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Objective: To determine the feasibility, validity, inter-rater, and intertest reliability of 4 previously published video-based rating scales, for technical skills assessment on a benchmark laparoscopic procedure., Summary Background Data: Assessment of technical skills is crucial to the demonstration and maintenance of competent healthcare practitioners. Traditional assessment methods are prone to subjectivity through a lack of proven validity and reliability., Methods: Nineteen surgeons (6 novice and 13 experienced) performed a median of 2 laparoscopic cholecystectomies each (range 1-5) on 53 patients within 2 Academic Surgical Departments. All patients had a diagnosis of biliary colic. Surgical technical skills were rated posthoc in a blinded manner by 2 experienced observers on 4 video-based rating scales. The different scales used had been developed to assess generic or procedure-specific technical skills in a global manner, or on a procedure-specific checklist., Results: Six of 53 procedures were excluded on the basis of intraoperative difficulty. Of the remaining 47 procedures, 14 were performed by 6 novice surgeons and 33 by the 13 experienced surgeons. There were statistically significant differences between performance of the 2 groups on the generic global rating scale (median 24 vs. 27, P = 0.031), though not on procedural or checklist-based scales. All scales demonstrated inter-rater reliability (alpha = 0.58-0.76), though only the global rating scales exhibited intertest reliability (alpha = 0.72)., Conclusions: Video-based technical skills evaluation in the operating room is feasible, valid and reliable. Global rating scales hold promise for summative assessment, though further work is necessary to elucidate the value of procedural rating scales.

Objective: To assess the use of a synchronized video-based motion tracking device for objective, instant, and automated assessment of laparoscopic skill in the operating room., Summary Background Data: The assessment of technical skills is fundamental to recognition of proficient surgical practice. It is necessary to demonstrate the validity, reliability, and feasibility of any tool to be applied for objective measurement of performance., Methods: Nineteen subjects, divided into 13 experienced (performed >100 laparoscopic cholecystectomies) and 6 inexperienced (performed <10 LCs) surgeons completed LCs on 53 patients who all had a diagnosis of biliary colic. Each procedure was recorded with the ROVIMAS video-based motion tracking device to provide an objective measure of the surgeon's dexterity. Each video was also rated by 2 experienced observers on a previously validated operative assessment scale., Results: There were significant differences for motion tracking parameters between the 2 groups of surgeons for the Calot triangle dissection part of procedure for time taken (P = 0.002), total path length (P = 0.026), and number of movements (P = 0.005). Both motion tracking and video-based assessment displayed intertest reliability, and there were good correlations between the 2 modes of assessment (r = 0.4 to 0.7, P < 0.01)., Conclusions: An instant, objective, valid, and reliable mode of assessment of laparoscopic performance in the operating room has been defined. This may serve to reduce the time taken for technical skills assessment, and subsequently lead to accurate and efficient audit and credentialing of surgeons for independent practice.

Objectives: To assess the first commercially available virtual reality (VR) simulator to incorporate procedural modules for training of inexperienced gynaecological surgeons to perform laparoscopic salpingectomy for ectopic pregnancy., Design: Prospective cohort study., Setting: Departments of surgery and gynaecology in central London teaching hospitals., Sample: Thirty gynaecological surgeons were recruited to the study, and were divided into novice (<10 laparoscopic procedures), intermediate (20-50) and experienced (>100) groups., Methods: All subjects were orientated to the VR simulator with a basic skills task, followed by performing ten repetitions of the virtual ectopic pregnancy module, in a distributed manner., Main Outcome Measures: Operative performance was assessed by the time taken to perform surgery, blood loss and total instrument path length., Results: There were significant differences between the groups at the second repetition of the ectopic module for time taken (median 551.1 versus 401.2 versus 249.2 seconds, P = 0.001), total blood loss (median 304.2 versus 187.4 versus 123.3 ml, P = 0.031) and total instrument path length (median 17.8 versus 8.3 versus 6.8 m, P = 0.023). The learning curves of the experienced operators plateaued at the second session, although greater numbers of sessions were necessary for intermediate (seven) and novice (nine) surgeons to achieve similar levels of skill., Conclusions: Gynaecological surgeons with minimal laparoscopic experience can improve their skills during short-phase training on a VR procedural module. In contrast, experienced operators showed nonsignificant improvements. Thus, VR simulation may be useful for the early part of the learning curve for surgeons who wish to learn to perform laparoscopic salpingectomy for ectopic pregnancy.

The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed subgroup of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for 6 different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into 2 basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. While level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org).

Background: Studies have demonstrated the beneficial effect of training novice laparoscopic surgeons using virtual reality (VR) simulators, although there is still no consensus regarding an optimal VR training curriculum. This study aims to establish and validate a structured VR curriculum to provide an evidence-based approach for laparoscopic training programmes., Methods: The minimally invasive VR simulator (MIST-VR) has 12 abstract laparoscopic tasks, each at 3 graduated levels of difficulty (easy, medium, and hard). Twenty medical students completed 2 sessions of all tasks at the easy level, 10 sessions at the medium level, and finally 5 sessions of the 2 most complex tasks at the hard level. At the medium level, subjects were randomized into 2 equal groups performing either all 12 tasks (group A) or the 2 most complex tasks (group B). Performance was measured by time taken, path length, and errors for each hand. The results were compared between groups, and to those of 10 experienced laparoscopic surgeons., Results: Baseline performance of both groups was similar at the easy level. At the medium level, learning curves for all 3 parameters reached plateau at the second (group A, P < .05) and sixth (group B, P < .05) repetitions. Performance at the hard level was similar between the 2 groups, and all achieved the pre-set expert criteria., Conclusion: A graduated laparoscopic training curriculum enables trainees to familiarise, train and be assessed on laparoscopic VR simulators. This study can aid the incorporation of VR simulation into established surgical training programmes.

