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ABSTRACT: BACKGROUND: Although numerous assessment tools currently exist to evaluate laparoscopic surgical skills, no studies have demonstrated the reliability of such tools when used with telementoring technology. This study aimed to determine the reliability of the Global Operative Assessment of Laparoscopic Skills (GOALS) rating scale for assessing laparoscopic skills remotely and to identify how factors unique to remote assessment such as bandwidth and image quality influence its reliability. METHODS: Four trained observers evaluated 19 participants for their technical performance during a laparoscopic cholecystectomy using the GOALS assessment tool. One observer assessed the study participants directly in the operating room, whereas the three remaining observers were randomly assigned and blinded to a high- (1.5 Mbps), medium- (256 kbps), or low- (64.4 kbps) bandwidth restriction and observed remotely via Skype. The Maryland Visual Comfort Scale was used to evaluate the video quality of the respective connections. RESULTS: The intraclass correlation coefficient (ICC) calculated for the total GOALS score demonstrated a statistically significant correlation of high, medium, and low bandwidths respectively with ICC 0.693 (95 % confidence interval [CI], 0.226-0.883), 0.518 (95 % CI 0.089-0.783), and 0.499 (95 % CI 0.025-0.781). There was a statistically significant difference in the overall perceived visual quality between the high/low (Z = -3.222; P = 0.001) and the medium/low (Z = -3.567; P < 0.001) bandwidth comparison but no difference between the high/medium bandwidths (Z = -0.610; P = 0.542). CONCLUSION: The data suggest that the GOALS assessment tool retains its reliability for intraoperative assessment of laparoscopic skills when used remotely. This is a key requirement in telesimulation programs allowing for structured feedback between the mentor and the mentee. This study quantifies the effect that bandwidth has on the reliability of remote assessment, demonstrating that higher bandwidths improve the utility of these tools.
Surgical Endoscopy 08/2012; · 4.01 Impact Factor
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ABSTRACT: PurposeCentral alveolar hypoventilation syndrome (CAHS) is a rare disease characterized by the loss of autonomic control of breathing.
This condition causes hypoventilation and obstruction during sleep. Throughout their lives, these patients require ventilatory
assistance by means of positive pressure ventilation to their lungs via mask, tracheotomy, or other means, such as phrenic
nerve pacers. The diaphragm pacing stimulation system (DPSS) is a new treatment where electrodes are implanted into the diaphragm
and cause contraction on stimulation. The DPSS has been used successfully in tetraplegic patients and patients suffering from
amyotrophic lateral sclerosis (ALS). It has been shown to improve quality of life and to extend survival in patients with
advanced respiratory muscle weakness. In our case, we describe the perioperative management of an adult patient with acquired
CAHS who presented for laparoscopic DPSS insertion.
Clinical featuresOur patient was a 50-yr-old female who developed CAHS at age thirteen after contracting encephalitis. Since the onset of her
disease, she had been managed with positive pressure ventilation to her lungs via mask. Due to her longstanding disease, she
presented with pulmonary hypertension and cor pulmonale and was scheduled for laparoscopic DPSS implantation. Our anesthetic
technique included a total intravenous technique with remifentanil and propofol, and her trachea was intubated without the
use of muscle relaxants. The pacemakers were switched on when the patient emerged from anesthesia, which provided her with
ventilatory support and allowed us to extubate her trachea.
ConclusionWe present the successful anesthetic management of an adult patient with CAHS undergoing laparoscopic DPSS insertion.
ObjectifLe syndrome d’hypoventilation alvéolaire centrale congénitale (HVACC) est une maladie rare qui se caractérise par la perte
du contrôle autonome de la respiration. Cette affecte provoque de l’hypoventilation et une obstruction pendant le sommeil.
