The use of simulation in the acquisition of laparoscopic suturing skills

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Review

The use of simulation in the acquisition of laparoscopic suturing skills

Mohammad Dehabadi

a

, Bimbi Fernando

b

, Pasquale Berlingieri

c,*

a_{North Central Thames Deanery, London, UK} b_{Centre for Surgery, Royal Free Hospital, London, UK}

c_{Centre for Screen-Based Medical Simulation, Royal Free Hospital, Royal Free Hampstead NHS Trust, Pond Street, London NW3 2QG, UK}

a r t i c l e i n f o

Article history:

Received 8 December 2013 Accepted 25 January 2014 Available online 4 February 2014

Keywords:

Laparoscopic suturing Simulation

Surgical education

a b s t r a c t

Objective: Laparoscopic suturing is recognised as one of the most difﬁcult laparoscopic skills to master. With the use of simulation increasing in the training of future surgeons, a comprehensive literature review was carried out to evaluate the current evidence for the role of simulators in facilitating the acquisition of this particular skill.

Method: A PubMed search was performed using terms‘laparoscopy’, ‘suturing’, and ‘simulation’. The resulting literature was then analysed for relevance and summarised.

Results: A total of 68 relevant articles were found and evaluated; despite the relatively small sample size in most studies, simulation has been proven to provide an effective method for the tuition of surgical trainees in laparoscopic suturing. Furthermore, the skills acquired through simulator training appear to be successfully transferable to the operating room environment. Simulators have also shown potential as valuable tools in the assessment of proﬁciency in trainees, with their evaluation of individuals correlating well with expert observer ratings in complex laparoscopic tasks such as suturing. Questions regarding the type of simulator to be used, the nature of the training curriculum, and how such a curriculum can practically be integrated into current surgical training programmes remain to be answered.

Conclusions: Simulation is an integral tool in the training of future laparoscopic surgeons, and further research is required to answer the question of how to maximise beneﬁt from these invaluable training implements.

1. Introduction

Laparoscopic suturing is a means of tissue approximation without the use of mechanical clips or staples. It is a surgical technique required to perform many complex laparoscopic opera-tions, being described as the rate limiting step in a laparoscopic skills training as it prevents practicing surgeons from performing more advanced procedures[1,2]. While laparoscopy offers advan-tages like better visualisation through magniﬁcation, it also in-troduces challenges for the operator, to the extent that even experienced surgeons initially struggle when facing obstacles such as: loss of depth perception, limited haptic feedback, and fulcrum effect of instruments. Laparoscopic suturing in particular is a skill with a steep learning curve, its acquisition within current surgical programmes being difﬁcult; this is mainly due to the trainee’s lack of adequate exposure to advanced laparoscopic procedures requiring intracorporeal suturing, and to the fact that training for

such an advanced technique in the operating room is both time consuming and expensive[3,4].

The use of simulation in the acquisition of laparoscopic skills is fast becoming integrated into surgical training worldwide. Simu-lators provide an effective means of acquiring complex skills such as laparoscopic suturing through repetitive practice in a non-threatening environment before entering the operating room. Since ever more complex laparoscopic procedures are being carried out using this technique, it is therefore imperative that an efﬁcient means of teaching laparoscopic suturing to trainee surgeons should be established.

The aim of this literature review is to evaluate the use of simulation in the acquisition of laparoscopic suturing skills by assessing the following three areas:

Type of simulator providing the most effective means for acquiring complex laparoscopic skills;

Role of construct validity for simulation and the transferability of simulator acquired skills to the operating room;

How the simulator based training curriculum for laparoscopic suturing could be shaped.

* Corresponding author. Tel.: þ44 020 7794 0500x36857. E-mail address:p.berlingieri@ucl.ac.uk(P. Berlingieri).

Contents lists available atScienceDirect

International Journal of Surgery

j o u r n a l h o m e p a g e : w w w . j o u rn a l - s u r g e r y . n e t

http://dx.doi.org/10.1016/j.ijsu.2014.01.022

International Journal of Surgery 12 (2014) 258e268

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2. Search strategy

A search of the PubMed database was carried out using the following phrase:“laparoscopy” AND “suturing” AND “simulation”, resulting in 91 articles.

After exclusion of 5 non-English language articles, the remain-ing 86 abstracts were examined. Of these, a further 38 articles were deemed irrelevant as they did not focus on the topic in question; 16 articles focused on subjects other than the acquisition or evaluation of laparoscopic suturing with simulators, 7 were concerning lapa-roscopic tasks other than suturing, 6 discussed robotic surgery, 2 did not feature simulators, 2 were reviews not focused on this topic, 2 were editorial comments, 1 discussed game consoles, 1 concerned veterinary medicine, and 1 was a duplication, discussing results from an already included publication.

