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Background: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH., Methods: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants., Results: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047)., Conclusions: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice., Trial Registration: ISRCTN 83733979.

To assess the role of live porcine simulation in robotic surgical skills training. A qualitative and quantitative survey was conducted of participants of a live porcine robotic simulation course undertaken in a regional training centre. Data on participants' experience, robotic surgical ability, the educational impact and outcomes from the course were collected. Thirty-nine participants from four different countries completed the survey. Clinical experience varied; however, prior robotic surgical experience (median 0 cases, range 0-100) and technical ability were low. The perceived usefulness, effectiveness and realism of the training course were all highly scored. Participants rated the most useful course components as port placement and docking, basic robotic skills training and repair of a bladder injury. Training resulted in significant increases in technical ability (p < 0.0001). Following the course, 49% of participants continued to either train or perform robotic surgery. This survey demonstrates that live porcine simulation for robotic surgery is a highly valued, acceptable and feasible form of training. The majority of participants were relatively inexperienced but nonetheless significant improvements in technical ability were reported. The results of this survey support the use of live porcine training for robotic surgery.

Objectives: To report the study protocol for the first international multicentre randomized controlled trial investigating the effectiveness of simulation-based surgical training and the development process for an evidence-based training curriculum, to be delivered as an educational intervention., Participants and Methods: This prospective, international, multicentre randomized controlled clinical and educational trial will recruit urology surgical trainees who must not have performed ≥10 of the selected index procedure, ureterorenoscopy (URS). Participants will be randomized to simulation-based training (SBT) or non-simulation-based training (NSBT), the latter of which is the current sole standard of training globally. The primary outcome is the number of procedures required to achieve proficiency, where proficiency is defined as achieving a learning curve plateau of 28 or more on an Objective Structured Assessment of Technical Skills (OSATS) assessment scale, for three consecutive operations, without any complications. All participants will be followed up either until they complete 25 procedures or for 18 months. Development of the URS SBT curriculum took place through a two-round Delphi process., Results: A total of 47 respondents, consisting of trainees (n = 24) with URS experience and urolithiasis specialists (n = 23), participated in round 1 of the Delphi process. Specialists (n = 10) finalized the content of the curriculum in round 2. The developed interventional curriculum consists of initial theoretic knowledge through didactic lectures followed by select tasks and cases on the URO-Mentor (Simbionix, Lod, Israel) VR Simulator, Uro-Scopic Trainer (Limbs & Things, Bristol, UK) and Scope Trainer (Mediskills, Manchester, UK) models for both semi-rigid and flexible URS. Respondents also selected relevant non-technical skills scenarios and cadaveric simulation tasks as additional components, with delivery subject to local availability., Conclusions: SIMULATE is the first multicentre trial investigating the effect and transferability of supplementary SBT on operating performance and patient outcomes. An evidence-based training curriculum is presented, developed with expert and trainee input. Participants will be followed and the primary outcome, number of procedures required to proficiency, will be reported alongside key clinical secondary outcomes, (ISCRTN 12260261)., (© 2020 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: Tools for assessment of technical skills are a crucial part of surgical education. They provide trainees with quantitative feedback highlighting both proficiency and areas for improvement. For this to be relevant to day-to-day practice, the tools used have to be validated and relevant to each surgical situation. This study aims to evaluate the validity of assessment tools used within surgery., Materials and Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted searching the MEDLINE and Embase databases (International Prospective Register of Systematic Reviews: CRD42018104674). Studies utilizing any assessment tool in any surgical specialty were included. Messick's criteria were used for literature evaluation, and the Modified Educational Oxford Centre for Evidence-Based Medicine was used to assess levels of recommendation., Results: A total of 303 studies and 76 tools were included. The most commonly used tool was Objective Structured Assessment Tool Skills (OSATS; n = 137, 45.2%). OSATS was used in conjunction with another tool or tools in an additional 55 studies (18.2%). Seven further tools were used in at least 3 studies. A total of five studies evaluated contained all five aspects of Messick's validity., Conclusions: There are several widely validated tools for assessing technical skills, the most common of which is OSATS. There is an emerging trend for crowdsourcing as a quick, cheap method for