Tout au long de leur vie, les patients atteints de ce syndrome nécessitent une assistance ventilatoire qui s’effectue en fournissant
une ventilation en pression positive à leurs poumons via un masque, une trachéotomie, ou d’autres moyens, tels que les stimulateurs
phréniques. Le stimulateur phrénique intradiaphragmatique est un nouveau traitement qui consiste à implanter des électrodes
dans le diaphragme, lesquels provoquent une contraction lorsqu’elles sont stimulées. Le stimulateur phrénique intradiaphragmatique
a été utilisé avec succès chez des patients tétraplégiques et des patients atteints de sclérose latérale amyotrophique (SLA).
Il a été démontré que ce dispositif améliorait la qualité de vie et prolongeait la survie chez les patients atteints d’une
faiblesse avancée des muscles respiratoires. Dans le cas présenté ici, nous décrivons la prise en charge périopératoire d’une
patiente adulte atteinte d’une HVACC acquise qui s’est présentée pour l’insertion par laparoscopie d’un stimulateur phrénique
intradiaphragmatique.
Éléments cliniquesNotre patiente était une femme âgée de 50 ans qui a manifesté une HVACC à l’âge de treize ans après avoir contracté une encéphalite.
Depuis l’apparition de sa maladie, elle a été prise en charge par ventilation en pression positive de ses poumons via un masque.
En raison de sa maladie prolongée, elle s’est présentée avec une hypertension pulmonaire et un cœur pulmonaire; une chirurgie
d’implantation par laparoscopie d’un stimulateur phrénique intradiaphragmatique a été prévue. Notre technique anesthésique
consistait en une technique intraveineuse totale à l’aide de rémifentanil et de propofol, et l’intubation de la trachée a
eu lieu sans curare. Les stimulateurs ont été enclenchés lorsque la patiente s’est réveillée de l’anesthésie, ce qui lui a
procuré un soutien ventilatoire et nous a permis d’extuber sa trachée.
ConclusionNous présentons la prise en charge anesthésique réussie d’une patiente adulte atteinte de HVACC subissant une insertion de
stimulateur phrénique intradiaphragmatique par laparoscopie.
Canadian Journal of Anaesthesia 04/2012; 58(11):1034-1038. · 2.35 Impact Factor
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ABSTRACT: The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery, and shorten hospital stay. This study was designed to determine which ERAS strategies contribute to overall shortened length of hospital stay in patients undergoing elective colorectal surgery in hospitals.
A retrospective cohort study of 336 consecutive patients at seven hospitals was performed. Demographic and data on 18 ERAS components identified from a systematic review of the literature were collected. A multiregression analysis was performed to assess for factors independently associated with a total length of hospital stay of 5 days or less.
Fifty-five percent were male (mean age, 62 years), 57.5% had an ASA III or IV, 76.9% had cancer, and 28.6% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On bivariate analysis, strategies associated with a stay ≤ 5 days were preoperative counseling, avoidance of oral bowel preparation, use of a laparoscopic approach, use of a transverse incision, introduction of clear fluids on day of surgery, and early discontinuation of the Foley catheter (all P < 0.05). On multivariate analysis, factors that remained significantly associated with a stay ≤ 5 days included use of a laparoscopic approach (odds ratio (OR), 1.24; 95% confidence interval (CI), 1.12-1.38), preoperative counseling (OR, 1.26; 95% CI, 1.15-1.38), intraoperative fluid restriction (OR, 1.26; 95% CI, 1.15-1.37), clear fluids on day of surgery (OR, 1.09; 95% CI, 1.00-1.2), and Foley urinal catheter discontinued within 24 h of colon surgery and 72 h of rectal surgery (OR, 1.13; 95% CI, 1.01-1.27).
In hospitals with variable uptake of ERAS strategies, preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, and early discontinuation of the Foley catheter are all independently associated with shortened length of stay.
