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Supplemental Digital Content is available in the text., Background: Although methods to overcome difficulties associated with mirror-image conditions have been investigated, the ideal spatial relationship among the operator line of sight, monitor location, and camera location remains unclear. Moreover, the best training method for improving laparoscopic surgical skills under varying operator line of sight, camera, and monitor positions is unknown. We aimed to investigate the role of laparoscopic training under mirror-image conditions in improving surgical efficiency and whether prior surgical experience affects such training. Methods: This prospective study was conducted at the Department of Surgical Oncology, Tokyo University, Japan. Twenty-five surgeons participated. Novice (n=14), trained (n=7), and expert (n=4) participants performed the simulated task in a box trainer while varying the positional relationships among the surgeons, camera, and monitor. Five patterns were repeatedly performed 5 times per day for 4 days over 2 weeks. Results: The most significant differences in terms of the time required to complete the task under mirror-image conditions among the 3 groups were on day 1 (novices: 185.8 s, trained: 79.7 s, and experts: 46.5 s, P=0.009). However, after 4 days of training, the corresponding times did not differ among the 3 groups (26.0, 30.7, and 23.1 s, respectively; P=0.415). Laparoscopic training was sufficiently effective under mirror-image conditions. Conclusions: Mirror-image surgical conditions provided the most difficult setting, because surgeons and assistants often became disoriented, and task performance was most degraded. However, just 4 days of training was found to be sufficient to overcome the difficulties encountered while performing laparoscopic procedures under mirror-image conditions.

Background The availability of validated laparoscopic simulators has not resulted in sustainable high-volume training. We investigated whether the validated laparoscopic serious game Underground would increase voluntary training by residents. We hypothesized that by removing intrinsic barriers and extrinsic barriers, residents would spend more time on voluntary training with Underground compared to voluntary training with traditional simulators. Methods After 1 year, we compared amount of voluntary time spent on playing Underground to time spent on all other laparoscopic training modalities and to time spent on performing laparoscopic procedures in the OR for all surgical residents. These data were compared to resident’ time spent on laparoscopic activities over the prior year before the introduction of Underground. Results From March 2016 until March 2017, 63 residents spent on average 20 min on voluntary serious gaming, 17 min on voluntary simulator training, 2 h and 44 min on mandatory laparoscopic training courses, and 14 h and 49 min on laparoscopic procedures in the OR. Voluntary activities represented 3% of laparoscopic training activities which was similar in the prior year wherein fifty residents spent on average 33 min on voluntary simulator training, 3 h and 28 min on mandatory laparoscopic training courses, and 11 h and 19 min on laparoscopic procedures. Conclusion Serious gaming has not increased total voluntary training volume. Underground did not mitigate intrinsic and extrinsic barriers to voluntary training. Mandatory, scheduled training courses remain needed. Serious gaming is flexible and affordable and could be an important part of such training courses.

Background Adaptive training is an approach in which training variables change with the needs and traits of individual trainees. It has potential to mitigate the effect of personality traits such as impulsiveness on surgical performance. Selective performance feedback is one way to implement adaptive training. This paper investigates whether selective feedback can direct performance of trainees of either high- or low impulsiveness. Methods A total of 83 inexperienced medical students of known impulsiveness performed a four-session laparoscopic training course on a Virtual Reality Simulator. They performed two identical series of tasks every session. During one series of tasks they received performance feedback on duration and during the other series they received feedback on damage. Performance parameters (duration and damage) were compared between the two series of tasks to assess whether selective performance feedback can be used to steer emphasis in performance. To assess the effectiveness of selective feedback for people of high- or low impulsiveness, the difference in performance between the two series for both duration and damage was also assessed. Results Participants were faster when given performance feedback for speed for all exercises in all sessions (average z-value = − 4.14, all p values < .05). Also, they performed better on damage control when given performance feedback for damage in all tasks and during all sessions except for one (average z-value = − 4.19, all but one p value < .05). Impulsiveness did not impact the effectiveness of selective feedback. Conclusion Selective feedback on either duration or damage can be used to improve performance for the variable that the trainee receives feedback on. Trainee impulsiveness did not modulate this effect. Selective feedback can be used to steer training focus in adaptive training systems and can mitigate the negative effects of impulsiveness on damage control.