The remaining 48 papers were read in detail, and their refer-ences lists searched for further relevant articles, leading to the addition of 20 more studies.

3. Type of simulators

A wide variety of laparoscopic simulators are available commercially, or as prototypes, and they can be broadly categorised as[5,6]:

1. Video-scopic (VS): surgical box trainers allowing manipulation of real objects, often using real laparoscopic instruments. Whilst this group offer real, or physical, haptic feedback, a pure box trainer would require manual collection of performance metrics (Fig. 1).

2. Computer-enhanced (CE): a video-scopic simulator with the additional ability of providing computer generated performance metrics (Fig. 2).

3. Virtual reality (VR): a completely virtual environment with the capability of producing computer generated performance met-rics[7].

a) Low ﬁdelity: with no computer generated haptic feedback (Fig. 3)

b) High ﬁdelity: with computer generated haptic feedback (Fig. 4);

A major technical discriminator between the above simulators categories is the presence of haptic feedback, and several studies tried to ascertain whether this feature has any impact on the ability of a simulator to teach laparoscopic suturing.

While subjectively surgical trainees often prefer VS simulators to lowfidelity VR simulators when learning laparoscopic suturing, often citing the lack of haptic feedback as the main disadvantage of lowfidelity VR equipment[5,8e10], some objective investigations showed that no significant difference can be detected in novices’ performance in laparoscopic suturing tasks after training on sim-ulators with and without haptic feedback. This lack of difference in performance was demonstrated when comparing CE and low fi-delity VR simulators[11], and when comparing VS with lowfidelity VR simulators[12_e14].

A recent review of the range of simulators available for laparo-scopic training[15]concluded that CE simulators are better suited for teaching complex tasks such as laparoscopic suturing due to the combination of realistic physical haptic feedback, use of real in-struments, and the provision of performance metrics. However, the authors did not incorporate more recent highﬁdelity VR simulators which have subsequently been proven to be as effective as VS box trainers in teaching laparoscopic suturing to novices with no sig-niﬁcant differences in performance[16].

One interesting study compared the performance of two randomised groups on learning a complex laparoscopic task not strictly related to suturing. Surprisingly, it was found that the group which started training with haptic feedback, and then moved on to a non-haptic feedback training session, performed significantly better than the group which carried out the training in the reverse fashion; despite both groups received equal tuition time in both training conditions, the authors concluded that haptic feedback could accelerate the performance curve in surgical simulator training [17]. A more recent investigation looking at laparoscopic suturing, reinforced that haptic feedback improved training efficacy, but only significantly in the first 5 h of training

[18]. Fig. 1. The Pop-up trainer (Simulab Corporation, Seattle, Washington, USA) is an

example of a video-scopic box trainer.

Fig. 2. The CAE ProMIS (CAE Healthcare, Toronto, Ontario, Canada) is an example of a computer-enhanced simulator.

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4. Construct validity for simulation in the teaching of laparoscopic suturing

While on subjective questionnaires laparoscopists reported VR simulators to be“good to excellent” in areas of realism, didactic value, and haptic feedback, as well as a useful tool in training for laparoscopic procedures such as suturing[19,20], a more objective means of answering this question is to evaluate their construct validity.

In surgical simulation, construct validity is the ability of simu-lators to demonstrate a learning curve for individual trainees, and to distinguish between operators of different ability and experience using the performance metrics collected during tasks[21]. Such an improving performance curve was demonstrated in studies with novices learning to perform laparoscopic suturing on a variety of simulator types[5,11e14,16,22e35]. These investigations showed that novices are able to successfully acquire laparoscopic suturing skills using all simulator types discussed above.

Several trials involving surgical trainees of varying experience also demonstrated the ability of VS, CE, and VR simulators in distinguishing between laparoscopists of different competence while performing suturing tasks, reinforcing that laparoscopic simulators have construct validity [23,36e42]. Although all the trials showed that simulators distinguished between novices and senior laparoscopists more effectively than intermediate and se-nior laparoscopists, Duffy et al. found that while the same was true on basic laparoscopic tasks, on the more complex suturing task the simulator could differentiate between laparoscopists of all abilities[37].