Surgical Endoscopy 02/2012; 26(2):442-50. · 4.01 Impact Factor
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ABSTRACT: The Fundamentals of Laparoscopic Surgery (FLS) box trainer is the gold standard for development of laparoscopic technical skills however the scoring metrics require a trained proctor and do not allow for immediate feedback. The Lap Mentor™ virtual-reality (LMVR) FLS tasks, with automated scoring metrics and haptic feedback, may be a suitable alternative. We determined the construct and concurrent validity of LMVR-FLS. Participants with a range of laparoscopic experience performed 3 FLS tasks on both simulators. The LMVR-FLS demonstrated moderate concurrent validity and evidence for construct validity. Further research is required to determine if skill acquisition on these modules is transferable to the operating room.
Studies in health technology and informatics 01/2012; 173:349-55.
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ABSTRACT: Surgical resection of hepatic lesions is associated with intraoperative and postoperative morbidity and mortality. Our center has introduced a laparoscopic liver resection (LLR) program over the past 3 years. Our objective is to describe the initial clinical experience with LLR, including a detailed cost analysis.
We evaluated all LLRs from 2006 to 2010. Each was matched to 2 open cases for number of segments removed, patient age, and background liver histology. Model for End-Stage Liver Disease (MELD) and the Charlson comorbidity index were calculated retrospectively. Nonparametric statistical analysis was used to compare surgical and economic outcomes. Analyses were performed including and excluding converted cases.
Fifty-seven patients underwent attempted LLR. Demographic characteristics were similar between groups. Estimated blood loss was lower in the LLR vs the open liver resection (OLR) group, at 250 mL and 500 mL, respectively (p < 0.001). Median operating room times were 240 minutes and 270 minutes in the LLR and OLR groups, respectively (p = 0.14). Eight cases were converted to open (14%): 2 for bleeding, 2 for anatomic uncertainty, 1 for tumor size, 1 for margins, 1 for inability to localize the tumor, and 1 for adhesions. Median length of stay was lower for LLR at 5 days vs 6 days for OLR (p < 0.001). There was no difference in frequency of ICU admission, reoperation, 30-day emergency room visit, or 30-day readmission rates. Median overall cost for LLR was lower at $11,376 vs $12,523 for OLR (p = 0.077).
Our experience suggests that LLR confers the clinical advantages of reduced operating room time, estimated blood loss, and length of stay while decreasing overall cost. LLR, therefore, appears to be a clinically and fiscally advantageous approach in properly selected patients.
Journal of the American College of Surgeons 12/2011; 214(2):184-95. · 4.55 Impact Factor
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ABSTRACT: The cost implications of laparoscopic distal pancreatectomy (LDP) and a detailed breakdown of hospital expenditures has not been presented in the literature to date. This study aimed to compare hospital costs and short-term clinical outcomes between LDP and open distal pancreatectomy (ODP).
The authors evaluated all the distal pancreatic resections performed at their center between January 2004 and March 2010. Parametric and nonparametric statistical analysis was used to compare hospital departmental and total hospital costs as well as oncologic and surgical outcomes.
A total of 118 cases (42 laparoscopic resections, including 5 conversions, and 76 open resections) were analyzed. The demographic characteristics were similar between the groups except for a predominance of females in the laparoscopic group (P = 0.036). The indications for surgery differed by a paucity of malignant tumors being approached laparoscopically (P < 0.001). Intraoperatively, there were no differences in estimated blood loss, operating room time, or transfusion requirement. The pathologic outcomes did not differ significantly. The median hospital length of stay (LOS) was 5 days (range 3-31 days) for the LDP cohort and 7 days (range 4-19 days) for the ODP cohort (P < 0.001). Postoperative pancreatic fistula occurred for 22 patients, with a higher proportion observed in the LDP group (28.57%; n = 12) than in the open group (13.16%; n = 10; P = 0.05). However, the rates for grade B and higher grade fistula were higher in the ODP group (0 LDP and 4 ODP). The median preadmission and operative costs did not differ significantly. The ODP cohort had significantly higher costs in all other hospital departments, including the total cost.
