Task-specific bench model training versus basic laparoscopic skills training for laparoscopic radical prostatectomy: A randomized controlled study
Abstract
Performing a laparoscopic urethrovesical anastomosis (LUA) after a radical prostatectomy is technically challenging for the novice laparoscopic surgeon. We developed a low-fidelity urethrovesical model (UVM) to allow a urologist to practise this critical step. The aim of our study was to compare the effect of task-specific bench model training (anastomotic suturing on the UVM) with that of basic laparoscopic suturing on intracorporeal urethrovesical anastomosis performance.
We recruited 28 senior surgical residents, fellows or staff surgeons for this prospective, single-blinded, randomized controlled study. We randomly assigned participants to an intervention group practising LUA on the UVM or to a control group practising basic laparoscopic suturing and knot-tying on a foam pad. After practising, we videotaped participants performing 5 intra-corporeal interrupted sutures on a foam pad and a LUA on the UVM. A blinded expert scored the videotaped performance using a laparoscopic suturing checklist (CL) and a global rating scale (GRS), and timed the performance.
On the foam pad suturing task, the group that trained on the UVM had significantly higher CL scores (10.9 v. 8.1, p = 0.017). On the LUA task, the group that trained on the UVM had significantly higher CL scores (10.9 v. 8.1, p = 0.017), GRS (29.6 v. 22.8, p = 0.005) and shorter times (27.6 v. 38.3 min, p = 0.004) than the control group.
Our task-specific bench model was shown to be superior to basic laparoscopic suturing drills on a foam pad.
CUAJ • February 2009 • Volume 3, Issue 1
© 2009 Canadian Urological Association
22
ORIGINAL RESEARCH
Task-specific bench model training versus basic laparoscopic skills
training for laparoscopic radical prostatectomy: a randomized
controlled study
Robert Sabbagh, BPharm, MSc, MD;
*
Suman Chatterjee, MD;
†
Arun Chawla, MD;
†
Anil Kapoor, MD;
†
Edward D. Matsumoto, MD, M.Ed
†
Abstract
Background: Performing a laparoscopic urethrovesical anastomo-
sis (LUA) after a radical prostatectomy is technically challenging
for the novice laparoscopic surgeon. We developed a low-fidelity
urethrovesical model (UVM) to allow a urologist to practise this
critical step. The aim of our study was to compare the effect of
task-specific bench model training (anastomotic suturing on the
UVM) with that of basic laparoscopic suturing on intracorporeal
urethrovesical anastomosis performance.
Methods: We recruited 28 senior surgical residents, fellows or staff
surgeons for this prospective, single-blinded, randomized con-
trolled study. We randomly assigned participants to an interven-
tion group practising LUA on the UVM or to a control group prac-
tising basic laparoscopic suturing and knot-tying on a foam pad.
After practising, we videotaped participants performing 5 intra-
corporeal interrupted sutures on a foam pad and a LUA on the
UVM. A blinded expert scored the videotaped performance using
a laparoscopic suturing checklist (CL) and a global rating scale
(GRS), and timed the performance.
Results: On the foam pad suturing task, the group that trained
on the UVM had significantly higher CL scores (10.9 v. 8.1,
p
= 0.017). On the LUA task, the group that trained on the UVM
had significantly higher CL scores (10.9 v. 8.1,
p
= 0.017), GRS
(29.6 v. 22.8,
p
= 0.005) and shorter times (27.6 v. 38.3 min,
p
= 0.004) than the control group.
Conclusion: Our task-specific bench model was shown to be super-
ior to basic laparoscopic suturing drills on a foam pad.
Résumé
Généralités : L’anastomose urétrovésicale par voie laparoscopique
(AUL) suivant une prostatectomie radicale pose certaines diffi-
cultés techniques au chirurgien peu expérimenté avec la laparo-
scopie. Nous avons créé un modèle urétrovésical basse-fidélité
(MUB) permettant aux urologues de pratiquer cette étape cruciale
de l’intervention. Le but de l’étude était de comparer l’impact
d’exercices avec un modèle spécifique à la tâche (sutures anasto-
Can Urol Assoc J
2009;3(1):22-30
See related article on page 31
motiques sur le modèle urétrovésical) et d’exercices de sutures
laparoscopiques sur l’aptitude à effectuer des anastomoses urétro-
vésicales intracorporelles.