This study was conducted to evaluate the feasibility and therapeutic safety of laparoendoscopic single-site ovariectomy (LESS-OVE) and 3-portal laparoscopic ovariectomy (Lap-OVE) in dogs. Ten female mixed breed dogs were included in the study. Dogs were divided into group 1 (LESS-OVE; n = 5) and group 2 (Lap-OVE; n = 5). All procedures were performed by laparoscopic-skilled surgeons, and the anesthetic protocol was the same for all patients. In both groups, the ovarian vascular pedicle and ligaments were transected using a bipolar vessel sealer/divider device. The mean total surgical time was slightly longer in LESS-OVE (36.6 ± 3.5 min) than Lap-OVE (32.0 ± 3.0 min); however, the differences were not significant. Perioperative complications were not reported in any group. Both laparoscopic techniques were shown to be equally feasible and safe for patients. However, surgeons found LESS-OVE to require more skill than Lap-OVE. Therefore, additional studies should be conducted to evaluate this novel approach in clinical veterinary practice, and a proper laparoscopic training program for veterinary surgeons should be developed.

Laparoscopy is a cornerstone of modern surgical care. Despite clear advantages for the patients, it has been associated with inducing upper body musculoskeletal disorders amongst surgeons due to the propensity of non-neutral postures. Furthermore, there is a perception that patients with obesity exacerbate these factors. Therefore, novice, intermediate and expert surgeon upper body posture was objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess the subsequent postural data during laparoscopic training on patient models that simulated BMI’s of 20, 30, 40 and 50 kg/m2. In all experience groups, the posture of the upper body significantly worsened during simulated surgery on the BMI 50 kg/m2 model as compared to on the baseline BMI model of 20 kg/m2. These findings suggest that performing laparoscopic surgery on patients with severe obesity increases the prevalence of non-neutral upper body posture and may further increase the risk of musculoskeletal disorders in surgeons.

Objective To analyze the applicability and efficiency of amulti-approach laparoscopic training in improving basic laparoscopic skills of obstetrics and gynecology (OBGYN) residents. Methods Cross-sectional, observational and descriptive study, developed at the Experimentation and Surgery Training Center (CETEC, in the Portuguese acronym) of the Hospital Israelita Albert Einstein with OBGYN residents. Theoretical and practical tests were applied to 24 OBGYN residents to assess their laparoscopic skills before and after their participation in an 8-week course. The course involved theoretical lectures and practical laparoscopic surgery exercises developed using rubber models, black boxes, virtual simulators and animal models (pigs). Results There was an overall improvement in the ability of the residents, with an increase in the number of correct answers in the theoretical evaluation and decrease in the time needed to perform practical tests (needle holder assembly and laparoscopic node). The course was evaluated by the students as highly relevant for both improving their surgical skills and motivating them to continue practicing. Conclusion Laparoscopic training using multiple approaches resulted in significant improvement of surgical skills with a high satisfaction level of the participants. Further studies are still needed to measure the long-term retention of these acquired skills. Resumo Objetivo Analisar a aplicabilidade e eficiência de um treinamento em laparoscopia com múltiplas abordagens, em melhorar as habilidades laparoscópicas básicas de residentes de ginecologia e obstetrícia (GO). Métodos Estudo transversal, observacional e descritivo, desenvolvido no Centro de Treinamento em Experimentação e Cirurgia (CETEC) do Instituto de Pesquisa do Hospital Albert Einstein com residentes de GO. Foram aplicadas avaliações teóricas e práticas a 24 residentes de GO com o objetivo de avaliar suas habilidades laparoscópicas antes e após sua participação em um curso de 8 semanas. O curso envolveu palestras teóricas e exercícios práticos de cirurgia laparoscópica através de modelos de borracha, caixas pretas, simuladores virtuais e modelos animais (porcos). Resultados Houve uma melhora geral na habilidade dos residentes, comaumento do número de respostas corretas na avaliação teórica e diminuição do tempo na execução dos testes práticos (montagem do porta-agulha e realização de nó laparoscópico). O curso foi avaliado pelos alunos como altamente relevante por melhorar suas habilidades cirúrgicas e motivá-los a continuar praticando. Conclusão O treinamento laparoscópico utilizando múltiplas abordagens resultou em melhora significativa das habilidades cirúrgicas atrelado a alto nível de satisfação dos participantes. Novos estudos ainda são necessários para mensurar a retenção destas habilidades adquiridas a longo prazo.