LDP is both a cost-effective and safe approach for distal pancreatic lesions. This series showed a shorter LOS and lower total hospital costs for LDP than for ODP, accompanied by equivalent postoperative outcomes.
Surgical Endoscopy 12/2011; 26(5):1220-30. · 4.01 Impact Factor
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ABSTRACT: Central alveolar hypoventilation syndrome (CAHS) is a rare disease characterized by the loss of autonomic control of breathing. This condition causes hypoventilation and obstruction during sleep. Throughout their lives, these patients require ventilatory assistance by means of positive pressure ventilation to their lungs via mask, tracheotomy, or other means, such as phrenic nerve pacers. The diaphragm pacing stimulation system (DPSS) is a new treatment where electrodes are implanted into the diaphragm and cause contraction on stimulation. The DPSS has been used successfully in tetraplegic patients and patients suffering from amyotrophic lateral sclerosis (ALS). It has been shown to improve quality of life and to extend survival in patients with advanced respiratory muscle weakness. In our case, we describe the perioperative management of an adult patient with acquired CAHS who presented for laparoscopic DPSS insertion.
Our patient was a 50-yr-old female who developed CAHS at age thirteen after contracting encephalitis. Since the onset of her disease, she had been managed with positive pressure ventilation to her lungs via mask. Due to her longstanding disease, she presented with pulmonary hypertension and cor pulmonale and was scheduled for laparoscopic DPSS implantation. Our anesthetic technique included a total intravenous technique with remifentanil and propofol, and her trachea was intubated without the use of muscle relaxants. The pacemakers were switched on when the patient emerged from anesthesia, which provided her with ventilatory support and allowed us to extubate her trachea.
We present the successful anesthetic management of an adult patient with CAHS undergoing laparoscopic DPSS insertion.
Canadian Anaesthetists? Society Journal 08/2011; 58(11):1034-8. · 2.31 Impact Factor
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ABSTRACT: Although a validated simulator exists for adult laparoscopy, there is no pediatric counterpart. The objective of this study is to develop and validate a pediatric laparoscopic surgery (PLS) simulator.
A PLS simulator was developed. Participants were stratified according to level of expertise and tested on the fundamentals of laparoscopic surgery (FLS) and PLS simulators. A subsequent group was tested exclusively on the PLS simulator.
The PLS intracorporeal suturing score was lower than its adult counterpart (P = .02). The PLS pattern-cutting score was higher than in the FLS simulator (P < .001). If the latter was eliminated from the calculation, the revised total FLS score was significantly better than the revised PLS score. When all participants were combined, total PLS scores as well as performance on 3 of 5 tasks allowed differentiation between novice, intermediate, and expert.
The PLS simulator was able to discriminate between the novice, intermediate, and expert using the total PLS score and the performance on 3 of the 5 tasks, thus providing evidence for construct validity. The other 2 tasks will require formal modification or a change in the scoring metrics to establish their independent construct validity.
Journal of Pediatric Surgery 05/2011; 46(5):897-903. · 1.45 Impact Factor
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ABSTRACT: General surgery trainees' perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level.
Two hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training.
Two hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department's responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present.
There exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed.
Surgical Endoscopy 04/2011; 25(9):3057-65. · 4.01 Impact Factor
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ABSTRACT: There are numerous reports in the literature documenting high recurrence rates after laparoscopic paraesophageal hernia repair. The purpose of this study was to determine the learning curve for this procedure using the Cumulative Summation (CUSUM) technique.
Forty-six consecutive patients with paraesophageal hernia were evaluated prospectively after laparoscopic paraesophageal hernia repair. Upper GI series was performed 3 months postoperatively to look for recurrence. Patients were stratified based on the surgeon's early (first 20 cases) and late experience (>20 cases). The CUSUM method was then used to further analyze the learning curve.
