparoscopic skill acquisition than the use of either training method alone. Palter et al. also reported that residents with structured training methods consisting of a box trainer, VR simulator training, and several training sessions outperformed residents with conventional training in technical performance during the first to fourth sequential laparoscopic cholecystectomies (p<0.05) [40]. The combination of both methods of training may become an important part of the early stages of laparoscopic skills acquisition for trainees.

Effective Management of Training Methods for Educational Programs (Table 2): A number of studies also addressed the effective management of laparoscopic surgical training methods, such as the order of training, multimodality training, and the maintenance of training. The participants of most of these studies were also medical students and surgical interns. The assessments of each study were based on laparoscopic performance or technical skills demonstrated on either a simulator or a porcine cadaver.

Table 2: Effective management of training methods for educational programs.




  
    Author
    Country
    Year
    Citation
    Study design
    Training
    
    Assessment
    
  
  
    Training method
    Training period
    Participants (μ)
    Method
    Outcome assessment
    Results
  
  
    Nickel F [40]
    Denmark
    2015
    Medicine S4, e764
    RCI
    VRS vs Low cost blusted learing (BL) (BI + E learning)
    12 hrs
    MS (84)
    Operative performance on cadaveric    porcine laproscopic
    OSAIS score, operation time, rate    of operations completed and knowledge test
    VRS (
  
  
    Bridusu VM [41]
    The Netherlands
    2012
    Surg Endosc 26, 21, 72-78
    Comparative study
    Single Modality (VRS abuse) vs Multimodality (VRS + BI)
    45 minutes × 6
    MS (36)
    Pre and post tests and VRS
    Five different basic skills and
    No difference
  
  
    Sra [37]
    Japan
    2013
    22, 150-156
    RCI
    BI- VRS group (BI followed by VRS) vs VRS-BI group(VRS followed by    VRS)
    60 minutes for each
    Surg without prior laproscopic    experience (20)
    Motion analysis system
    Laproscopic skills
    VRS-BI
  
  
    Botlen SM [39]
    The Netherlands
    2008
    Surg Endosc 22, 1214-1222
    Compartive study
    BI-VRS group (BI followed by VRS) vs VRS-BI (VRS followed by VRS) &    BI ab
    One 30 minutes session
    surgical gynecology (45)
    Sub
    structural
    No difference
  
  
    Bri WM [38]
    The Netherlands
    2013
    Surg Endosc 27, 3581-3590
    Compartive study
    BI-VRS group (BI followed by VRS) vs VRS-BI (VRS followed by BI)
    -
    Eperienced laproscopic and medical    interns (28)
    Eight repetitions of the transfer    fish and questionarie
    Completion time and error
    BI- VRS
  
  
    Khan MW [33]
    Austrlia
    2014
    J surg Educ 71, 79-84
    RCI
    BI vs VRS
    6 months
    MS interns,
    2 practices on both simulators
    Score
    BI IS
  
  
    Van Bro S [43]
    Belgium
    2013
    J surg Educ 27, 3823-9
    RCI
    maintanance programe after    training No training vs unused    training vs BI ( vs VRS (
    missed training-150 min after 2.5    months distrbuted training -5 monthly 30- mintues training sessions
    MS (39)
    Model
    On performance (time and
    BI
  
  
    RCT:    Randomized Controlled Trials; VRS: Virtual Reality Simulator; BT: Box    Trainer; MS: Medical Students; OSATS: Objective Structured Assessment of    Technical Skills



Table 2: Effective management of training methods for educational programs.

Some research investigated the optimal order of these training methods. Sumitani et al. [41] determined that VR training followed by box training effectively improved the dexterity of surgeons [41], but Brinkman et al. implied that assessment on the VR simulator after pretraining on the box trainer was acceptable [42]. Botden et al. [43] reported that the total score of the group who started training on the box trainer and subsequently moved to the VR simulator was higher than group who began on the VR simulator followed by the box trainer, but not significantly so. Although the combination of VR training and box training is a better method for trainees than either training method alone, the optimal order of these training methods continues to be unclear.