Resumen: Introducción: la enseñanza de la cirugía atraviesa un cambio de paradigma, siendo el entrenamiento en laparoscopía avanzada uno de sus mayores desafíos. El objetivo de este estudio es describir y evaluar la experiencia de un servicio de cirugía universitario con un modelo de entrenamiento simulado de anastomosis intestinal laparoscópica. Método: tres residentes de cirugía general completaron un programa de entrenamiento de cuatro semanas. Se utilizó un modelo biológico ex vivo en box trainer, evaluando objetivamente la realización de una anastomosis entero-entérica. Resultados: el tiempo de ejecución del procedimiento se redujo en una media de 15 minutos, con una mejoría significativa del desempeño según la escala OSATS. Discusión: la implementación de un programa validado y modificado de simulación en laparoscopía avanzada permitió obtener resultados positivos, utilizando para ello solo el 4% de la carga horaria semanal curricular. El modelo tiene una alta fidelidad, bajo costo y es fácilmente reproducible. Conclusiones: el entrenamiento simulado en laparoscopía es una herramienta obligatoria y beneficiosa durante la formación del cirujano general. Summary: Background: there is a changing paradigm in surgical education, being laparoscopic training one of its major challenges. The objective of this study is to describe and evaluate our experience with a simulated laparoscopic small bowel anastomosis training model at a universitary surgical center. Methods: a 4-week training program was conducted with participation of 3 general surgery residents. An ex vivo biological model in a box trainer was used to objectively evaluate a simulated entero-enterostomy. Results: final procedure time was reduced an average of 15 minutes, with better outcomes according to OSATS scale. Discussion: implementation of a modified, validated advanced laparoscopic skills training program showed positive results, taking only 4% of the weekly curricular schedule. The model has high fidelity, low cost and is easily reproducible. Conclusions: simulated laparoscopic training is both mandatory and beneficial in surgical education. Resumo: Introdução: o ensino da cirurgia atravessa um cambio de paradigma, sendo o treinamento em laparoscopia avançada um de sus maiores desafios. O objetivo deste estudo é descrever e avaliar a experiencia de um serviço universitário de cirurgia com um modelo de treinamento simulado de anastomose intestinal laparoscópica. Métodos: 3 residentes de cirurgia general completaram um programa de treinamento de 4 semanas. Foi empregado um modelo biológico ex vivo em simuladores de caixa, avaliando objetivamente a realização de uma anastomose entero-entérica. Resultados: o tempo de execução do procedimento foi reduzido em média 15 minutos, com una melhoria significativa do desempenho segundo a escala OSATS. Discussão: a implementação de um programa validado e modificado de simulação em laparoscopia avançada permitiu obter resultados positivos, utilizando somente 4% da carga horaria semanal curricular. O modelo tem alta fidelidade, baixo custo e é facilmente reproduzível. Conclusões: o treinamento simulado em laparoscopia é uma ferramenta obrigatória e benéfica durante a formação do cirurgião geral.

INTRODUCTION AND OBJECTIVE:There is limited data demonstrating the efficacy of laparoscopic training curricula, such as BLUS (Basic Laparoscopic Urologic Skills), in improving technical skills. Des...