Nine patients (21%) had anatomic recurrence. There was a trend toward a higher recurrence rate during the first 20 cases, although this did not achieve statistical significance (33% vs. 13%, p = 0.10). However, using a CUSUM analysis to plot the learning curve, we found that the recurrence rate diminishes after 18 cases and reaches an acceptable rate after 26 cases.
Surgeon experience is an important predictor of recurrence after laparoscopic paraesophageal hernia repair. CUSUM analysis revealed there is a significant learning curve to become proficient at this procedure, with approximately 20 cases required before a consistent decrease in hernia recurrence rate is observed.
Surgical Endoscopy 04/2011; 25(4):1083-7. · 4.01 Impact Factor
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ABSTRACT: FLS is an educational program developed by the Society of American Gastrointestinal and Endoscopic Surgeons and endorsed by the American College of Surgeons. The goal of the FLS program is to teach and assess the basic cognitive and psychomotor skills required to perform laparoscopic surgery. The purpose of this study is to review the results from the first 5 years of FLS certification testing.
FLS test data were prospectively collected for all participants taking the FLS certification examination since its inception. Deidentified data were reviewed and analyzed using standard descriptive statistics.
The FLS examination was taken by 2,689 participants between October 2004 and December 2009. There was a yearly increase in the number of individuals seeking FLS certification. Complete demographic information was available for 1,882 participants: 12% were junior residents (PGY 1-3), 69% were senior residents (PGY 4-5) or fellows, and 19% were attending surgeons. A breakdown of participants by specialty revealed that 88% were general surgeons, 4% were gynecologists, 2% were urologists, and 6% were labeled as "other." The mean (standard deviation, SD) score on the cognitive examination was 519 (157), with a 93% pass rate. The mean score on the technical skills examination was 525 (117), with a 92% pass rate. After combining both scores, the overall FLS certification pass rate was 88%.
The FLS certification examination has gained widespread acceptance among laparoscopic surgeons in training and practice, with a marked increase in testing since the American Board of Surgery mandate for certification was announced. The overall pass rate of 88% on the examination approaches the target pass rate of 90% established during the test-setting process.
Surgical Endoscopy 04/2011; 25(4):1192-8. · 4.01 Impact Factor
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ABSTRACT: Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study's objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa.
One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other's simulators, and communicate in real time. Learner's opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet.
Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post-multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar's chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = -0.11 ± 1.22 [95% CI = -0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = -0.06 to 0.08 seconds]).
Telesimulation is a novel method for teaching procedural skills. The session improved physicians' knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.
Academic Emergency Medicine 04/2011; 18(4):420-7. · 1.86 Impact Factor
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Surgical Endoscopy 02/2011; · 4.01 Impact Factor
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Iman Ghaderi,
Marilou Vaillancourt,
Gideon Sroka,
Pepa A Kaneva,
Melina C Vassiliou,
Ian Choy, Allan Okrainec,
F Jacob Seagull,
Erica Sutton,
Ivan George,
Adrian Park,
Rita Brintzenhoff,
Dimitrios Stefanidis,
Gerald M Fried,
Liane S Feldman
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ABSTRACT: Laparoscopic incisional hernia repair (LIHR) is a common procedure requiring advanced laparoscopic skills. This study aimed to develop a procedure-specific tool to assess the performance of LIHR and to evaluate its reliability and validity.
The Global Operative Assessment of Laparoscopic Skills-Incisional Hernia (GOALS-IH) is a 7-item global rating scale developed by experts to evaluate the steps of LIHR (placement of trocars, adhesiolysis, estimation of mesh size and shape, mesh orientation and positioning, mesh fixation, knowledge and autonomy in use of instruments, overall competence), each rated on a 5-point Likert scale. During LIHR, 13 attending surgeons and fellows experienced in minimally invasive surgery (MIS) and 19 novice surgeons (postgraduate years [PGYs], 3-5) were evaluated at four teaching hospitals by the attending surgeon, a trained observer, and self-assessment using GOALS-IH, and by a previously validated 5-item general laparoscopic rating scale (GOALS). Interrater reliability was assessed by intraclass correlation (ICC), and internal consistency of rating items was assessed by Cronbach's alpha. Known-groups construct validity was assessed by using the t-test and by correlating of the number of self-reported LIHR cases with the total score. Concurrent validity was assessed by correlating the GOALS-IH score with the GOALS general rating scale. Data are presented as mean and 95% confidence interval (CI).