Méthodologie : Vingt-huit résidents séniors en chirurgie, chercheurs-
boursiers et chirurgiens ont été recrutés pour cette étude prospec-
tive et contrôlée, menée à simple insu avec répartition aléatoire.
Les participants ont été répartis au hasard en 2 groupes, soit un
groupe qui a pratiqué l’anastomose urétrovésicale sur le MUB et
un groupe témoin qui a pratiqué les sutures laparoscopiques et
la formation de nœuds sur un coussinet de mousse. Après la pra-
tique, les participants ont été filmés pendant qu’ils effectuaient
5 suturations intracorporelles interrompues sur un coussinet de
mousse et une anastomose urétrovésicale par laparoscopie à l’aide
du modèle urétrovésical. Un expert ne connaissant pas le type
d’exercices utilisé a ensuite évalué les chirurgiens à l’aide d’une
liste de vérification des éléments clés d’une suturation laparoscopique
(LV), d’un score global et du temps requis pour les suturations.
Résultats : Lors de la tâche de suturation avec coussinet de mousse,
le groupe qui avait pratiqué à l’aide du modèle urétrovésical a
obtenu des scores LV significativement plus élevés (10,9 contre
8,1;
p
= 0,017). Quant à la tâche d’anastomose urétrovésicale
par laparoscopie, le groupe qui avait pratiqué sur le modèle urétro-
vésical a également obtenu des scores LV significativement plus
élevés (10,9 contre 8,1;
p
= 0.017), mais aussi un score global
plus élevé (29,6 contre 22,8,
p
= 0,005), et il a effectué la tâche
en moins de temps (27,6 minutes contre 38,3 minutes,
p
= 0,004)
par rapport au groupe témoin.
Conclusion : Nous avons élaboré un modèle spécifique à la tâche
qui s’est révélé supérieur aux exercices de suturation laparo-
scopique sur coussinet de mousse.
Introduction
Laparoscopic radical prostatectomy (LRP) has been intro-
duced as a minimally invasive approach for the manage-
ment of localized prostate cancer.1This procedure has a
steep learning curve, and one of the most difficult and
critical steps to learn is the laparoscopic urethrovesical anas-
tomosis (LUA).2,3 To reduce the learning curve and to
CUAJ • February 2009 • Volume 3, Issue 1 23
Task-specific bench model training v. basic laparoscopic skills training
improve the performance of trainees suturing a
LUA, we designed a low-cost urethrovesical latex
model (UVM) to teach this skill.
We hypothesized that, for complex skills such
as laparoscopic urethrovesical suturing, a model
incorporating task-specific surgical skills training is
essential. We sought to compare the impact of task-
specific bench model training (LUA suturing on
UVM) to nonspecific laparoscopic practice (basic
laparoscopic suturing and knot-tying) on intracor-
poreal urethrovesical anastomosis performance.
Methods
The Research Ethics Boards at St. Joseph’s
Healthcare, and the Hamilton Health Sciences
Corporation, Hamilton, Ont. approved our study.
We recruited 28 senior surgical residents, fellows
or staff surgeons in urology, general surgery and
gynecology (Table 1 and Table 2) through surgi-
cal rounds and advertisement. We obtained
informed consent from each participant and
assigned them each a study identification number.
We randomly assigned participants to Group 1
(task-specific) to practise on the UVM perform-
ing running LUA sutures (Fig. 1 and Fig. 2) or to
Group 2 (control) to practise basic laparoscopic
suturing and knot-tying on a foam pad. All par-
ticipants completed a questionnaire on their
laparoscopic experience (Appendix 1) and
watched a 15-minute video of an actual intra-
operative LUA being performed. The purpose of
the video was to show how the skills chosen for
this study relate to the actual procedure.
