Results of a Novel Long-Term Method for Laparoscopic Skills Online Training

Introduction

Ensuring patient safety in minimally invasive surgery (MIS) within the field of pediatric surgery requires systematic and extensive practice. However, due to the rarity of certain conditions, acquiring the necessary psychomotor skills can be challenging, particularly for surgeons with limited experience. ¹ Consequently, it has become imperative to seek skill acquisition outside the operating room since it has shown a better patient outcome. ² Simulation-based education (SBE) has emerged as a crucial approach to facilitate the acquisition of competence in a safe environment, while also offering cost-effective alternatives.^1,3–5 Even experienced surgeons can benefit from SBE by maintaining and enhancing their skills. ⁶

In recent years, various groups have proposed mastery learning programs encompassing a range of training methods, from on-site instruction to virtual assistance.^7–11 However, short courses often have a narrow focus on specific objectives, limiting opportunities for sustained training beyond the duration of the course. It has been observed that participants in such courses express a desire to continue practicing exercises to preserve their acquired skills.

Therefore, our objective was to analyze our results with an online long-term competency-based and supervised training.

Materials and Methods

This is a retrospective cohort study with prospective data collection of scores and performance of trainees during online courses from October 2020 to April 2023. Participants were categorized into three different levels of expertise according to the number of surgeries performed. (1—beginner, <20 MIS; 2—intermediate, between 21 and 60; 3—advanced, >60).

A specialized training model was developed according to our previous published guide for long-term MIS courses. ⁶

Setting up the personal gym

Upon registration, each trainee received a package containing the necessary materials to set up their personal gym at their provided address. The package included the MTBOX 7 box trainer, an endocamera, a kit for performing essential exercises, and 5 mm laparoscopic surgery instruments (scissors, Maryland dissector, grasper, and a needle holder). Trainees were responsible for assembling their personal gym (Fig. 1) by connecting the provided materials to a notebook and a secondary device, following the provided tutorials. Before the start of the course, a virtual technical meeting was conducted to assist participants in the setup process.

OPEN IN VIEWER

FIG. 1.

Diagram illustrating the setup of the personal gym.

Organization of the course

The online SBE program consisted of both synchronous and asynchronous activities. All the necessary support materials such as bibliographies, exercises, videos, and tutorials, as well as assignments, were made available to the students through a virtual classroom created using the web-based instructional platform Google Classroom^®. The materials were organized into six didactic modules corresponding to each stage of training, along with general considerations.

Synchronous virtual meetings were conducted using the Zoom^® platform. Debriefing sessions were held at the beginning and end of each educational session, and breakout rooms were utilized to facilitate small group interactions. Each faculty member interacted with no more than 2 participants at a time. Trainees were assessed by faculties through two different cameras, capturing their movements inside and outside the trainer (Fig. 2).

OPEN IN VIEWER

FIG. 2.

Synchronous online meeting. One instructor with 1 participant.

Asynchronous activities were also incorporated into the course. Participants were required to upload videos of their training to the virtual classroom and complete forms to evaluate their weekly progress and register any requests. Communication between meetings was maintained through email and WhatsApp^®, where instructors responded to participant questions in an informal manner.

Both types of activities were maintained along the two stages of the course.

Course stages

(a) Intensive stage (first month): The main objective of this stage was to exercise and develop technical skills. Synchronous activities consisted of four weekly 3-hour meetings, during which participants trained with the faculties. Trainees were expected to review the supporting materials before each meeting. After each session, they received a personalized report containing their outcomes and suggestions for further training. To assess progress in this stage, exercises from the first three meetings were repeated in the final meeting. The same instructor who had evaluated the trainee's progress in the earlier meetings conducted the final assessment and developed a follow-up program.

(b) Follow-up stage (2nd to 6th month): The goal of this stage was to maintain and improve the skills acquired during the previous period. Participants were provided with different tasks and tutorials to continue their training. Two virtual meetings were held in the fourth and sixth months to review participants' skills and progress. In addition, goals and ergonomics were reassessed during these meetings. The training course concluded at the end of the sixth month.

Results

Between October 2020 and August 2023, we had 76 participants but only got full data on 63 participants (39.6% male), from 5 different Hispanic countries.

All participants were able to set up their personal training gym with no difficulties and 100% completed the intensive stage of the course. During this initial stage, 70% answered the surveys, all of whom managed to train with an average of 4.4 hours per week.

When comparing the scores in meeting I and IV in the intensive stage, the total score evolved from 2.60 ± 0.56 at the first meeting to 3.67 ± 0.61 at the fourth meeting, exhibiting a significant difference (P < .013). As it can be observed in Figure 3A, not only the minimum score was increased but also the group showed a more uniform behavior.

OPEN IN VIEWER

FIG. 3.

Statistical analysis of scores between the encounters. (A) First encounter of the intensive stage versus 4th encounter of the intensive stage. (B) First encounter of the intensive stage versus last encounter at 6 months.

According to the “middle term” and “intensive stage” surveys, the use of the trainer, together with the online course, was useful for skills acquisition.

A considerable drop out was observed in the follow-up stage, with only 53.8% of the participants completing the course. Of them, 31.4% attended both meetings, 17.1% only the fourth-month meeting, and 51.5% the sixth-month meeting. Of those who participated, only 24% incorporated training routinely, for >2 hours per week.

At the end of this stage, 97.15% of the assessed participants maintained or improved their skills when compared with the first meeting with a mean general score of 3.85 ± 0.25 (P < .013) (Fig. 3B), the mean scores from the fourth encounter to the 6-month test, of those who attended, improved from 3.77 ± 0.24 to 3.85 ± 0.25 though it was not significant.

Discussion

The results of this study provide valuable insights into the effectiveness of a new educational online proposal for MIS, based on a structured and personalized training course, with a focus on skills acquisition and maintenance. As the data demonstrated, the course had a significant positive impact on participants' skills, as well as their ability to set up and maintain personal training gyms.

One of the notable strengths of the course was the high level of participant engagement and completion of the intensive stage with 100% of them completing this initial phase.

The analysis of skills development between the first and fourth meetings during the intensive stage revealed participants improved their skills, with a statistically significant increase in the total scores from 2.60 ± 0.56 at the first meeting to 3.67 ± 0.61 at the fourth meeting. The same pattern was observed at the last encounter of the follow-up stage with mean scores of 3.85 ± 0.25.

The findings of this study are consistent with current research, which highlights the efficacy of training for enhancing laparoscopic skills.^1,14,15 Moreover, they corroborate earlier studies suggesting that online training can yield results comparable to traditional in-person training.^7,8,10 In addition, it changes the current flow of short-term courses to a more sustained program that favored skill retention.

However, it is essential to acknowledge a significant dropout rate during the follow-up stage, with only 53.8% of participants completing the course. Furthermore, a relatively low proportion (24%) managed to incorporate training into their routines for >2 hours per week. This could have happened due to extensive working hours that surgeons are used to have, or lack of acknowledging the benefits of continuous training. Nevertheless, among those who completed the program, an impressive 97.15% maintained or improved their skills.

Although these results suggest the course's effectiveness in fostering skill retention among actively engaged participants, it is essential to recognize that our study's limitations lied in the dropouts and a lack of information on nonpracticing individuals. Further attempts to maintain the surgeon's interest in training are being done including the incorporation of more challenging scenarios.

Conclusions

We have presented a novel online training program, based on continuous training and mastery learning that demonstrated that the unlimited access to a personal training gym allows surgeons to improve and maintain MIS skills. In addition, the personalized mentoring, with on-demand specific material guaranteed high adhesion to the program.