Interrater reliability for the total GOALS-IH score was 0.79 (95% CI, 0.60-0.89) between observers and attending surgeons, 0.81 (95% CI, 0.58-0.92) between participants and attending surgeons, and 0.89 (95% CI, 0.76-0.96) between participants and observers. Internal consistency was high (Cronbach's alpha, 0.93). Experienced surgeons performed significantly better than novices as assessed by GOALS-IH (31; 95% CI, 29-33 vs. 21; 95% CI, 19-24; p < 0.01). Very good correlation was found between GOALS-IH and previous LIHR experience (r = 0.82; p < 0.01) and strong correlation between GOALS-IH and generic GOALS total scores (r = 0.90; p < 0.01).
Surgical performance during clinical LIHR can be assessed reliably using GOALS-IH. Results can be used to provide formative feedback to the surgeon and to identify steps of the operation that would benefit from specific educational interventions.
Surgical Endoscopy 02/2011; 25(8):2555-63. · 4.01 Impact Factor
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ABSTRACT: The purpose of this study was to explore resident perceptions regarding four current models for teaching laparoscopic suturing and to assess the current quality of training in advanced minimally invasive surgical techniques at an academic teaching center.
This study included 14 senior general surgery residents (PGY 3-5) participating in a workshop in advanced laparoscopy. Four training tools were used in the course curriculum: the Fundamentals of Laparoscopic Surgery (FLS) black box suturing model, a synthetic Nissen fundoplication model, a virtual reality (VR) simulator suturing task, and a porcine jejuno-jejunostomy model. After the workshop, residents were asked to complete a questionnaire relating to their experience with laparoscopic surgery, and their opinions regarding the four training models. Model rank was analyzed with one-way ANOVA, and χ(2) analysis with Fisher's exact test was used to analyze model effectiveness.
The majority of residents had strong experience in basic laparoscopic cases such as cholecystectomy and appendectomy; however, few participants had experience in advanced cases. As a group, the residents ranked the porcine model first (average 1.6, median 1), followed by the synthetic Nissen model (average 2.0, median 2), the FLS model (average 2.5, median 3), and the VR trainer (average 3.2, median 4). Finally, each resident was asked to rate the four models individually with respect to their educational value. Scores were on a Likert scale from 1 to 5. Nine of 11 (81.8%) residents rated the animal model as "extremely helpful" while only 3 of 14 (21.4%) participants rated the VR model as "extremely helpful" (p = 0.048).
This study demonstrates that operative experience in advanced laparoscopy for senior residents is suboptimal. Residents learning this skill in a simulated environment prefer animal or video-trainers as teaching models rather than virtual reality. This has implications when designing a curriculum for advanced endoscopy.
Surgical Endoscopy 11/2010; 24(11):2830-4. · 4.01 Impact Factor
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ABSTRACT: Independent learning with simulators might be improved if simulators could "diagnose the learner" by identifying common novice problems, thereby directing self-guided learning. Our goal was to determine if data collected by a virtual reality simulator could be used to predict the problem areas in novice trainees' laparoscopic performance.
Fourteen expert laparoscopists were interviewed to identify common problem areas experienced by novices as they learn laparoscopy. Two expert laparoscopists rated 20 novices' simulator performances regarding the extent of each problem area.
Moderate interrater reliability and high "interproblem" correlations suggest that experts did not reliably distinguish between the five identified problem areas as expected.