Background: Simulation plays an important role in surgical training. We developed a simulator for laparoscopic ventral hernia repair (LVHR) surgery based on porcine tissue, characterized by low cost and high reality. Methods: Our LVHR model is based on porcine tissue mounted in a human mannequin. The anterior abdominal wall is constructed to allow laparoscopic training. Training sessions are conducted in a simulated operating room environment. Results: During preliminary tests, the LVHR simulator was found to be highly realistic in terms of tissue feedback, instrumentation usage, and performing the key steps of the LVHR procedure. The model was evaluated as a very useful tool for residents' training allowing to gain laparoscopic skills, learn the key steps of LVHR, and practice team work. Conclusions: Our simulator, based on porcine tissue mounted in a mannequin, offers a very realistic and cost-effective model for simulating LVHR surgery.

The objective of this study was to examine the impact of an intensive laparoscopic training course incorporating structured assessment and immediate feedback on residents' operative performance in animal lab.Surgical residents participated in a 2-day intensive laparoscopic training course. They performed the same procedures on two consecutive days on live pigs. Junior residents (PGY1-2) performed laparoscopic cholecystectomy and incisional hernia repair and the senior residents (PGY3-5) performed laparoscopic Nissen fundoplication, splenectomy, and low anterior colon resection. Assessment tools with proven validity evidence (global and procedure-specific rating tools for operative assessment of laparoscopic skills) were used to assess their operative performance. Faculty assessment and self-assessments were completed immediately after each procedure on both days. The Wilcoxon rank test was used to examine the effect of training on resident performance after one repetition.Forty surgical residents (20 junior and 20 senior residents) participated. There was a significant improvement in general laparoscopic skills during incisional hernia repair and Nissen fundoplication using global rating scales (p 0.05). Moreover, there was an improvement in their performance during cholecystectomy, incisional hernia repair, and low anterior colectomy when procedure-specific skills assessments were used (p 0.05). There was a positive correlation between residents' self-reported confidences and their operative performance CONCLUSION: Trainees showed significant improvements in performance in general and procedure-specific laparoscopic skills in a wide range of procedures after an intensive training course. This study demonstrates the benefit of a structured training curriculum in improving operative performance in basic and advanced laparoscopic skills in a simulated environment. Future studies are needed to examine the duration of training required to achieve skill retention and competency.

Several studies have demonstrated that training with a laparoscopic simulator improves laparoscopic technical skills. We describe how to build a homemade, low-cost laparoscopic training simulator (LABOT) and its validation as a training instrument. First, sixty surgeons filled out a survey characterized by 12 closed-answer questions about realism, ergonomics, and usefulness for surgical training (global scores ranged from 1&mdash, very insufficient to 5&mdash, very good). The results of the questionnaires showed a mean (&plusmn, SD) rating score of 4.18 &plusmn, 0.65 for all users. Then, 15 students (group S) and 15 residents (group R) completed 3 different tasks (T1, T2, T3), which were repeated twice to evaluate the execution time and the number of users&rsquo, procedural errors. For T1, the R group had a lower mean execution time and a lower rate of procedural errors than the S group, for T2, the R and S groups had a similar mean execution time, but the R group had a lower rate of errors, and for T3, the R and S groups had a similar mean execution time and rate of errors. On a second attempt, all the participants tended to improve their results in doing these surgical tasks, nevertheless, after subgroup analysis of the T1 results, the S group had a better improvement of both parameters. Our laparoscopic simulator is simple to build, low-cost, easy to use, and seems to be a suitable resource for improving laparoscopic skills. In the future, further studies should evaluate the potential of this laparoscopic box on long-term surgical training with more complex tasks and simulation attempts.