5. From simulators to the operating roome skills transferability

Several investigations evaluated whether simulation training could improve laparoscopic suturing skills, and if these acquired skills could be successfully transferred to the real operating envi-ronment (so called “VR2OR” transferability e “virtual reality to operating room”)[43e49]. The studies showed some improvement in the performance of simulator-trained groups when compared to conventionally trained, or untrained groups on a porcine Nissen fundoplication model; in addition, although a variety of different simulator types were used, the areas of improvement were consistently found to be: quicker task completion, and committing fewer errors during the task. Interestingly however, Verdaasdonk et al. found that the objective assessment of the simulator-trained group by expert observers did not differ significantly from the group receiving no training, suggesting that to the expert eye both groups were still of similar ability[44]_{e this specific finding was}

however contradicted by other studies which found that objective assessment by expert observers did successfully distinguish be-tween simulator trained participants and those with no training

[46,48,50].

A randomised controlled trial (RCT) took the testing of VR2OR transferability further by measuring performance retention gained by simulator training at 5 months. Simulator trained novices out-performed the control group both on simulator assessments of suturing, and on a porcine Nissen fundoplication model post training. Encouragingly, while a slight drop in simulator assessed performance was seen at 5 months in the trained group, no sig-niﬁcant drop in performance was found when subjects were re-tested on the porcine model[30].

While all the above studies tested the VR2OR transferability on a porcine model, Orzech et al. demonstrated that residents who learnt laparoscopic suturing skills on either VS or VR simulators, signiﬁcantly outperformed conventionally trained residents when placing intracorporeal sutures on real patients in theatre[31].

6. Shaping the simulator based training curriculum

Various components have to be considered in designing a training curriculum, and this section will evaluate the available evidence regarding laparoscopic suturing (Table 1).

Fig. 3. The SIMENDO laparoscopy trainer (SIMENDO, Rotterdam, Netherlands) is an example of lowﬁdelity virtual reality simulator.

Fig. 4. The LAP Mentor (Simbionix Corporation, Cleveland, Ohio, USA) is an example of a highﬁdelity virtual reality simulator.

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Table 1

Laparoscopic suturing investigations addressing educational components useful in designing a training curriculum. Author, year, country Study design Study arrangements Participants (IG/CG)/

(Gxey)

Group discriminators Methods of measurement Results IG vs CG/BT vs AT/ Gx vs Gy (p-value) Authors conclusions Task breakdown Dubrowsky 2007[51] Canada Randomised controlled study

Instruction video. Pre-test on VS simulator. Training. Post test evaluation on VS simulator. Retention test at 1 week.

24 (12/12) Surgical residents (PGY 1)

IG: increasing difﬁculty training. CG: constant difﬁculty training. ICSAD MN Time DT

Both groups improved on all measures (<0.01)

Despite spending less time practicing actual suturing, the group of residents who progressed through the sequence of steps performed as well as those who practiced the entire task in its full complexity. Champion 1996[24] USA Prospective observational study 2 h training session on VS simulator with 5 tasks: tasks 1e3 video skills. Task 4 extracorporeal suturing. Task 5 intracorporeal suturing.

14 Medical students e Time Time: 1 min 45 s for extracorporeal suture 3 min 12 s for intracorporeal suture

Novice students were able to perform extra and

intracorporeal suturing with 2 h of practice, utilizing a systematic program of teaching basic video skills.

Kolozsvari 2011[53]

Canada

Randomised controlled study

Instruction video. Pre-test on peg transfer and suturing tasks. Randomisation. Training. Post-test. Retention test at 1 month. 77 (28/26/23) Simulator naïve novices

CG: suturing training. IG1: peg transfer task training to‘pass’ followed by suturing training.

IG2: peg transfer task over-training to ‘mastery’ followed by suturing training.

Learning plateau for suturing task Learning rate for suturing task

CG vs IG1 vs IG2 Plateau: 452 vs 459 vs 467 (<0.01)

Learning rate: 15 trials vs 14 trials vs 13 trials (¼0.01)

For surgically naïve subjects, part-task training with peg transfer alone was associated with slight improvements in the learning curve for laparoscopic suturing. Stefanidis 2010[54] USA Randomised controlled study Pre-test on FLS suture module. Randomisation according to performance. Intervention. Tutorial video. Training to proﬁciency on VS simulator FLS suture module. Evaluation on VS simulator. Retention test at 2 weeks. 20 (10/10) Medical students

IG: basic laparoscopic skills training. CG: no basic laparoscopic skills training. Time to proﬁciency Cost of training Time to proﬁciency: 145 min vs 310 (<0.001) Cost: $159 vs $307 (<0.001)

Teaching novices basic laparoscopic skills before a more complex laparoscopic task produces substantial cost savings (by reducing training time, and reducing the amount of active instruction). Stefanidis 2007[46] USA Randomised controlled study Pre-test on porcine Nissen fundoplication. Randomisation. Training. Post-test on porcine Nissen fundoplication and survey. 32 (6/13/13) Medical students G1: no training. G2: trained to proﬁciency on VS simulator FLS model. G3: same as G2, but constrained space, shorter suture, start with dropped needle, theatre noise in background.