Group 1 received specific instructions on angling
the needle within the needle driver, approaching
and holding the urethra or bladder, setting and
advancing the needle into the tissue, and when to
use the opposite hand or to backhand a needle. The
double-armed suture consisted of two 3–0 Prolene
sutures (ETHICON, Johnson & Johnson) 15 cm in
length, tied tail to tail with a SH needle at each end.
For orientation and communication purposes, while
looking into the pelvis from the head in a supine
position, the 12 o’clock position was the anterior
urethra or bladder and the 6 o’clock position was
the posterior urethra or bladder. We instructed par-
ticipants to pass both needles out-to-in at the
6 o’clock bladder position using each arm of the
suture to perform a running anastomosis up each
side. They then passed 3 running anastomosis
stitches connecting the bladder to the urethra from
6 to 9 o’clock on the left side and from 6 to 3 o’clock
on the right side. They inserted an 18 Fr. Foley
catheter from the urethral end of the model tube
beyond the completed posterior half of the anas-
tomosis. Once the catheter passed across the anas-
tomosis, continuing the same suturing completed
the anterior part of the anastomosis. When the
sutures met at 12 o’clock, both were tied together
with 3 knots to complete the task.
Group 2 practised suturing on foam pads
Table 1. Distribution of surgical specialty and level of training
among participants in the task-specific and control groups
No. of participants
Surgical specialty; level of training Group 1* Group 2†
Urology 8 3
Urologists 4 1
Fellows 2 0
PGY-4 2 2
Gynecology 2 5
Gynecologists 1 2
PGY-5 1 2
PGY-4 0 1
General surgery 4 6
Fellows 2 2
PGY-5 2 2
PGY-4 0 2
All participants 14 14
PGY = postgraduate year.
*Group 1: task-specific training on the model.
†Group 2: non–task specific training on the foam pad.
CUAJ • February 2009 • Volume 3, Issue 1
24
Sabbagh et al.
acquired from Limbs and Things (Bristol, UK). We
instructed participants to place single, simple-
interrupted sutures across the foam and tie 3 knots.
Group 2 also practised running the suture across
opposing straight edges of foam to practise needle-
and instrument-handling, but participants were not
required to tie these sutures. They also received
basic suture-handling and instrument-handling
instructions similar to Group 1, but they did not
perform any circular running sutures.
All participants received feedback from an experi-
enced laparoscopic urologist during the practice
session.
After 2 hours of training, both groups performed
a post-training laparoscopic suturing test consist-
ing of 2 tasks. The first task was to complete 5 fig-
ures of 8 and tie 3 knots on the foam pad. The
second task was to perform a running LUA on
the UVM (Fig. 3). For both tasks, we videotaped
and timed performances. A blinded laparoscop-
ic expert evaluated the performances using a task-
specific checklist (CL) and global rating scale (GRS)
(Appendix 2 and Appendix 3).
We performed our statistical analysis using
SigmaStat Version 3.10.0 (Systat Software Inc.).
From an earlier study, looking at bench model
Table 2. Distribution of previous laparoscopic/endoscopic experience among
participants in the task-specific and control groups
No. of cases
Participants Procedures Group 1* Group 2†
All participants Laparoscopic radical prostatectomy 0 0
Urology
All urologists
Laparoscopic nephrectomy
Participant #2 1–4
Participant #3 0
Participant #4 0
Participant #11 0
Participant #14 1–4
All fellows None performed 0 0
All PGY-4 None performed 0 0
Gynecology
All gynecologists
Diagnostic laparoscopy > 15 > 15
Laparoscopic tubal ligation > 15 > 15
All PGY- 5 Diagnostic laparoscopy > 15 > 15
Laparoscopic tubal ligation > 15 > 15
All PGY-4 Diagnostic laparoscopy 10–15
Laparoscopic tubal ligation 1–4
General surgery
All fellows and PGY- 5 Cholecystectomy > 15 > 15
OGD/ERCP > 15 > 15
Colonoscopy > 15 > 15
PGY- 4
Participant #8 Cholecystectomy 10–15
OGD/ERCP 5–10
Colonoscopy 5–10
Participant #22 Cholecystectomy 5–10
OGD/ERCP 1–4
Colonoscopy 1–4
ERCP = endoscopic retrograde cholangiopancreatography; OGD = esophagogastroduodenoscopy; PGY = postgraduate year.
