Abstract
Background:
During COVID-19 pandemic, many restrictions were applied in the field of health care. For this reason, we decided to adopt the laparoscopic simulator Laparo® Analytic to allow the trainees of our pediatric surgery training program to continue their training activity, and we determined its impact on their surgical education.
Methods:
We used Laparo Analytic Simulator for laparoscopic surgery training among the residents of our center. Fifteen residents from different years of the pediatric surgery program participated in this study. Each participant performed a 2-hour training session per week, consisting of three different exercises: Rubber Bands, Knotting, and Suturing. For each training session, the following parameters were analyzed: training time, economy of movement, smoothness, instrument activity (IA), instrument visibility (IV), and instrument symmetry.
Results:
Results were collected after the first training session (T0), at 3 months after the beginning of the study (T1) and at 6 months after the beginning of the study (T2). At T2 of training with Laparo Analytic Simulator, residents were able to complete their tasks significantly faster (P = .001) and had a significant improvement in smoothness of movements, IA, IV, and instrument symmetric movements during the tasks analyzed.
Conclusion:
On the basis of our results, we believe that Laparo analytic is an excellent system to adopt in minimally invasive surgery (MIS) training programs, in particular, during periods of surgical restrictions, as COVID-19 pandemic, or in centers with a limited MIS activity.
Introduction
The rapidly expanding use of minimally invasive surgery (MIS) with its two-dimensional view system and counter-intuitive instruments has set the need to develop easy and rapid ways to acquire the complex psychomotor skills required. As a matter of fact, despite its benefits, laparoscopy has a steep learning curve in suturing techniques and tissue manipulation leading to longer operative times1,2 without full expertise. In particular, suturing techniques prove to be difficult especially in children, due to smaller tissues and limited abdominal space available for instrument manipulation. 3 In a period of pandemics, such as the one we faced with COVID-19, the need to acquire and practice MIS techniques has become more and more evident, especially for trainees and residents who, due to surgical restrictions, had to limit their access to the hospital and operating rooms.
In this context, simulation-based training allows surgeons to practice their skills in a safe, realistic setting 4 that, even in the absence of a senior tutor, enables assessments of each performance based on objective data.5,6 Laparoscopic skill training with Laparo® Analytic allows performing laparoscopic training sessions with a complete report on the quality of the technique predominantly used during the exercise and highlights on mistakes, therefore becoming an objective tutor itself.
Furthermore, working on basic skills such as suturing, knotting, and body positioning, the use of simulation reduces the time needed to reach a sufficient level of proficiency and self-consciousness before practicing on patients. In other words, it can improve laparoscopy learning curve, as it is well documented that different types of laparoscopic operations need to be performed 15–100 times before reaching a low plateau of complications.7–9
In addition, it could decrease surgeons' emotional distress deriving from insufficient knowledge and poor learning environments. 10
However, it remains unclear whether the use of simulation-based training should be routinely used in MIS residency programs and, if yes, in which modality and timing.
The answer to this question, in fact, would allow a delineation of proper technical and structural improvements for both pediatric and general MIS programs.
The current study was designed to determine the impact of laparoscopic training with Laparo analytic in pediatric surgery residents, especially during COVID-19 pandemic.
Materials and Methods
Participants
The study took place in the surgical training laboratory at Federico II Hospital, Naples, Italy.
Fifteen residents from different years of the pediatric surgery program participated in this study.
The characteristics of the participants can be seen in Table 1.
Patients Characteristics
LSs, laparoscopic surgeries; LSim, laparoscopic simulators.
In addition to participant demographics and previous surgical laparoscopic experience, questions concerning experience with the laparoscopic simulator as well as computer games were posed. Appropriate Institute Review Board (IRB) approval was obtained for this study.
Study procedure/design
Each participant performed a 2-hour training session per week, consisting of three different exercises: Rubber Bands, Knotting, Suturing (Figs. 1–3).
Rubber bands. Color images are available online.
Knotting. Color images are available online.
Suturing. Color images are available online.
For each training session, the following parameters were analyzed: training time (TT), economy of movement (EM), smoothness (S), instrument activity (IA), instrument visibility (IV), and instrument symmetry (IS).
Results were collected after the first training session (T0), at 3 months after the beginning of the study (T1) and at 6 months after the beginning of the study (T2).
Laparo Analytic simulator
The Laparo Analytic is a tool for laparoscopy skill training that allows performing laparoscopic training sessions with a complete report on quality of technique and highlights on mistakes. Each training session is concluded with a score result that is a weighted average of subscores calculated based on TT, EM, smoothness, IA, IV, and IS.
Training time
TT is counted from the moment the first instrument is inserted through the trocar until the training scenario is completed. The trainee should aim to complete the exercise within the predefined time limit.
Economy of movement
EM is based on three parameters: the distance travelled by the instrument, the number of clamps made, and instrument insertion.
Regarding the distance travelled by the instrument, the trainee should aim to reduce it during training because this translates to more effective habits and develops safer laparoscopic technique.
The number of clamps made indicates how many times instrument tips are opened and closed throughout the exercise.
Insertion is the parameter that informs on whether the instruments were inserted straight into the training area. If the instrument is inserted in a perfect straight line, the score will be maximum.
Fluidity of movement (S)
The fluidity of movement is composed of four parameters: acceleration, jolt, handshake, and clamp speed.
The “instrument acceleration” parameter reflects the sudden changes in the acceleration of the instrument. When learning laparoscopy, sudden movements should be avoided to prevent sudden changes of the conditions in the operating area.
The “jolt” parameter is focused on the sudden and sharp changes of acceleration not controlled by the trainee, such as when instruments hit each other or solid. Trainees should learn how to plan and avoid these jolts so that they can maintain a predictable level of control over the operating area.