Objective score Time spent training Repetitions performed Objective score: 0 vs 210 vs 218 (<0.001) G2 vs G3; Time: 239 min vs 329 (<0.001) Repetitions: 59 vs 81 (<0.001) Proﬁciency-based simulator training reliably results in improved operative performance. Although increasing the level of training difﬁculty increased trainees’ workload; the strategy we used in this study did not enhance their operative performance.

Supervision and feedback O’Connor 2008[55] USA Randomised controlled study Initial instruction on laparoscopic suturing. Randomisation. Training on simulator (ProMIS). Continual assessment. 9 (3/3/3) Medical students G1: no knowledge of results. G2: knowledge of results. G3: knowledge of resultsþ active tuition.

Time Path length SM G1 vs G2þ 3 showed signiﬁcant differences in time: (0.019) and path length: (0.005) SM: (0.0245)

While knowledge of results was necessary for learning to suture, continual instruction had limited additional beneﬁts. However, knowledge of results with instruction did reduce subjects’ perceived overall workload.

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Table 1 (continued )

Author, year, country Study design Study arrangements Participants (IG/CG)/ (Gxey)

Group discriminators Methods of measurement Results IG vs CG/BT vs AT/ Gx vs Gy (p-value) Authors conclusions Van Bruwaene 2009 [56]Belgium Randomised controlled study

Basic laparoscopic skills curriculum. 1 h hands on instruction on laparoscopic suturing. Pretest. Randomisation. Training for 4 60 min. Post training evaluation on box trainer at 1 week and 4 months.

20 (10/10) Medical students

IG: only video instructions and peer feedback throughout training. CG: continuous expert feedback throughout training. Derived performance score Score at 1 week: 190 s vs 192 s (¼0.63) Score at 4 months: 220 s vs 223 s (¼0.60)

Both training methods are very efﬁcient at improving laparoscopic suturing skills and provide excellent skill retention. Structured training with video demonstrations and peer feedback can replace expert supervision to teach laparoscopic suturing skills to novices. Halvorsen 2011[57] Norway Randomised controlled study Instructional video. Pretest (sutures placed, but no knot tied). Randomisation. Intervention. Post-test.

22 (11/11) Surgical interns

IG: 4 training sessions on VR simulatore but with no feedback (SimSurgery surgical education platform). CG: no speciﬁc training. Time No of stitches No of needle drops Time: 96 s vs 7 s (NS) No of stitches: 20 vs 15 (NS) No of needle drops: 0 vs 1 (NS)

This study indicates that virtual reality simulator training alone may not increase laparoscopic suturing skills. Stefanidis 2013[47] USA Randomised controlled study Instructional video. Pretest (ProMIS-FLS laparoscopic suturing task). Randomisation. Training. Post-test (porcine Nissen fundoplication). Retention test at 3 months (porcine Nissen fundoplication).

42 (14/15/13) Premedical students

G1: trained to proﬁciency with speed metrics.

G2: trained to proﬁciency with motion metrics. G3: trained to proﬁciency with speed and motion metrics.

Blinded expert rater score

No signiﬁcant difference in performance between groups

The incorporation of motion metrics into the time/accuracy goals of the FLS laparoscopic suturing curriculum had limited impact on participant skill transfer to the operating room. Inter-training interval Stefanidis 2009[32] USA Retrospective data analysis from 3 randomised controlled trials

3 trials. All using FLS suturing module training at different inter-training intervals (range 1e43 days)

66 College and medical students

e Time BT vs AT;

Time: 530 s vs 81 s (<0.001)

There was no correlation of performance change and inter-interval training, performance deterioration was also similar. Training duration was however shorter with shorter intervals. Trainee assessment

Xeroulis 2009[38]

Canada

Observational study Performed 4 FLS tasks (including suturing). Assessed by both blinded expert rater, and ICSAD. 26 Surgery residents PGY 1e6 e Time DT NM

ICSAD and expert scores had signiﬁcant correlation in DT (<0.001), NM (<0.001), time (<0.001)

There is a high correlation between FLS standard scoring and motion efﬁciency metrics. The use of ICSAD for the objective assessment of FLS tasks may in the future offer an adjunctive method of evaluation. Stefanidis 2007[58] USA Prospective observational study

Dual task assessment. Primary task: FLS suturing model knot tying on VS simulator. Secondary task: computer generated visual spatial processing task. 29 (10/9/3/7) G1: novices. G2: surgical residents. G3: laparoscopy experts. G4: simulator trained individuals. Time Number of repetitions Correct percentage on secondary task Time: 300þ s vs 218 s vs 68 s vs 71 s (<0.001) No of rep: 2 vs 3 vs 10 vs 9 (<0.001) % on secondary task: 6 vs 6 vs 40 vs 73 (<0.001)

Although the performance of experts and trained individuals did not differ signiﬁcantly based on suturing scores, experts achieved higher secondary-task scores; a visual espatial secondary task that assesses spare attentional capacity may help distinguish among individuals of variable laparoscopic expertise when standard performance measures fail to do so.