Background Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3–0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial. Methods Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor. Results Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding. Conclusions The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Pediatric laparoscopy box with sliding tray, Background: Pediatric procedures have the difficulty of being performed in reduced spaces. Training in reduced spaces has proven to be different in complexity compared to adult laparoscopic endotrainers. Aim: To develop and validate a new neonatal/reduced-space endotrainer. Methods: The simulator was tested and assessed by users with different skill levels and experience in laparoscopic pediatric surgery through an 8-item questionnaire. Construct validity was determined by evaluating the performance of each subject on nine exercises. Results: A 10.5 x 10 x 18 cm acrylic simulator was created, with an internal working surface of 9 x 9 cm. An HD camera was incorporated, with a 0-180° range of movement. All exercises of a Basic Laparoscopic Training Program were adapted on a scale of 1:0.5 to fit in. From 49 participants, 42 (85.71%) answered the survey; 80.5% considered that the simulator reproduces similar conditions to procedures performed in children under one year of age; 61.1% thought that the simulator represents a difficulty identical to procedures performed in newborns; 73.7% considered that the neonatal simulator is more complicated than the adult simulator. Experts showed significantly better performance in all proposed exercises. Conclusion: The simulator has a high-quality image and design that allows training with basic tasks. The endotrainer permitted to discriminate between these different skill levels and was well evaluated by users with diverse surgical experience.

Abstract: Introduction and aim: Minimally invasive techniques are gaining popularity in pediatric surgery, confident knowledge in endoscopies is one of the main purposes of the training. This survey analyzed the laparoscopic training for pediatric surgeons. Method: We sent questionnaires to all trainees and pediatric surgeons specialized after 2012 by e-mail. The questionnaire focused on their opportunities for laparoscopy during the training and their subjective opinions. Results: 34 questionnaires were sent by email. 17 trainees and 11 specialists responded (82%). The rate of endoscopic surgeries is 15% in the clinical centers without trauma surgery, and 2–10% in other training centers. Routine laparoscopies are performed in all centers, and in 40–60% of the centers, advanced endoscopies are also applied. Half of the surgeons performed laparoscopy in the first 2 years of training. An average of 20 laparoscopies were carried out by trainees in the 3–6th year. 50% of the trainees had the opportunity to use pelvitrainer, however, video-watching (100%) is the most common preparation before endoscopies. The surgeons’ subjective opinion about having enough laparoscopic experience by the time of the specialty exam was yes: n = 6 (21%), sufficient: n = 12 (43%) and no: n = 10 (36%). The training could be more effective with more equipment, free courses on pelvitrainers or animal models, and with more patient and dedicated attitude of the instructors. Conclusion: Laparoscopy is in everyday practice in major centers, however, trainees do not have enough experience in terms of its confident use. Endoscopic training could be better with the regular use of pelvitrainers and more surgical practice. Revision of the operation list and the rise in the number of laparoscopies are necessary. Orv Hetil. 2018; 159(43): 1747–1753.

Because of the long and variable learning curve of laparoscopic surgery, before its actual application, a well-designed practical simulating instruments like laparoscopic training boxes are needed. But because of unfavourable cost-effectiveness and huge sizes of these boxes, surgeons hardly procure, and carry them. We aimed to design a new, cheap, light and handy laparoscopic training box. Our training box is made of aluminium and used with smartphone or tablet. There is no need for a power unit. Our foldable box has dimensions of 52×38×4 cm, and weighs 2.8 kg and foldable. There are 5 working ports in it. Compared to its alternatives "Fu-Lap T-Box" is much cheaper, lighter and more comfortable. In our opinion it is possible to design and use a new cheaper and portable simulator to gain more hands-on experience before the real surgery.

The laparoscopic environment induces high attentional demands on operators due to the perceptual-motor distortions inherent in this environment. Further, successful surgical outcomes necessitate surgeons to have adequate situation awareness of the patient and the surgery. Thus, surgeons need to obtain information that is often displayed visually at different locations in the operating theater, requiring visual scanning. The present study assessed the impact of the distance between different displays on visual scanning behavior when performing a concurrent laparoscopic training task. The results of the present study have practical implications for laparoscopic surgery, indicating that critical information displayed visually should be located close to the monitor that displays the target tissue. Further, relatively difficult laparoscopic procedures (e.g., those with increased disruption of hand-eye mapping) might result in longer viewing times, and thus critical information might not be attended to because of decreased frequency of visual scanning.