*Group 1: task-specific training on the model.
†Group 2: non–task specific training on the foam pad.
CUAJ • February 2009 • Volume 3, Issue 1 25
Task-specific bench model training v. basic laparoscopic skills training
fidelity in ureteroscopic training, we found that the
mean difference in GRS between the group that
trained on the low-fidelity model and the group
that underwent didactic teaching was 10.166. We
calculated the pooled standard deviation as 5.0.
Using
t
test sample size calculation, to achieve
a power of 80% at an αof 0.05, our study required
a minimum of 6 participants per group. To account
for the possibility of dropouts and the differences
in the complexity of the procedure and training
intervention, compared with the original ure-
teroscopy study, we recruited an additional 8 par-
ticipants per group. This allowed us to detect a
difference of 15% between the 2 groups. We ran-
domly assigned participants using sealed envelopes
prepared by our statistician. We performed com-
parisons between Group 1 and Group 2 using a
Mann–Whitney test. We considered
p
< 0.05 to
be statistically significant.
Results
At baseline, we detected no differences in previous
laparoscopic experience, distribution of surgical
specialty and level of training between groups
(Table 1 and Table 2). None of the participants
had performed an LRP. On the foam pad sutur-
ing task, Group 1 had significantly higher CL scores
(10.9 v. 8.1,
p
= 0.017), but we noted no significant
Fig. 1.
The urethrovesical model sutured together with a Foley
catheter passing through.
Fig. 2.
Urethrovesical model positioned in the pelvic trainer simu-
lated orientation within the male pelvis.
24 participants
15-minute video on laparoscopic urethrovesical
anastomosis
12 participants
• Task-specific
laparoscopic training
• Laparoscopic circular running suture
anastomosis training on the bladder-
urethra bench model
• 2 hours training
12 participants
• Nontask-specific
laparoscopic training
• Basic laparoscopic suturing and knot
tying on a foam pad
• 2 hours training
Post-training laparoscopic suturing test
videotaped
1. Anastomosis on bench model
2. Foam pad
1 hour
Post-training laparoscopic suturing test
videotaped
1. Anastomosis on bench model
2. Foam pad
1 hour
Fig. 3.
Study design.
CUAJ • February 2009 • Volume 3, Issue 1
26
Sabbagh et al.
differences in GRS or time (Table 3). On the LUA
task, Group 1 had a significantly higher task-
specific CL score (10.9 v. 8.1,
p
= 0.017), GRS
(29.6 v. 22.8,
p
= 0.005) and shorter times
(27.6 min v. 38.3 min,
p
= 0.004) than the control
group (Table 3).
Discussion
Reconstructive laparoscopy is technically more
difficult than ablative surgery, demanding more
skills and experience. With laparoscopic recon-
struction, the ability to suture is a necessity. Often,
suturing is performed with extreme angles and
positions owing to the natural orientation of organs.
In addition, suturing with standard laparoscopic
needle drivers means loss of degrees of freedom.
Unlike the Da Vinci robotic arm (Intuitive Surgical),
which has 7 degrees of freedom because of a
“wrist” within the abdominal/pelvic cavity, the
pure laparoscopic surgeon has to compensate for
the lack of a “wrist” by positioning and advancing
a needle with a corrective angle in relation to the
bladder or urethra. A urologist must learn these
subtle techniques to perform a urethrovesical anas-
tomosis successfully. Furthermore, working with
instruments in the pelvis requires substantial mod-
ification of instrument-handling, suturing and tying
owing to the relatively narrow confines compared
with the wide-open space for transperitoneal kid-
ney surgery.