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Stefanidis 2008[59] USA Prospective observational study Introductory video. Pre-training assessment of primary task (FLS suturing model knot tying on VS simulator) and secondary task (computer generated visual spatial processing task). 4 months training period until proﬁciency reached on both tasks.

12 Pre-medical students e Suturing score, Correct percentage on secondary task, Number of repetitions 11 out of 12 participants achieved suturing proﬁciency, but no one achieved secondary-task proﬁciency. Participants who performed>100 repetitions (n¼ 4) achieved higher secondary-task scores (P< 0.03).

Although novices achieve simulator proﬁciency after relatively short training durations, the attainment of automaticity requires substantially longer training periods. Stefanidis 2012[48] USA Randomised controlled study Introductory video. Pre-test. Training. Post-test (IG: post-Post-test on porcine Nissen fundoplication once ‘expert level’ achieved according to time/error, and once again after achieving‘expert level’ according to secondary task performance).

30 (20/10) Pre-medical students

IG: trained until they reached expert levels ﬁrstly on time and error basise and then based on a visual spatial secondary task (automaticity). CG: no training. Objective suturing score

Post proﬁciency training: IG: 220

Post automaticity training: IG: 345

(<0.001)

Simulator training to automaticity takes more time but is superior to proﬁciency-based training, as it leads to improved skill acquisition and transfer. Secondary task metrics that reﬂect trainee automaticity should be implemented during simulator training to improve learning and skill transfer.

Duration and setting of training

Aggarwal 2006[60]UK Observational study Baseline tests (placement of single intracorporeal suture on synthetic bowel in CE simulator). 2 day laparoscopic suturing course. Post course evaluation. 23 (9/14) Surgical residents (PGY1-5) G1: senior surgical trainees (PGY4-5). G2: junior surgical trainees (PGY1-2). Time Suture quality DT NM

At post course evaluation both groups improved signiﬁcantly in all 4 parameters; G1 (<0.02) G2 (<0.01)

Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation. Mereu 2013[61]Italy Prospective

observational study Subjects attended 5-day intracorporeal suturing course (4 h theory, 35 h on VS simulator). End of course assessment on 3 VS simulator tasks. Evaluation of what percentage were then using this skill in vivo.

44 Surgical/gynae/ urology residents

e Observer score for depth, coordination, dexterity, posture BT vs AT; Depth: 2.48 vs 4.05 (0.017) Coordination: 2.41 vs 3.66 (0.001) Dexterity: 2.36 vs 4 (0.000) Posture: 2.48 vs 4.05 (0.003)

% applying new skill in vivo: 10% vs 79%

The present study

demonstrates the utility of a 5-day suturing course in teaching laparoscopic suturing technique. The three-step model allows the majority of the trainees to apply laparoscopic suturing in vivo.

Stefanidis 2006[62] USA Prospective observational study Instructional video. Pre-test. 3 h training on VS simulator with supervision until proﬁciency. Post-test. 18 Surgical residents and practicing surgeons

e Objective score (from time, accuracyþ knot security errors) BT vs AT: Score: 229 vs 472 (<0.001) Time: 314 s vs 120 s (<0.001) Accuracy errors: 0.7 vs 0.2 (<0.05) Security errors: 5.3 vs 0.6 (<0.05) Although 4 h may be insufficient for some trainees, an intensive half-day CME course is feasible and effective in significantly improving performance and allowing the majority of participants to achieve proficiency. Rinewalt 2012[63]USA Observational study Pretest. Training

program on VS simulator for 3 weeks (including laparoscopic suturing task). Post-test.

20 Surgical residents (PGY1-4)

e Observer score Suturing task: improved (¼0.02)

Simulation leads to improvement in laparoscopic skills and that our curriculum is a valid educational tool.

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Table 1 (continued )

Author, year, country Study design Study arrangements Participants (IG/CG)/ (Gxey)

Group discriminators Methods of measurement

Results IG vs CG/BT vs AT/ Gx vs Gy (p-value)

Authors conclusions Chang 2007[64]USA Prospective

observational study

2 h training session and curriculum review. Voluntary training sessions. Amount of time spent on simulator recorded. Trainee survey at 3 months.

29 Surgical residents (PGY1-5)

e e 33% used simulator once in 3 months.

