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Background: Laparoscopic camera navigation is vital to laparoscopic surgery, yet often falls to the most junior member of the surgical team who has limited laparoscopic operating experience. Previously published reports on simulation models fail to address qualitative scoring of movement, method of communication and correct physician location with respect to patient position. The purpose of this study was to develop and evaluate a novel laparoscopic camera navigation simulation model that addresses these deficiencies., Methods: A novel, low-cost laparoscopic camera navigational maze was constructed from pliable foam for use in a standard laparoscopic surgery box trainer. Participants (n = 37) completed a camera navigation exercise by following a pre-recorded set of verbal instructions using correct anatomic terminology that is used in the operating room, to simulate an actual operating room experience of receiving verbal cues from senior surgeons. The sample group consisted of participants at various levels of Obstetrics and Gynecology training, representing novice to expert laparoscopists. Each trial was recorded with a multi-channel video camera. Performances were scored by a blinded evaluator for excess gross and fine camera movements as well as overt errors, including camera collisions and failure to follow directions., Results: Our model demonstrated evidence of validity by discriminating performance by level of laparoscopic experience with a statistically significant decrease in number of movements and errors in experts compared to novices. A trend emerged toward improvement with each additional year of training, with reduced variability among performances in more experienced participants., Conclusions: This novel, low-cost box-trainer simulation model for laparoscopic camera navigation offers a mechanism for assessment of laparoscopic camera operation skills. Moreover, this model closely replicates operating room logistics and communication. Given the necessity for improved laparoscopic camera operation education, our model represents a unique, complementary tool to other laparoscopic simulation curricula.

Introduction: Laparoscopic tissue handling is quite difficult to measure using virtual-reality laparoscopic simulators and box-trainer exercises, and therefore, completion time is the predominant performance measure for simulation-based laparoscopic training exercises. The purpose of this study was to evaluate the construct validity of a training and assessment model for precise laparoscopic handling of delicate tissue., Methods: Participants (n = 35) completed 2 progressively challenging laparoscopic tissue translocation exercises using delicate foam pieces and templates. Deidentified performances were scored using objective measures for tissue damage, accuracy, percentage complete, and completion time. Evaluation included multiple analysis of variance with repeated measures among the 3 groups as follows: medical students, residents and faculty who perform laparoscopic surgery less than once per week, and faculty members who perform laparoscopic surgery at least once per week., Results: The model demonstrated significant construct validity by discriminating performances between the types of shapes and templates and across the levels of surgical experience on all dimensions. A significant interaction effect between the level of expertise and the difficulty of the exercise revealed excellent discrimination between experienced laparoscopic surgeons and others., Discussion: This low-cost model provides an alternative or adjunct platform for laparoscopic training and assessment that requires precise and measurable handling of a delicate tissue.

Introduction: Low-cost, high-fidelity models for training in advanced laparoscopic surgery techniques are not currently available. The objective of this study was to evaluate a model and assessment protocol for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making., Methods: Novice to expert laparoscopists (n = 41) were asked to remove the peel of a clementine in as few pieces as possible, separate and remove all albedo from and between all fruit segments, and return the clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision making included deciding when unacceptable segment damage would result by removing difficult-to-extract albedo, analogous to treating lesions or metastases through other methods, rather than risking damage to vital anatomic structures. Faculty assessed deidentified video-recorded performances. Data analyses included analysis of variance with Bonferroni post hoc., Results: A single-performance construct (operative ability) with 2 scoring dimensions (surgical skills and clinical judgment) was confirmed through factor analysis. There were significant performance differences between all experience levels (F2,41 = 59.175, P < 0.000). There were no statistical time differences between the groups., Conclusions: Validation of this low-cost, easily facilitated model for developing advanced laparoscopic surgical skills may support the preparation of residents and fellows and provide a platform for skill acquisition, assessment, and basic critical thinking for performing laparoscopic tasks.

Background: This study aimed to quantify learner reactions manifesting from a realistic contextual stressor while training with a laparoscopic simulator, and to identify learner-derived stress-modifying behaviors. Stress factors are known to affect cognitive and psychomotor performance. Simulation-based medical training typically occurs in environments that are relatively stress free compared with the applied context. Training is most effective when it occurs in a highly faithful context, so the inclusion of typical clinical stressors in simulated laparoscopic learning environments may be beneficial., Methods: Preclinical medical students (N = 27) completed tasks using a laparoscopic simulator under the following 2 conditions: faculty direct observation (stressor) and unobserved (no stressor). The data included simulator performance, blood pressure, real-time heart rates, videotaped behavior, and pre/post surveys of latent anxiety and stress factors associated with participating in the research (eg, STAI 9)., Results: Physiologic and behavioral manifestations of stress were observed for all participants during the stressor condition and during poor performance on simulator tasks. Stress was highest during periods of poor performance under the stressor condition. Focusing on the task itself mitigated stress reactions and improved performance on the simulator., Conclusion: Stress reactions can be induced in a laboratory setting where simulation-based training occurs. Stressors imposed on the learner during simulation-based training may help support the acquisition of stress management skills that are necessary in the applied clinical setting. A ramped-up sequence of acquiring technical skills and clinical decision making, followed by stress management techniques, may lead to a more efficient transfer of learning from the simulated context to the clinical area.