assessment of technical skills. This technique has been validated using both GEARS and GOALS. Numerous tools were found to be used only once and demonstrate a tendency for units to create their own tools for a specific task or specialty., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The increasing challenges facing the training of future neurosurgeons have led to continued development of simulation-based training, particularly for neurosurgical subspecialties. The simulators must be scientifically validated to fully assess their benefit and determine their educational effects. In this second part, we aim to identify the available simulators for spine, pediatric neurosurgery, interventional neuroradiology, and nontechnical skills, assess their validity, and determine their effectiveness., Methods: Both Medline and Embase were searched for English language articles that validate simulation models for neurosurgery. Each study was screened according to the Messick validity framework, and rated in each domain. The McGaghie model of translational outcomes was then used to determine a level of effectiveness for each simulator or training course., Results: Overall, 114 articles for 108 simulation-based training models or courses were identified. These articles included 24 for spine simulators, 3 for nontechnical skills, 10 for 9 pediatric neurosurgery simulators, and 12 for 11 interventional neuroradiology simulators. Achieving the highest rating for each validity domain were 3 models for content validity; 16 for response processes; 1 for internal structure; 2 for relations to other variables; and only 1 for consequences. For translational outcomes, 2 training courses achieved a level of effectiveness of >2, showing skills transfer beyond the simulator environment., Conclusions: With increasing simulators, there is a need for more validity studies and attempts to investigate translational outcomes to the operating theater when using these simulators. Nontechnical skills training is notably lacking, despite demand within the field., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses. We aim to identify the currently available simulators and training courses for neurosurgery, assess their validity, and determine their effectiveness., Methods: Both MEDLINE and Embase were searched for English language articles which validate simulation models for neurosurgery. Each study was screened according to the Messick validity framework and rated in each domain. The McGaghie model of translational outcomes was then used to determine a level of effectiveness (LoE) for each simulator or training course., Results: On screening of 6006 articles, 114 were identified to either validate or determine an LoE for 108 simulation-based training models or courses. Achieving the highest rating for each validity domain were 6 models and training courses for content validity, 12 for response processes, 4 for internal structure, 14 for relations to other variables, and none for consequences. For translational outcomes, 6 simulators or training achieved an LoE >2 and thus showed skills transfer beyond the simulation setting., Conclusions: With the advent of increasing neurosurgery simulators and training tools, there is a need for more validity studies. Further attempts to investigate translational outcomes to the operating theater when using these simulators is particularly warranted. More training tools incorporating full-immersion simulation and nontechnical skills training are recommended., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Difficult surgical procedures may result in a higher mental workload, leading to increased fatigue and subsequent errors. This study was aimed to investigate the effect of repeated simulation training in ureterorenoscopy in a high-fidelity setting on the performance and mental workload of novice operators., Methods: Medical students voluntarily participated in the present simulation study. After a didactic and video-based lecture, they underwent simulation training involving a renal stone case, including a rigid cystoscope component (task 1, performing a WHO checklist, assembling a scope, and insertion of a guide-wire and an access sheath after examining the bladder) and a flexible ureterorenoscope component (task 2, retrieving a stone located in the upper calyx using a basket after inspecting the upper, middle, and lower calyx). Training was performed in a mock operating theater. Technical skills were assessed by one author (an experienced urologist) onsite using an Objective Structured Assessment of Technical Skills (OSATS) score at each training session. The mental workload was subjectively evaluated by the National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire after each training session., Results: Seventeen students completed a minimum of 6 training sessions (male: female = 10: 7, median age of 22) over a median of 21 days (range, 10-32). In both tasks 1 and 2, the OSATS score improved over the 6 sessions with evidence of plateauing (MANOVA model, task 1: p < 0.0001, task 2: p < 0.0001). In contrast, the NASA-TLX score persistently decreased without plateauing (task 1: p = 0.0005, task 2: p = 0.0028)., Conclusions: Under repeated simulation training in ureterorenoscopy in a high-fidelity setting, participants showed a continual decrease of the mental workload, while the improvement of technical skills reached a plateau over the 6 sessions. Our study showed the important benefit of simulation training to reduce the mental workload by repeated scenario training before actual clinical practice.