14% used simulator at least three times in 3 months.

Voluntary use of a surgical simulation lab leads to minimal participation in a training curriculum.

Participation should be mandatory if it is to be an effective part of a residency curriculum. Korndorffer 2012[65] USA Randomised controlled study Instructional video. Pre-test on VS suturing task. Training. Post-test. Retention test at 60 days. 20 (10/10) Surgical residents (PGY1-5) CG: self-directed simulation center training.

IG: self-directed home training with VS simulator. Derived suturing score Pre-test: 149 vs 162 (>0.05) Post-test: 417 vs 411 (>0.05) Retention test: 385 vs 429 (>0.05)

Both home, and simulation center training leads to signiﬁcant improvement in laparoscopic suturing skills. No signiﬁcant difference in performance can be seen between the two groups. van Empel 2012[66]

Netherlands

Observational study Questionnaire and time-log analysis of trainees’ autonomous simulator training at home over 6 weeks following an advanced suturing course.

97 Surgical residents e e Average Training done/ week: 76.5 min

Reasons for not training: no time after work (83%), preferral to practice during work (32%), another surgical interest other than laparoscopy (15%)

Autonomous practice should be structured and inclusive of adequate and sufﬁcient feedback. A minimally required practice time should be set. An obligatory assessment, including corresponding consequence should be conducted.

Seymour 2005[49]USA Observational study Baseline test on porcine Nissen fundoplication. 2e4 h of mentored training on Simulator (MIST-VR). Self directed practice in schedule and free time (over 7 months). Post training evaluation on porcine model.

21 Surgical residents PGY1-5

e Time Time: 154 s vs 91 s (<0.01) The suturing task in the animal lab was accomplished faster post-training. Early results suggest that broadly applied VR training is of significant benefit in increasing resident technical skills. Griffin 2006[67]UK Prospective observational study 1 h teaching session on laparoscopic suturing. Baseline test. Randomisation. Training. Post training evaluation.

10 (4/6) Urology residents (PGY1-3)

IG: 4 weeks of training at home on home made box trainer. CG: no training. Time % of sutures acceptable quality Time: 111.3 s vs 202.2 s (<0.0001) % acceptable: 100% vs 66%

Intracorporeal suturing skills can be learned using a home-constructed system. This could be beneﬁcial for those wishing to develop the advanced skills required for various laparoscopic urologic procedures. De Win 2013[68] Belgium Randomised controlled study Randomisation (as medical students). G3 receiving simulator training before starting residency. Pre-test on VS simulator suturing task at start of residency. 6 months of residency (G1 receiving simulator training during this time). Post-test on VS simulator suturing task. 30 (10/8/12) Surgical residents (PGY1) G1: received 18 h additional simulator training during Y1 of residency. G2: traditional surgical training with no simulation. G3: Received 18 h simulator training before commencing Y1 of residency. Expert observer score Time At start of residency: EOS: 11.5 vs 12.8 vs 16.68 (<0.001) Time: 743 s vs 758 s vs 420 s (<0.001) At 6 months: EOS: 19.66 vs 14.43 vs 21.58 (<0.001) Time: 499 s vs 649 vs 294 s (<0.001) Structured, preclinical proﬁciency-based training is better than clinical training combined with laboratory training or clinical training alone.

AT: after training; BT: before training; CE: computer enhanced; CG: control group; DT: distance travelled; EOS: expert observer score; FLS: fundamentals of laparoscopic surgery; G(x-y): various study groups; ICSAD: Imperial College Surgical Assessment Device; IG: intervention group; NM: number of movements; NS: not signiﬁcant; SM: smoothness of movement; VR: virtual reality; VS: video-scopic.

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6.1. Task breakdown

Data on this educational aspect is somewhat conflicting; while some investigations found that breaking the task of suturing down into smaller steps, rather than teaching it in its full complexity, makes no difference in trainees’ performance[51], others demon-strated that becoming proficient in basic laparoscopic skills before learning laparoscopic suturing leads to a faster achievement of proficiency with less active instruction, reducing training costs

[24,52e54]. Stefanidis and colleagues examined the effects of increasing training difﬁculty by constraining the operating space, and using shorter sutures,ﬁnding that stress inducing measures only increase the training workload, with no change in the per-formance level[46].