Background: Many surgical training programs are introducing virtual-reality laparoscopic simulators into their curriculum. If a surgical simulator will be used to determine when a trainee has reached an "expert" level of performance, its evaluation metrics must accurately reflect varying levels of skill. The ability of a metric to differentiate novice from expert performance is referred to as construct validity. The present study was undertaken to determine whether the LapMentor's metrics demonstrate construct validity., Methods: Medical students, residents and faculty laparoscopic surgeons (n = 5-14 per group) performed 5 consecutive repetitions of 6 laparoscopic skills tasks: 30 degrees Camera Manipulation, Eye-Hand Coordination, Clipping/Grasping, Cutting, Electrocautery, and Translocation of Objects. The LapMentor measured performance in 4 to 12 parameters per task. Mean performance for each parameter was compared between subject groups for the first and fifth repetitions. Pairwise comparisons among the 3 groups were made by post hoc t-tests with Bonferroni technique. Significance was set at P < 0.05., Results: Of the 6 tasks evaluated, only the Eye-Hand Coordination task (3/12 parameters) and the Clipping and Grasping (1/7 parameters) had expert-level discrimination when performance was compared after completion of 1 repetition. Comparison of the fifth repetition performance (representing the plateau of the learning curves), demonstrated that the parameters Time and Score had expert level discrimination on the Eye-Hand Coordination task, and Time on the Cutting task. The remaining LapMentor tasks evaluated did not exhibit the ability to differentiate level of expertise based on the built-in metrics on either repetition 1 or 5., Conclusions: The majority of the LapMentor tasks' metrics were unable to differentiate between laparoscopic experts and less skilled subjects. Therefore, performance on those tasks may not accurately reflect a subject's true level of ability. Feedback to the manufacturer about these findings may encourage the development of evaluation parameters with greater sensitivity.

Objective: To determine if prior training on the LapMentor laparoscopic simulator leads to improved performance of basic laparoscopic skills in the animate operating room environment., Summary Background Data: Numerous influences have led to the development of computer-aided laparoscopic simulators: a need for greater efficiency in training, the unique and complex nature of laparoscopic surgery, and the increasing demand that surgeons demonstrate competence before proceeding to the operating room. The LapMentor simulator is expensive, however, and its use must be validated and justified prior to implementation into surgical training programs., Methods: Nineteen surgical interns were randomized to training on the LapMentor laparoscopic simulator (n = 10) or to a control group (no simulator training, n = 9). Subjects randomized to the LapMentor trained to expert criterion levels 2 consecutive times on 6 designated basic skills modules. All subjects then completed a series of laparoscopic exercises in a live porcine model, and performance was assessed independently by 2 blinded reviewers. Time, accuracy rates, and global assessments of performance were recorded with an interrater reliability between reviewers of 0.99., Results: LapMentor trained interns completed the 30 degrees camera navigation exercise in significantly less time than control interns (166 +/- 52 vs. 220 +/- 39 seconds, P < 0.05); they also achieved higher accuracy rates in identifying the required objects with the laparoscope (96% +/- 8% vs. 82% +/- 15%, P < 0.05). Similarly, on the two-handed object transfer exercise, task completion time for LapMentor trained versus control interns was 130 +/- 23 versus 184 +/- 43 seconds (P < 0.01) with an accuracy rate of 98% +/- 5% versus 80% +/- 13% (P < 0.001). Additionally, LapMentor trained interns outperformed control subjects with regard to camera navigation skills, efficiency of motion, optimal instrument handling, perceptual ability, and performance of safe electrocautery., Conclusions: This study demonstrates that prior training on the LapMentor laparoscopic simulator leads to improved resident performance of basic skills in the animate operating room environment. This work marks the first prospective, randomized evaluation of the LapMentor simulator, and provides evidence that LapMentor training may lead to improved operating room performance.

Background: Computer-aided simulators may increase the safety and efficiency of training in laparoscopic surgery. Before implementation of the Immersion LapSim (Gaithersburg, MD) simulator in our training curriculum, we wished to determine its construct validity (ie, whether the simulator could differentiate laparoscopic novices from trainees with greater experience)., Methods: Subjects were medical students (MS), residents (RES), and laparoscopic faculty (FAC). Subjects performed 10 repetitions of 6 LapSim tasks. The LapSim measured performance in 6 to 10 parameters per task, and performance was compared between groups. Post hoc t tests were used to make pair-wise comparisons among the 3 groups using the Bonferroni technique. Statistical significance was set at P < .05., Results: The degree of prior laparoscopic experience was reflected in performance on at least 1 parameter for each task. Several patterns of performance between MS, RES, and FAC were observed., Conclusions: The LapSim has performance parameters that reliably differentiate between subjects with varying laparoscopic experience. However, some performance parameters do not differentiate between groups. To accurately measure a trainee's skill level, only parameters that sensitively measure the true level of performance should be used.

Abstract: Background: This study compares a laparoscopic skill training protocol without proficiency targets to the same protocol with explicit targets and notification of progress. Methods: Fourteen surgery interns were randomized into 2 groups. The intervention group received task-specific proficiency criteria to guide practice. The control group did not. After training, participants were evaluated by blinded faculty during laparoscopic cholecystectomy. Results: The control group met significantly fewer of the 7 LapSim (Surgical Science Sweden AB, Gotëborg) targets (mean = 1.14) than the intervention group (mean = 7.00; P = .001) and significantly fewer of the 5 video trainer targets (mean = .86) than the intervention group (mean = 5.00; P = .001). Ratings of depth perception, bimanual dexterity, efficiency, tissue handling, autonomy, and overall competence were higher for the intervention group. Effect sizes ranged from medium to large (.394–.981), indicating an impact of the proficiency-based training protocol. Conclusions: Delineation of proficiency targets with reporting of progress improves interns'' practice results, and appears to have a positive effect on their early operating room (OR) performance of laparoscopic cholecystectomy. [Copyright &y& Elsevier]