The “handshake” parameter is registered when the instruments start to shake. Algorithms built into software and hardware help identifying specifically this type of movement and distinguish it from jolts and accelerations.
“Clamp speed” is counted as the number of clamps per second. If the user opens and closes the instrument repetitively and passes the limit set for the scenario then the score for this parameter will be reduced accordingly.
Instrument activity
IA parameter is based on information about the movement of the instruments during training. The speed of an instrument can be below the predefined minimum threshold, then the instrument will be recorded as inactive, above the predefined maximum threshold, then the instrument will be recorded as overactive, or between the minimum and maximum thresholds, then it will be registered as active and will not influence the result.
The score for activity is radically reduced when the instruments are registered as overactive. These types of movements are simply seen as too dangerous during laparoscopic procedures, especially during training and learning.
Instrument visibility
With the use of the camera and a computer vision system, the trainer can independently perceive the presence of both left and right instruments separately. Each time an instrument is not visible to the camera, it is considered dangerous in a real-life operation.
Instrument symmetry
The system independently measures the movements of left and right instruments. Not all training scenarios are subject to symmetry analysis. Some training scenarios should be performed asymmetrically.
Statistics
The comparison of the parameter of performance at T0, T1, and T2 was performed using the paired sample T-test. The level of statistical significance was set at P < .05.
Results
Participants characteristics
Of the 15 residents participating in this study, 7 were males and 8 were females while 12 were right-handed and 3 were left-handed. No participant had any previous experience with a virtual reality simulator, but their previous surgical laparoscopic experience was different according to the year of residency: 3 residents had never performed laparoscopic surgeries, 3 had already performed up to 10 laparoscopic surgeries, 3 up to 20 laparoscopic surgeries, 3 up to 30 laparoscopic surgeries, and 3 up to 50 laparoscopic surgeries. In addition, 5 of them were experienced in gaming (online gaming, videogames, etc.) (Table 1).
Performance results
The scores of each participant in the three exercises proposed is reported in Tables 2–4.
Rubber Bands at T0, T1, and T2
EM, economy of movement; IA, instrument activity; IS, instrument symmetry; IV, instrument visibility; S, smoothness; T0, first training session; T1, 3 months after the beginning of the study; T2, 6 months after the beginning of the study; TT, training time.
Knotting at T0c T1, and T2
EM, economy of movement; IA, instrument activity; IS, instrument symmetry; IV, instrument visibility; T0, first training session; T1, 3 months after the beginning of the study; T2, 6 months after the beginning of the study; TT, training time; S, smoothness.
Suturing at T0, T1, and T2
EM, economy of movement; IA, instrument activity; IS, instrument symmetry; IV, instrument visibility; T0, first training session; T1, 3 months after the beginning of the study; T2, 6 months after the beginning of the study; TT, training time; S, smoothness.
The statistical analysis using the paired sample T-test, with a significance level of P < .05, demonstrated that residents significantly improved in all the three tasks according to the total score (P < .05). In particular, there was an important improvement between knotting at T0 and T2 (P = 1.434e-8) and between knotting at T1 and T2 (P = 2.049e-7), as well as between suturing at T1 and T2 (P = 2.008e-7), suturing at T0 and T2 (P = 6.563e-7), and suturing at T0 and T1 (P = .00000869). The improvement between knotting at T0 and T1 was statistically significant, but with the smallest P-value (P = .001035).
In addition, we compared performance results between T0 and T1, T1 and T2, and T0 and T2 according to residents' experience (Table 5) and found that, while the improvements in the short term were not statistically significant in most of the tasks, especially knotting, the statistical analysis on the long term showed a statistical improvement.
Differences in Performance Results (P Values) According to Residents' Experience
LSs, laparoscopic surgeries.
Discussion
The education of young residents in the field of MIS must consider a steep learning curve, due to its two-dimensional view system and counter-intuitive instruments requiring complex psychomotor skills. In particular, the basic tasks of suturing and tissue manipulation are the ones leading to longer operative times in laparoscopy. Simulation technologies have been developed to help surgeons acquire a sufficient level of proficiency and self-consciousness before practicing on patients. They encompass diverse products, including computer-based virtual reality simulators, high-fidelity and static mannequins, plastic models, live animals, inert animal products, and human cadavers.11,14
In this study, we used Laparo Analytic, a simulation tool for laparoscopy skill training that has precise sensors and live computer vision, enabling the simultaneous monitoring and information collection on all instrument movements.
Our findings showed that pediatric surgery residents that had never performed a laparoscopic procedure were the ones that benefit more from training with Laparo Analytic in terms improvement.
In addition, we found no significant difference between the improvements of residents with a certain degree of experience in gaming with those that were not frequent gamers, notwithstanding their laparoscopic experience.
Moreover, hand dominance was not an important factor to consider in terms of differences in improvements.
Conclusion
We believe that new technologies for laparoscopy simulation, in particular Laparo Analytic, could enable high-quality learning and teaching for pediatric surgery residents regardless of their experience. As showed in the literature, studies that have more TT embedded in their curriculum, distributed over more than 1 day, 12 with well-established goals, 13 are associated with improved performance and less skill decay. Our findings were consistent with this statement, showing a continuous improvement in all the skills analyzed, demonstrating that simulation training with Laparo Analytic should be a continuous training philosophy, especially in the pandemic era.
Footnotes
Authors' Contributions
C.E. was the main contributor to study conception. All authors contributed to study design. Literature search, material preparation, data collection, and analysis were performed by B.L., R.C., and G.A. The first draft of the article was written by B.L. and all authors commented on previous versions of the article. All authors read and approved the final article.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.