6.2. Supervision and feedback

RCTs have investigated the necessity of constant expert super-vision in the acquisition of laparoscopic suturing skills using simulation, suggesting that after an initial expert tuition session, as long as trainees were provided with feedback on their perfor-mance, continual instruction from experts had limited additional beneﬁts, and video instructions were just as effective [55,56]. Without feedback on their performance or expert tuition however, simulator trained individuals perform no better than individuals without training, emphasising the value of performance feedback over continual expert tuition[57]. One study investigated the most informative types of metric feedback for trainees. Using the Fun-damentals of Laparoscopic Surgery (FLS) module on a ProMIS simulator, the authors found that the use of traditional metrics related to speed (task completion time) alone were effective in training novices to proﬁciency, with the addition of motion metrics (path lengths or smoothness) having limited impact on the par-ticipant’s skills transfer to the OR[47].

6.3. Inter-training interval

An analysis of three RCTs by Stefanidis et al. evaluated the ideal inter-training interval for learning laparoscopic suturing on a simulator, but found that inter-training interval had no correlation with trainee performance; nevertheless, it was also noticed that shorter intervals between training sessions meant shorter overall training duration[32].

6.4. Trainee assessment

Another signiﬁcant feature of the curriculum is the way in which trainees are assessed throughout their laparoscopic suturing training; Xeroulis et al. demonstrated a high correlation between the scoring of expert raters and those obtained from motion ef ﬁ-ciency metrics used in the Imperial College Surgical Assessment Device (ICSAD) when assessing tasks such as laparoscopic suturing

[38].

Subsequent studies looked at the concept of automaticity as a more effective way of assessing performance on complex simulator tasks. Automaticity is the ability to perform a task with little effort and few attentional resources. Many repetitive motor tasks can become automatic with enough practice, leaving the operator with spare attentional capacity to carry out other tasks. The following studies demonstrated that secondary task performance, which re-ﬂects spare attentional capacity, improves with practice on a complex task such as intracorporeal suturing. They also displayed that when individuals meet‘expert level’ proﬁciency criteria for time and accuracy, substantial learning is still continuing, as sec-ondary task performance is just beginning to improve[58,59]. A

recent RCT by the same group found that when tested in an animal model, novices who train to proﬁciency using automaticity scores out-perform those trained to proﬁciency based on traditional metrics[48].

6.5. Duration and setting of training

Observational studies indicated that laparoscopic suturing can be successfully taught to surgical residents through short didactic skills courses (1e5 days) using simulator training with encouraging post course performance [60e62]. Two of these investigations showed that both juniors with no laparoscopic experience, and senior trainees with previous laparoscopic experience beneﬁt signiﬁcantly from such suturing courses [60,62], Mereu et al. additionally found that nearly 73% of attendees later reported being able to apply their newly found laparoscopic suturing skills in the operating theatre [61]. Improved suturing scores were also demonstrated with a longer course of 3 weeks duration incorpo-rated into a training program[63].

While the above demonstrates the success of simulation training in a stand-alone course setting, studies have also investi-gated incorporation of simulator training into current surgical residency programmes; an observational study of 29 surgical resi-dents, who were allowed voluntary access to simulator training after a 2 h introductory course, showed very poor attendance when only 33% had returned to use the simulator on 1 occasion during the 3 month study period [64]. Although self-directed simulator training at home is as effective as self-directed training at a simu-lation centre [65], even when voluntary simulator access is pro-vided to trainees at home, the compliance appears to be poor, with trainees stating‘lack of time after work’ as the main reason for non-compliance[66].

An additional observational study involved 11 surgical residents in a mandatory programme of VR simulator training over a 7-month period. Despite the compulsory nature of the programme however, the authors observed that Post-Graduate Year (PGY) 1e2 residents were able to attend more sessions than PGY3-5 residents, who missed numerous sessions due to operating room obligations. Nevertheless, all residents showed improved performance on the tasks as assessed by the simulator metrics provided, and PGY3-5 residents all showed an improvement in the time taken to carry out intracorporeal suturing and knot-tying in a porcine model when comparing pre- and post-training performance[49].

Another interesting investigation of 10 junior urology residents in the UK explored the use of‘home made’ VS simulators in self-directed practice at home over a 4-month period following a 1 h teaching session, with encouraging results[67].

A recently published RCT following 30 medical students entering surgical residency suggested that structured, preclinical proﬁciency-based simulator training is better than clinical training combined with laboratory training or clinical training alone, when the subjects were tested at 6 months on tasks such as suturing[68]. Thisﬁnding has important implications on how early in a surgeon’s career structured simulator based training needs to be incorporated.

7. Discussion

This review features studies reflecting over a decade of research on the role of simulators in the acquisition of laparoscopic suturing skills. Thefirst striking aspect was the small sample volume of the majority of investigations, making the statistical significance of some results questionablee the expense of simulators, and time constraints of trainee surgeons probably being the main reasons for this.