Laparoscopic surgery requires complex surgical skills; hence, surgeons require regular training to improve their surgical techniques. The quantitative assessment of a surgeon’s skills and the provision of feedback are important processes for conducting effective training. The aim of this study was to develop an inexpensive training system that provides automatic technique evaluation and feedback. We detected the instrument using image processing of commercial web camera images and calculated the motion analysis parameters (MAPs) of the instrument to quantify performance features. Upon receiving the results, we developed a method of evaluating the surgeon’s skill level. The feedback system was developed using MAPs-based radar charts and scores for determining the skill level. These methods were evaluated using the videos of 38 surgeons performing a suturing task. There were significant differences in MAPs among surgeons; therefore, MAPs can be effectively used to quantify a surgeon’s performance features. The results of skill evaluation and feedback differed greatly between skilled and unskilled surgeons, and it was possible to indicate points of improvement for the procedure performed in this study. Furthermore, the results obtained for certain novice surgeons were similar to those obtained for skilled surgeons. This system can be used to assess the skill level of surgeons, independent of the years of experience, and provide an understanding of the individual’s current surgical skill level effectively. We conclude that our system is useful as an inexpensive laparoscopic training system that might aid in skill improvement.

The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career. A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship. Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice. Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice.

Laparoscopy is used increasingly to treat malignant and benign colorectal surgical diseases. However, this practice is still not offered to all patients. Many barriers halt the widespread use of laparoscopic colorectal surgery. Both surgeon's and patient's factors contribute to limit a wider use of laparoscopy in colorectal surgery.We retrospectively analyzed 408 consecutive colorectal resections in a 4-year period, to find out if a selection bias exists in using laparotomy or laparoscopy for colorectal surgical diseases, and which factors are associated with a poor use of laparoscopy or to a preferred laparotomy.In our practice, advanced disease, American Society of Anesthesiologist class III and IV, and emergency status are all patient-related factors associated with laparotomy. Surgeon's age more than 52 years and lack of laparoscopic training are surgeon-related factors that negatively affect the chance of being operated on with the laparoscopic technique.An extensive laparoscopic colorectal training and a supporting environment, especially during the night shift, are needed to facilitate the use of laparoscopy in colorectal surgery avoiding a bias in selecting surgical candidates to one technique or another.

Objective The aim of this study was to assess performance carryover effects associated with different successive lateral camera rotations in the laparoscopic training environment. Background Laparoscopy requires surgeons to adapt to disruptions of visuomotor mapping. A gradual adaptation process is hypothesized to be effective up to a given rotation threshold; this threshold may have performance implications for successive exposure to different lateral camera rotations. Method Two experiments utilized a laparoscopic training task. Experiment 1 exposed novices to a subsequent rotation that was either 45° larger than one of the initial rotations of 45°, 75°, 105°, and 135° or 45° smaller than one of the initial rotations of 90°, 120°, 150°, and 180°. Experiment 2 exposed novices to either stepwise increasing rotations (0° to 180°) or stepwise decreasing rotations (180° to 0°). Results Regarding Experiment 1, performance generally improved for subsequent rotations that were 45° larger than the initial rotation, except for one condition (initial rotation, 105°; subsequent rotation, 150°). Performance generally improved for subsequent rotations that were 45° smaller than the initial rotation, except for one condition (initial rotation, 120°; subsequent rotation, 75°). Experiment 2 indicated worst performance at 120° for the increasing and decreasing conditions. This finding suggests an identical threshold for increasing and decreasing rotations, which is inconsistent with Experiment 1 results. Conclusion Improved performance due to carryover effects from successive exposure to lateral camera rotations in the laparoscopic training environment is contingent on the specific camera rotations. Application Supplementary laparoscopic training might be needed for surgeries that entail certain successive lateral camera rotations.