The process by which expert teachers "diagnose" student difficulties did not reduce well to numeric assessments using linear independent scales in the simulated context. This finding raises challenges for our ability to identify such difficulties using the data collected by simulators.
Academic medicine: journal of the Association of American Medical Colleges 10/2010; 85(10 Suppl):S5-8. · 2.34 Impact Factor
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ABSTRACT: The apprenticeship model that surgical training has traditionally relied on has proven to be an expensive, time-consuming, and inconsistent model for producing skilled surgeons. Combined with increased public scrutiny on patient safety, financial concerns, restricted work hours, and expanding skill requirements, it has become clear that a new pedagogic paradigm is required. This article reviews the evidence supporting the need and justification of simulation in surgical education and explores the existing and potential roles of simulation in the training and evaluation of future surgeons.
Surgical Clinics of North America 06/2010; 90(3):457-73. · 2.14 Impact Factor
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ABSTRACT: Several challenges exist with laparoscopic skills training in resource-restricted countries, including long travel distances required by mentors for onsite teaching. Telesimulation (TS) is a novel concept that uses the internet to link simulators between an instructor and a trainee in different locations. The purpose of this study was to determine the effectiveness of telesimulation for teaching the Fundamentals of Laparoscopic Surgery (FLS) to surgeons in Botswana, Africa.
A total of 16 surgeons from two centers in Botswana participated in this 8-week study. FLS TS was set up using two simulators, computers, webcams, and Skype software for eight surgeons in the TS group. A standard FLS simulator was available for the eight surgeons in the self-practice (SP) group. Participants in the TS group had one remote training session per week with an FLS proctor at the University of Toronto who provided feedback and demonstrated proper technique. Participants in the SP group had access to the FLS DVD and were instructed to train on FLS at least once per week. FLS post-test scores were obtained in Botswana by a trained FLS proctor at the conclusion of the study.
Participants in the TS group had significantly higher post-test FLS scores than those in the SP group (440 +/- 56 vs. 272 +/- 95, p = 0.001). All trainees in the TS group achieved an FLS simulator certification passing score, whereas only 38% in the SP group did so (p = 0.03).
Remote telesimulation is an effective method for teaching the Fundamentals of Laparoscopic Surgery in Africa, achieving a 100% FLS skills pass rate. This training platform provides a cost-effective method of teaching in resource-restricted countries and could be used to teach laparoscopic skills anywhere in the world with internet access.
Surgical Endoscopy 07/2009; 24(2):417-22. · 4.01 Impact Factor
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ABSTRACT: Enhanced recovery after surgery programs have been introduced with aims of improving patient care, reducing complication rates, and shortening hospital stay following colorectal surgery. The aim of this meta-analysis was to determine whether enhanced recovery after surgery programs, when compared to traditional perioperative care, are associated with reduced primary hospital length of stay in adult patients undergoing elective colorectal surgery.
MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials, and the reference lists were searched for relevant articles. Only randomized controlled trials comparing an enhanced recovery program with traditional postoperative care were included.
Three of four included studies showed significantly shorter primary lengths of stay for patients enrolled in enhanced recovery programs. There was no significant difference in postoperative mortality when the two groups were compared [relative risk (RR) = 0.53; 95% CI = 0.12-2.38; test for heterogeneity, p = 0.40 and I (2) = 0], and patients in enhanced recovery programs were less likely to develop postoperative complications (RR = 0.61, 95% CI = 0.42-0.88; test for heterogeneity, p = 0.95 and I (2) = 0).
There is some evidence to suggest that enhanced recovery after surgery programs are better than traditional perioperative care, but evidence from a larger, better quality randomized controlled trial is necessary.
Journal of Gastrointestinal Surgery 06/2009; 13(12):2321-9. · 2.83 Impact Factor
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ABSTRACT: The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa.
A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3.
Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 +/- 94 versus 132 +/- 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification.
To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.
Surgical Endoscopy 04/2009; 23(11):2493-8. · 4.01 Impact Factor