In this study, Group 1 performed the final run-
ning urethrovesical anastomosis quicker and had
better CL scores and GRS compared with Group 2.
This suggests that task-specific training on UVM
is an effective way of learning how to perform LUA.
Interestingly, Group 1 also performed the figure of
8 task better than Group 2. Training on the UVM
not only led to better running urethrovesical per-
formance, but also to better performance on sim-
ple suturing tasks.
Understanding the critical steps of a surgical
procedure is important when designing bench
models. The model does not have to look realis-
tic (high fidelity) to be effective as a teaching tool.
In 2 separate studies, low-cost, low-fidelity mod-
els have been shown to be effective teaching
tools.4,5 However, it is important to ensure the
model allows trainees to practise the essential steps
required in the real procedure. In our study, the
model reproduces almost all of the surgical steps
of a LUA. This latex UVM has been designed to
simulate anatomical and tissue characteristics (i.e.,
thickness) of the human bladder and urethra
(Fig. 1). Operating in a man’s pelvis is reproduced
when the UVM is inserted into a special pelvic
trainer (Limbs and Things) (Fig. 2). Not only does
a trainee have the opportunity to learn proper nee-
dle position and handling, they also learn how
to operate within the strict confines of the pelvic
structure. Standing at the sides and working down
the middle of the patient can be ergonomically
taxing. With proper instructions and practice,
trainees can anticipate the ergonomic challenges
of laparoscopic pelvic surgery.
Several authors have proposed different models
allowing trainees to acquire the skills necessary
to perform an LUA. Teber and colleagues6de-
veloped a standardized step-by-step program to
improve skills and enable trainees not experienced
in laparoscopy to increase reproducible perform-
ance in reconstructive laparoscopy. Katz and col-
leagues7proposed a simplified 5-step model for
training LUA. By using this model and dividing
complicated surgical steps into simplified tasks (e.g.,
passage of ligature, intracorporal knotting, intra-
corporeal suturing, linear anastomosis, circular run-
ning suture anastomosis with chicken skin), they
were able to substantially improve trainee per-
formance. Nadu and colleagues8developed a sim-
ple model using chicken skin in a pelvic trainer.
After performing 20 anastomoses on this model,
2 urology fellows reduced the time required for
performing the anastomosis from 75 to 20 minutes
Table 3. Post-training laparoscopic suturing test results
Mean ± 95% CI
Task Group 1* Group 2† p value
5 figures of 8 and 3 knot
ties on the foam pad
Time for performance, min 22.6 ± 3.0 25.6 ±3.6 0.15
Task-specific checklist/12 10.9 ±1.2 8.1 ±1.9 0.017
Global rating scale/35 29.9 ±3.2 27.9 ±2.7 0.17
Urethrovesical anastomosis
on the model
Time for performance, min 27.6 ±3.0 38.3 ±6.6 0.004
Task-specific checklist/12 10.9 ±1.2 8.1 ±1.9 0.017
Global rating scale/35 29.6 ±3.7 22.8 ±3.1 0.005
CI = confidence interval.
*Group 1: task-specific training on the model.
†Group 2: non–task specific training on the foam pad.
CUAJ • February 2009 • Volume 3, Issue 1 27
Task-specific bench model training v. basic laparoscopic skills training
and were able to create a watertight running LUA
in patients in a mean time of 40 minutes (range
30–55 min).8In our study, participants who
trained on the UVM performed the urethroves-
ical anastomosis in a mean time of 27.6 minutes,
approaching performance in the study by Nadu
and colleagues.8
Other training models studied include human
cadavers, live animals and virtual reality (VR) simu-
lators to teach surgical skills. Human cadavers most
closely resemble live patients but they are expen-
sive, have limited availability, have stiffer tissues
and may transmit infections. Animals remain an
alternative and have the benefit of providing living
simulations that are generally faithful to opera-
tive reality. However, they are expensive, neces-
sitate specialized facilities and personnel, and are
not always ethically acceptable.