Background Recently to improve depth perception, the performance of three-dimensional (3D) laparoscopic surgeries has increased. However, the effects of laparoscopic training using 3D are still unclear. This study aimed to clarify the effects of using a 3D monitor among novices in the early phase of training. Methods Participants were 40 novices who had never performed laparoscopic surgery (20 medical students and 20 junior residents). Three laparoscopic phantom tasks (task 1: touching markers on a flat disk with a rod; task 2: straight rod transfer through a single loop; and task 3: curved rod transfer through two loops) in the training box were performed ten times, respectively. Performances were recorded by an optical position tracker. The participants were randomly divided into two groups: one group performed each task five times initially under a 2D system (2D start group), and the other group performed each task five times under a 3D system (3D start group). Both groups then performed the same task five times. After the trial, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and the learning curves for both groups. Results Scores for all tasks performed under the 3D system were significantly better than scores for tasks using the 2D system. Scores for each task in the 2D start group improved after switching to the 3D system. However, scores for each task in the 3D start group were worse after switching to the 2D system, especially scores related to technical errors. Conclusions The stereoscopic vision improved laparoscopic surgical techniques of novices from the early phase of training. However, the performance of novices trained only by 3D worsened by changing to the 2D environment.

Recent technological progress offers the opportunity to significantly transform conventional open surgical procedures in ways that allow minimally invasive surgery (MIS) to be accomplished by specific operative instruments’ entry into the body through key-sized holes rather than large incisions. Although MIS offers an opportunity for less trauma and quicker recovery, thereby reducing length of hospital stay and attendant costs, the complex nature of this procedure makes it difficult to master, not least because of the limited work area and constricted degree of freedom. Accordingly, this research seeks to design a Teach and Playback device that can aid surgical training by key-framing and then reproducing surgical motions. The result is an inexpensive and portable Teach and Playback laparoscopic training device that can record a trainer’s surgical motions and then play them back for trainees. Indeed, such a device could provide a training platform for surgical residents generally and would also be susceptible of many other applications for other robot-assisted tasks that might require complex motion training and control.

Study Objective To pilot a remote learning Fundamentals of Laparoscopic Surgery (FLS) elective to pre-clinical medical students. Design Due to COVID-19 restrictions, pre-clinical medical students were required to strictly quarantine for two weeks upon arrival to their clinical rotation sites, during which they would engage in an elective of their choice. Medical students enrolled in the Remote Learning FLS Elective received a laparoscopic training box (Task It) with supplies prior to traveling around the continental United States for clinical rotations. Students also received instructions to access publicly available FLS modules and videos to introduce instruments and tasks. Each learner engaged in self-guided practice with coaching available via a live-streaming platform to assist with refining their skills during the course. Setting While quarantined in three different locations (Bethesda MD, San Antonio TX, and San Diego CA) learners utilized space in their living quarters to set up the Task II trainer and computer. Patients or Participants Three pre-clinical medical students enrolled in a 2-week distance learning FLS elective. Interventions Learners participated in a 2-week distance learning elective that utilized self-directed learning and practice, use of available FLS modules and videos, and individual coaching sessions with instructor. Measurements and Main Results All learners were true novices with no prior FLS or laparoscopic experience, and minimal to no experience with surgical skills. Learners practiced individually and timed themselves practicing each skill. Each was able to attain facility with object transfer, depth perception. Conclusion All learners improved from their baseline skills level. Remote coaching of FLS with true novices is a viable alternative to traditional face to face learning with motivated learners.

Laparoscopy is a cornerstone of modern surgical care, with clear advantages for the patients. However, it has also been associated with inducing upper body musculoskeletal disorders amongst surgeons due to their propensity to assume non-neutral postures. Further, there is a perception that patients with high body mass indexes (BMI) exacerbate these factors. Therefore, surgeon upper body postures were objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess posture during laparoscopic training on patient models that simulated BMIs of 20, 30, 40 and 50 kg/m2. In all surgeons the posture of the upper body significantly worsened during simulated laparoscopic surgery on the BMI 50 kg/m2 model as compared to the baseline BMI model of 20 kg/m2. These findings suggest that performing laparoscopic surgery on patients with high BMIs increases the prevalence of non-neutral posture and may further increase the risk of musculoskeletal disorders in surgeons.

Background Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India. Methods A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated. Results Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers. Conclusion Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context., Highlights • Structured training in gasless laparoscopy is feasible for rural surgeons. • Demonstrates overall improvement in knowledge and skill acquisition. • The training environment is an essential component for rural surgeons. • Lower costs support wider adoption in LMIC.