Background: The complexity of the operating room requires a surgeon to have both technical ability and an array of nontechnical skills. The emphasis on technical skills during surgical training is well established, however it is deficiencies in nontechnical skills that have been identified as the main cause of errors in the operating room., Objective: This systematic review aims to identify current methods used to teach nontechnical skills and how these methods are assessed to determine their validity, evidence, and role in training., Methods: MEDLINE and Embase databases were searched for English language articles between 2000 and 2017 for nontechnical surgical skills training. Original research articles were included if they described non-technical surgical skills training modalities and their assessment. Results were assessed for the level of evidence and each modality was awarded a level of recommendation, using a modified educational Oxford Centre for Evidence-Based Medicine classification, as adapted by the European Association of Endoscopic Surgery., Results: A total of 19 studies were identified pertaining to high fidelity simulation (n = 8), low fidelity simulation (n = 6), didactic teaching (n = 2) and crisis resource management (n = 3). Of the included studies 1 was classified Level 1b, 1 level 2b, 7 level 2b, 2 level 2c, and 8 level 3., Conclusion: With the importance of nontechnical skills being increasingly recognized, it is essential for surgeons to receive adequate training in nontechnical skills. Therefore the most valuable teaching modalities such as high and low fidelity simulation needs to be implemented into surgical training curricula., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Procedures for urolithiasis are a core part of the development for the urologist in training. Understanding the learning curve of the procedures is important, allowing for planning in the training and assessment of trainees. The aim of this study was to systematically review the literature pertaining to learning curves in urolithiasis surgery., Materials and Methods: The review was registered on the PROSPERO database and conducted in keeping with the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Embase, MEDLINE, and PsycINFO were systematically searched from inception to January 2018, with a reference review conducted. All empirical studies on learning curves in urolithiasis surgery were included irrespective of procedure. Articles describing pediatric surgery, nontechnical skills in surgery, or those not written in English were excluded., Results: Of 390 articles identified from screening, a final 18 studies were included. Fourteen studies identified the learning curve in percutaneous nephrolithotomy. These studies identified a learning curve of between 30 and 60 cases for both operative time (OT) and complication rates. Four articles focused on flexible ureteroscopy (FURS); the learning curve for FURS has been outlined as 60 cases for OT and 56 cases for fragmentation efficacy., Conclusions: The complexities of determining learning curves are extensive; studies use different parameters to measure outcomes and observe skill acquisition rates of surgeons with differing prior experience. Evidence in this article can guide trainee urologists with regard to the expected rate of progress. Multi-operator multicenter research utilizing standard outcome measures should be conducted to establish definitive learning curves.