Virtual reality simulators have been introduced
as training tools and could improve the perform-
ance in the operating room for laparoscopic sur-
gery.9–12 For example, a VR simulator named URO
Mentor (Simbionix) is commercially available for
training in endourology. Several studies have shown
that training on the simulator improves perform-
ance.13–15 However, studies validating VR simula-
tors in the operating room are limited. Simulators
also lack haptics (tactile feedback), which is essen-
tial in procedures such as laparoscopy.
There were limitations with our study. The ure-
throvesical anastomosis is an essential step in per-
forming an LRP, yet there are preceding steps that
have to be learned and consolidated before finish-
ing with the anastomosis. This study focused only
on a single step, and it is important to keep in mind
that a successful procedure requires multiple steps
to be completed successfully. From an education-
al perspective, the ability to deconstruct a pro-
cedure into steps and create an inventory is attract-
ive, as this facilitates teaching and evaluation of
complex surgeries. The challenge would be to find
a teaching model that incorporates all of the crit-
ical steps to teach a new procedure from begin-
ning to end. With advances in graphics and vir-
tual haptics, VR may provide the solution for the
acquisition of complex skills.
Other limitations include the lack of intra-
operative factors such as blood and urine, which
can hamper surgical performance. We included
only participants at an advanced level in a special-
ty where laparoscopy is currently used; however,
our population is homogeneous in the sense that
none of the participants had ever performed an
LRP. Owing to the limited number of urologists and
urology residents in our area and program, we
could not rely on them exclusively to reach our
sample size. Another limitation of this study is
model validation. The ideal validation method
would have been to perform the post-test on a
patient, but for ethical reasons such as the partici-
pants’ lack of experience, the transfer to this “high-
fidelity model” would be unacceptable. A more suit-
able high-fidelity model would be a live anesthetized
pig, as the pig urethrovesical junction and the pelvic
dimensions have anatomical and tissue characteris-
tics similar to humans. The second phase of our study
will research whether skills learned on the UVM
transfer to a high-fidelity live pig model.
Conclusion
Laparoscopic urethrovesical anastomosis is one of
the most challenging steps during an LRP. We have
developed a task-specific bench model that allows
a trainee to practise LUA. Training on this model
is superior to basic laparoscopic suturing practice.
The second phase of our study will assess whether
skills learned on the UVM leads to a better ure-
throvesical anastomosis on a live anesthetized pig.
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urology.
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2006;16:413-8.
3. Poulakis V, Witzsch U, De Vries R, et al. Intensive laparoscopic training: the impact
of a simplified pelvic-trainer model for the urethrovesical anastomosis on the learning
curve.
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the bench training model to the human model.
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on endourological skills: a randomized controlled study.
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2002;167:1243-7.
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scopic suturing: concept and validation.
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2005;19:230-8.
7. Katz R, Nadu A, Olsson LE, et al. A simplified 5-step model for training LUA.
J Urol
2003;169:2041-4.
This article has been peer reviewed.
From *Sherbrooke University, Department of Surgery, Division of Urology,
Sherbrooke, Que., and †McMaster University, Department of Surgery, Division of
Urology, Hamilton, Ont.
Competing interests: None declared.
CUAJ • February 2009 • Volume 3, Issue 1
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Sabbagh et al.
8. Nadu A, Olsson L., Abbou CC. Simple model for training in the laparoscopic vesicourethral
running anastomosis.
J Endourol
2003;17:481-4.
9. Korndorffer JR Jr, Dunne JB, Sierra R, et al. Simulator training for laparoscopic sutur-
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Correspondence: Dr. Edward D. Matsumoto, McMaster University, Department of
Surgery, Division of Urology, McMaster Institute of Urology at St. Joseph’s
Hospital, 50 Charlton Ave. E., Hamilton ON L8N 4A6; fax 905 308-7205;
matsumo@mcmaster.ca
Appendix 1. Participant questionnaire
Candidate no.