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Despite small sample sizes, it has been demonstrated that simulators offer an effective way to acquire both simple and com-plex laparoscopic skills such as intracorporeal suturing[11,22e26]. Moreover, as shown by both porcine and human studies, acquired skills can be transferred to the operating room successfully, resulting in quicker task completion and committing fewer errors

[30,31,43e45,50]. With the ethical obligation to move basic clinical skills learning away from patients, and into the safer environment of the skills laboratory, theseﬁndings demonstrate the utility of simulators in the acquisition of this complex laparoscopic tech-nique. Besides, simulator training results in a reduction in theatre time, and potentially signiﬁcant cost reductions in training as demonstrated by Orzech et al.[31].

The next question to be addressed is the type of simulator best suited to this task; apparently, no single simulator type clearly outshines the rest of theﬁeld. Although the basic VS simulators are the cheapest to acquire, they have the disadvantage of requiring large amounts of expert tuition, which is expensive, and lack the ability to give objective feedback to trainees in the form of com-puter generated performance data. While CE simulators provide a solution to performance data, they still require heavy input from expert tutors.

Although VR simulators are expensive, they allow the integra-tion of tuiintegra-tion videos, step-by-step teaching modules, performance data, and the ability to recreate a variety of situations with different degrees of difficulty, enabling a more self-directed training approach for laparoscopists. They therefore appear to provide the most self-sufficient means of simulator training for laparoscopic skills, empowering the users with a high degree of independence; given the difficulty of faculty recruitment for simulator training, this could be a significant advantage. The question of low versus highfidelity VR simulation, however, remains largely unanswered when choosing a VR simulator. This is due to the lack of data on the newer highfidelity VR simulators, and conflicting conclusions on the importance of haptic feedback in skill acquisition[8,11,12,15,17]. Thefinal aspect covered by this review is how a future simulator assisted curriculum for laparoscopic suturing could be shaped and integrated into current surgical training programmes. As evident from thefindings, one major issue is the lack of a single widely accepted standard as to the best way to teach practical skills such as laparoscopic suturing. It can however be established from this literature review that:

Becoming proﬁcient in basic laparoscopic skills can result in faster acquisition of more complex skills such as laparoscopic suturing[24,52,54]. There was however, a paucity of data to support or refute the breakdown of the suturing task itself into smaller chunks making any signiﬁcant difference in trainee performance.

Performance feedback, via simulator metrics or peers, is an essential aspect of learning, and if done effectively can reduce the need for constant expert instruction throughout the learning process when looking speciﬁcally at laparoscopic su-turing tasks[55e57]. This has very important implications for levels of expert stafﬁng required, and hence cost when designing a course.

Simulators with computer generated metrics can provide an effective means of evaluation of trainees, being able to distin-guish between trainees of differing ability consistently, and in good correlation with objective expert observer scores [38]. Furthermore, there is gathering evidence that our traditional ‘proﬁciency benchmarks’ are not as effective as methods based on concepts such as automaticity in measuring trainee improvement and performance at the higher end of the ability spectrum[58,59]. More research is required in thisﬁeld before

secondary task performance can become established as a new proﬁciency measure, but simulator assisted proﬁciency testing could become an important aspect of future trainee assessment and training.

While short simulator based courses can successfully teach novices how to carry out laparoscopic suturing[60,61], there are examples that demonstrate very low uptake of simulator use in current surgical training programmes if offered on a voluntary basis[64], with slightly more success when offered in a more timetabled fashion[49]. Nevertheless, the latter study clearly demonstrated that even less than full attendance of simulated sessions significantly improved senior trainee performance on laparoscopic suturing. It can therefore be said that a more structured, mandatory approach is recommended to ensure better implementation of simulator use in training programmes. As for inter-training interval, insufficient evidence was found of its correlation with trainee performance when learning lapa-roscopic suturing[32], but more research in thisfield is required to make any real conclusions on this aspect.

8. Conclusions

Simulators appear to be an effective tool in the cost-effective acquisition of complex laparoscopic skills such as intracorporeal suturing. While there is no doubt in their usefulness in the training of future laparoscopists, questions such as the type of simulator, the type training curriculum, and how it can be integrated successfully into current surgical training remain largely unanswered.

There is also room for considerable research in the following aspects of simulator training:

Opportunities for simulator led self-directed learning of intra-corporeal suturing;

The effect of breaking down laparoscopic suturing into smaller chunks for teaching purposes;

Finding the most effective inter-training intervals for simulator training.

Despite these challenges however, it is likely that simulation will play a pivotal role in the training of all future laparoscopists, and therefore further research into the discussed areas should be encouraged. Ethical approval Not applicable. Funding None declared. Author contribution

All authors have contributed to the study design, data collec-tions, data analysis and writing of the paper.

Conﬂict of interest None declared.

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