Objective: Otolaryngology is a highly technical and demanding specialty and the requirements for surgical trainees to acquire proficiency remains challenging. Simulation has been purported to be an effective tool in assisting with this. The aim of this systematic review is to identify the available otolaryngology simulators, their status of validation, and evaluation the level of evidence behind each training model and thereby establish a level of recommendation., Design: PubMed, ERIC, and Google Scholar databases were searched for articles that described otolaryngology simulators or training models between 1980 and April 2016. Any validation studies for simulators were also retrieved. Titles and abstracts were screened for relevance using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Level of evidence (LoE) and Level of recommendation (LoR) was awarded to each study and model, respectively., Results: A total of 70 studies were identified describing 64 simulators. Out of these, at least 54 simulators had 1 validation study. Simulators for the ear and temporal bone surgery were the most common (n = 32), followed by laryngeal and throat (n = 20) and endoscopic sinus surgery (n = 12). Face validity was evaluated by 29 studies, 20 attempted to show construct, 20 assessed content, 20 transfer, and only 2 assessed concurrent validity. Of the validation assessments, 2 were classified as Level 1b, 10 Level 2a, and 48 Level 2b. No simulators received the highest LoR, but 8 simulators received a LoR of 2., Conclusions: Despite the lack of evidence in outcome studies and limited number of high-validity otolaryngology simulators, the role of simulation continues to grow across surgical specialties Hence, it is imperative that the simulators are of high validity and construct for trainees to practice and rehearse surgical skills to develop confidence., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Simulation has become widely accepted as a supplementary method of training. Within urology, the greatest number of procedure-specific models and subsequent validation studies have been carried out in the field of endourology. Many generic-skills simulators have been created for laparoscopic and robot-assisted surgery, but only a limited number of procedure-specific models are available. By contrast, open urological simulation has only seen a handful of validated models. Of the available modalities, virtual reality (VR) simulators are most commonly used for endourology and robotic surgery training, the former also employing many high-fidelity bench models. Smaller dry-lab and ex vivo animal models have been used for laparoscopic and robotic training, whereas live animals and human cadavers are widely used for full procedural training. Newer concepts such as augmented-reality (AR) models and patient-specific simulators have also been introduced. Several curricula, including one recommended within, have been produced, incorporating various different training modalities and nontechnical skills training techniques. Such curricula and validated models should be used in a structured fashion to supplement operating room training.

Objective: Little integration of technical and nontechnical skills (e.g., situational awareness, communication, decision making, teamwork, and leadership) teaching exists within surgery. We therefore aimed to (1) evaluate the relationship between these 2 skill sets within a simulation-based environment and (2) assess if certain nontechnical skill components are of particular relevance to technical performance., Design: A prospective analysis of data acquired from a comparative study of simulation vs nonsimulation training was conducted. Half of the participants underwent training of technical and nontechnical skills within ureteroscopy, with the remaining half undergoing no training. All were assessed within a full immersion environment against both technical (time to completion, Objective Structured Assessment of Technical Skills, and task-specific checklist scores) and nontechnical parameters (Nontechnical Skills for Surgeons [NOTSS] rating scale). The data of whole and individual cohorts were analyzed using Pearson correlation coefficient., Setting: The trial took place within the Simulation and Interactive Learning Centre at Guy's Hospital, London, UK., Participants: In total, 32 novice participants with no prior practical ureteroscopy experience were included within the data analysis., Results: A correlation was found within all outcome measures analyzed. For the whole cohort, a strong negative correlation was found between time to completion and NOTSS scores (r = -0.75, p < 0.001), with strong positive correlations identified when NOTSS scores were compared with Objective Structured Assessment of Technical Skills (r = 0.89, p < 0.001) and task-specific checklist scores (r = 0.91, p < 0.001). Similar results were observed when each cohort was analyzed separately. Finally, all individual nontechnical skill components demonstrated a strong correlation with all technical skill parameters, regardless of training., Conclusions: A strong correlation between technical and nontechnical performance exists, which was demonstrated to be irrespective of training received. This may suggest an inherent link between skill sets. Furthermore, all nontechnical skill sets are important in technical performance. This supports the notion that both of these skills should be trained and assessed together within 1 curriculum., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Simulation