Background: The aim of this study was to analyze the learning curve for the GI Mentor II endoscope trainer and to determine whether psychomotor training can contribute to an improvement in the performance of virtual colonoscopy., Methods: To analyze the learning curve, 28 subjects were divided into three groups on the basis of their experience with gastrointestinal (GI) endoscopy: experienced surgeons (group 1, performed > 200 endoscopic procedures, (n = 8)) residents (group 2, performed < 50 endoscopic procedures, (n = 10)); and medical students (group 3, never performed GI endoscopy, (n = 10)). The participants were tested on the GI Mentor II virtual reality simulator 10 consecutive times. Assessment of the learning curve was based on the following three parameters: time used, number of punctured balloons, and number of wall collisions. In the second part of the study, 20 subjects who had never performed GI endoscopy were included. After performing a virtual colonoscopy, they were randomized to a group that received psychomotor training and a control group. Finally, all subjects performed a virtual colonoscopy. Assessment of endoscopic skills during the colonoscopy was based on nine parameters dealing with psychomotor skills., Results: The learning curve for time expended reached a plateau after the second repetition for group 1 (Friedman's test, p < 0.05), after the fifth repetition for group 2 (p < 0.05), and after the seventh repetition for group 3 (p < 0.05). Experienced surgeons did not improve their scores for regarding number of balloons punctured or number of wall collisions (p > 0.05), indicating the absence of a learning curve for these parameters. Group 2 improved their scores up to the fourth and fifth repetitions, respectively (p < 0.05), and group 3 up to the fifth and seventh repetitions, respectively (p < 0.05). Experienced surgeons achieved the best performance, followed by group 2 and then group 3. The surgeons who had received psychomotor training performed the second virtual colonoscopy significantly faster than the control group (Mann-Whitney test, p < 0.001) and made significantly greater improvement in all other parameters as well., Conclusions: There were different learning curves for surgeons depending on their endoscopic background. The familiarization rate on the simulator was proportional to the endoscopic experience of the surgeons. Psychomotor training had a significant effect on the performance of a simulated colonoscopy.

Objective: To reach an evidence-based consensus on the relative merits of vertical and transverse laparotomy incisions., Design: Review of all published randomised controlled trials that compared the postoperative complications after the two main types of abdominal incisions, vertical and transverse., Setting: Teaching hospital, Denmark., Subjects: Patients undergoing open abdominal operations., Interventions: For some of the variables (burst abdomen and incisional hernia) it was considered adequate to include retrospective studies. Studies were identified through Medline, Cochrane library, Embase, and a manual search of relevant journals. The references cited in these studies were reviewed to find out whether any other trials fitted the selection criteria., Main Outcome Measures: Early complications including postoperative pain, pulmonary complications, burst abdomen, wound infection, and hospital stay, and late complications (incisional hernia)., Results: Eleven randomised controlled trials and seven retrospective studies were identified. The transverse incision offers as good an access to most intra-abdominal structures as a vertical incision. The transverse incision results in significantly less postoperative pain and fewer pulmonary complications. Vertical laparotomy, however, is associated with shorter operating time and better possibilities for extension of the incision. The pooled odds ratio for burst abdomen in the vertical incision group was 2.86 (95% confidence interval 1.72 to 4.73, p = 0.0001), and regarding late incisional hernia the pooled odds ratio was 1.68 (95% confidence interval 1.10 to 2.57. p = 0.02)., Conclusions: Transverse incisions in abdominal surgery are based on better anatomical and physiological principles. They should be recommended, as the early postoperative period is associated with fewer complications (pain, burst abdomen, and pulmonary morbidity) and there is lower incidence of late incisional hernia after transverse compared with vertical laparotomy. A midline incision is still the incision of choice in conditions that require rapid intra-abdominal entry (such as trauma) or where the preoperative diagnosis is uncertain, as it is quicker and can easily be extended.

We describe an example of a rare benign intranodal haemorrhagic spindle cell tumour (also called intranodal myofibroblastoma), occurring in a lymph node of the right inguinal region of a 53 year-old male patient. This is the first documentation of this tumour in the Danish literature. The lesion presents typically as a unilateral, solitary, painless inguinal lump. The microscopic appearance is characterized by proliferating spindle-shaped cells, interstitial haemorrhage and amianthoid fibers. Differential diagnosis includes primary and secondary lymph node tumours, such as Kaposi's sarcoma; metastatic spindle cell carcinoma; melanoma; neurilemmoma and soft tissue sarcomas. The clinical behaviour of the tumour is benign and local excision is the treatment of choice.