Several reports assessed the effectiveness of multimodality training. Nickel et al. [44] compared VR training with low-cost blended training, which combined e-learning with box training, and they concluded that both methods could be applied for training on the basics of laparoscopic cholecystectomy [44]. Brinkman et al. [45] reported that performance outcomes of training basic skills did not differ between VR simulator training alone and multimodality training practiced on a VR simulator, box trainer, and an augmented reality simulator [45]. These studies suggest that the combination of several training methods may become a new trend. However, the most suitable combination of training methods remains controversial.

Two reports investigated the maintenance of training. Khan et al. [45] studied laparoscopic skills maintenance by assessments made at 1, 3, and 6 months after box trainer and VR simulator training [46]. They concluded that basic laparoscopic maintenance was more consistently achieved after initial training using a box trainer than a VR simulator, although over the long term, the skill levels were similar. Van Bruwaene et al. [47] also showed that a maintenancetraining interval of 1 month with training on box trainers seemed ideal, and VR simulator training did not show any benefit after the completion of laparoscopic suturing training [47]. Box training may be more suitable for the maintenance of training, especially suturing training, for laparoscopic surgery.

Application of Cadaver Training to Educational Programs (Table 3): Among the studies of cadaver training for laparoscopic surgery, the participants were surgeons and medical students taking a training course. Four studies were performed that compared cadaver and simulator training methods. The assessments of each training method were based on the technical skills demonstrated during cadaver training and operation on a live anesthetized pig, and on a questionnaire. Two of these studies reported that the cadaver training method was more useful than the VR simulator method [48,49]. Sharma et al. [50] demonstrated that median scores for basic laparoscopic tasks in senior surgeons were significantly higher in cadaver training group compared to VR simulator training group (p < 0.01) [48]. However, the other two studies reported that the VR simulator training method was adequate for laparoscopic surgery training [50,51]. And, these studies also stressed that overall satisfaction grade was significantly better for the cadaver training method than for the simulator methods (p=0.009). Wyles et al. performed a detailed opinion analysis of two training course models, fresh-frozen cadavers and anaesthetized pigs, for laparoscopic colorectal surgery, and they reported that the cadaveric model was perceived to be superior as a training model (Global assessment score 4.53 vs. 3.61, p=0.001) [52]. Even though the cadaver training method requires not only financial and time resources but also carries some ethical concerns, it provides realistic and satisfying training for the trainees.

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Citation: Ueda Y, Shiraishi N, Hirashita T and Inomata M. Training Tools and Methods for Laparoscopic Surgery. Austin J Surg. 2018; 5(8): 1152.

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Author	Country	Year	Citiation	Study design	Training method	Assessment
Author	Country	Year	Citiation	Study design	Training method	Participants (μ)	Method	Outcome assessment	Results
Le Blanc F [46]	USA	2010	J am coll surg 211, 290.5	Comparative study	Laproscopic signoid colectonies during human cadaver training (n=7) vs augmente drealty simulator (n=28)	Trainers and trainees (35)	OSATS forms	Technical skills,event scores, and satisfaction with training model	Simulator training (global satisfaction was better for the cadaver traning)
Le Blanc F [47]	USA	2010	J Surg educ 67,2004	Observational prospective comparative study	Hand assisted colectomies during human cadaver training (n=7) vs augmented realty simulator (n=27)	Practicing surgeons (34)	OSATS forms	Technical skills,event scores, and satisfaction with training model	Simulator training
Wyles SM [48]	UK	2011	Srg endosc 25, 1559-1566	A standardized anaymous questionarie survey	Fresh froozen cadavers vs Anesth	Trainers and trainees (103)	standardized anaymous questionarie and global assessment score	Questionarie and performance	Fresh frozen cadaver
Sharma M [44]	UK	2012	World J Surg 36, 1732.1	A prospective comparative face validity study	Fresh froozen cadavers vs high fidelty VRS	Surgeons (45)	Questionaire	Grade and level of training score, and open ended questionarie	Fresh frozen cadaver
Van Bruwaene S [45]	Belgium	2015	J Surg Educ 72, 483.90	RCT	No training vs pacine cadaver vs VRS	MS (30)	Laproscopic cholecystectamy on a live anesthetized pig	Time and quality	Cadaver training
RCT: Randomized Controlled Trials; VRS: Virtual Reality Simulator; MS: Medical Students; OSATS: Objective Structural Assessment of Technical Skills

Training Tools and Methods for Laparoscopic Surgery

Abstract

Introduction

Conclusion

References