is a common adjunct to operative training and various modalities exist for ureteroscopy. This systematic review aims the following: (1) to identify available ureteroscopy simulators, (2) to explore evidence for their effectiveness using characteristic criterion, and (3) to provide recommendations for simulation-based ureteroscopy training., Design: The preferred reporting items for systematic reviews and meta-analysis statement guidelines were used. A literature search was performed using the PubMed, EMBASE, and Cochrane Library databases., Results: In total, 20 articles concerning ureteroscopy simulators were included. Overall, 3 high-fidelity bench models are available. The Uro-Scopic Trainer has demonstrated face, construct, and concurrent validity, whereas the Scope Trainer has undergone content, construct, and predictive validation. The adult ureteroscopy trainer has demonstrated face, content, and construct validity. The URO Mentor is the only available ureteroscopy virtual-reality system; 10 studies were identified demonstrating its face, content, construct, concurrent, and predictive validity. The Uro-Scopic Trainer, the Scope Trainer, and the URO Mentor have demonstrated high educational impact. A noncommercially available, low-fidelity model has demonstrated effectiveness comparable to its high-fidelity counterpart at 185 times lesser than the price of the Uro-Scopic Trainer. The use of porcine models has also been described in 3 studies but require further study., Conclusions: Valid models are available for simulation-based ureteroscopy training. However, there is a lack of many high-level studies conducted, and further investigation is required in this area. Furthermore, current research focuses on the technical skills acquisition with little research conducted on nontechnical skills acquisition within ureteroscopy. The next step for ureteroscopy training is a formalized and validated curriculum, incorporating simulation, training models, development of nontechnical skills, and real-life practice., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background Training for robot-assisted thoracic lobectomy remains an issue, prompting the development of virtual reality simulators. Our aim was to assess the construct and face validity of a new thoracic lobectomy module on the RobotiX Mentor, a robotic surgery simulator. We also aimed to determine the acceptability and feasibility of implementation into training. Methods This prospective, observational, and comparative study recruited novice (n = 16), intermediate (n = 9), and expert (n = 5) participants from King's College London, the 25th European Conference on General Thoracic Surgery, and the Society of Robotic Surgery conference 2018. Each participant completed two familiarization tasks followed by the Guided Robotic Lobectomy module and an evaluation questionnaire. Outcome measures were compared using Mann-Whitney U tests. Results Construct validity was demonstrated in 12/21 performance evaluation metrics. Significant differences between groups were found in all metrics including: time taken to complete module, vascular injury, respect for tissue, number of stapler firings, time instruments out of view, number of instrument collisions, and number of movements. Participants deemed aspects of the simulator (mean 3/5) and module (3/5) as realistic and rated the simulator as both acceptable (3.8/5) and feasible (3.8/5) for robotic surgical training. Conclusions Face validity, acceptability, and feasibility were established for the thoracic lobectomy module of the RobotiX Mentor simulator. Moderate evidence of construct validity was also demonstrated. With further work, this simulation module could help to reduce the initial part of the learning curve for trainees and decrease the risk of errors during live training. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the face, content, and construct validity of a novel virtual reality simulator for holmium laser enucleation of the prostate (HoLEP) and to assess its feasibility and acceptability as a training model.Methods: This prospective observational study recruited 53 participants, comprising of 3 groups: HoLEP experts (n = 11), intermediates (n = 24), and novices (n = 18). All participants received an educational package and a 15-minute familiarization exercise with the simulator. All participants then carried out a full enucleation on an identical 60 cm(3) virtual prostate. Performance was assessed using in-built simulator metrics, and a questionnaire was distributed assessing face and content validity, as well as feasibility, and acceptability. Novice, intermediate, and expert groups were compared using the Mann-Whitney U test.Results: Construct validity data revealed significant differences in enucleation efficiency (grams enucleated per hour) when comparing experts to intermediates (P = .003), experts to novices (P <.001), and intermediates to novices (P = .001). Face validity was rated by experts as acceptable, with a mean score of 5.6 out of 10 when asked to rate the overall realism. Content validity questions showed that 85% of participants agreed that simulator-based assessment is essential for patient safety and 87% agreed that there was a role for a validated virtual reality simulator for use in HoLEP training.Conclusion: This study established face, content, and construct validity for this novel virtual reality HoLEP simulator. The majority of participants also thought that it is a feasible and acceptable model for HoLEP training. [ABSTRACT FROM AUTHOR]