How many of the following procedures have you performed by yourself? (i.e. > 80% of the procedure)
1. laparoscopic prostatectomy 0 1 to 4 5 to 10 10 to 15 >15
2. laparoscopic nephrectomy 0 1 to 4 5 to 10 10 to 15 >15
3. laparoscopic cholecystectomy 0 1 to 4 5 to 10 10 to 15 >15
4. OGD/ERCP 0 1 to 4 5 to 10 10 to 15 >15
5. colonoscopy 0 1 to 4 5 to 10 10 to 15 >15
6. other laparoscopic
procedure_________________
0 1 to 4 5 to 10 10 to 15 >15
How many of the following procedures have you assisted at? (i.e. < 80% of the pr ocedure)
1. laparoscopic prostatectomy 0 1 to 4 5 to 10 10 to 15 >15
2. laparoscopic nephrectomy 0 1 to 4 5 to 10 10 to 15 >15
3. laparoscopic cholecystectomy 0 1 to 4 5 to 10 10 to 15 >15
4. OGD/ERCP 0 1 to 4 5 to 10 10 to 15 >15
5. colonoscopy 0 1 to 4 5 to 10 10 to 15 >15
6. other laparoscopic
procedure_________________
0 1 to 4 5 to 10 10 to 15 >15
How many of the following procedures have you seen?
1. laparoscopic prostatectomy 0 1 to 4 5 to 10 10 to 15 >15
2. laparoscopic nephrectomy 0 1 to 4 5 to 10 10 to 15 >15
3. laparoscopic cholecystectomy 0 1 to 4 5 to 10 10 to 15 >15
4. OGD/ERCP 0 1 to 4 5 to 10 10 to 15 >15
5. colonoscopy 0 1 to 4 5 to 10 10 to 15 >15
6. other laparoscopic
procedure_________________
0 1 to 4 5 to 10 10 to 15 >15
ERCP = endoscopic retrograde cholangiopancreatography; OGD = esophagogastroduodenoscopy.
CUAJ • February 2009 • Volume 3, Issue 1 29
Task-specific bench model training v. basic laparoscopic skills training
Appendix 2. Participant questionnaire*
Task-specific checklist
Item Not done or incorrect Done correctly
1 Needle loaded one-half to two-thirds from tip 0 1
2 Uses laparoscopic needle holder and graspers to handle needle 0 1
3 Needle enters tissues at right angles (80% of bites) 0 1
4 Single attempt at needle passage through tissues (90% of bites) 0 1
5 Follow through on curve of needle on entrance (80% of bites) 0 1
6 Follow through on curve of needle on exit (80% of bites) 0 1
7 Minimal damage with graspers 0 1
8 Equal spacing 0 1
9 Equal bites on each side (80% of bites) 0 1
10 Square knots 0 1
11 Apposition of tissues without excessive tension on suture 0 1
12 Appropriate alignment of tissues (no torsion) 0 1
Maximum total score
Total score
*Adapted from task-specific checklist used in the Objective Structured Assessment of Technical Skills (OSATS). (Reznick R, Regehr G, MacRae H, et al. Testing technical skill
via an Innovative “Bench Station” Examination. Am J Surg 1997;173:226-30.
CUAJ • February 2009 • Volume 3, Issue 1
30
Sabbagh et al.
Appendix 3. Global rating scale
Candidate identification no.
Please rate the candidate's performance on the following scale:
1 2 3 4 5 Respect for tissue
Frequently used unnecessary force on
tissue or cased damage by inappropriate
use of instruments
Careful handling of tissue but occasionally
caused inadvertent damage
Consistently
handled tissues
appropriately with
minimal damage
1 2 3 4 5 Time and motion
Many unnecessary moves Efficient time/motion but some
unnecessary moves
Clear economy of
movement and
maximum
efficiency
1 2 3 4 5
Instrument
handling Repeatedly makes tentative or awkward
moves with instruments by inappropriate
use of instruments
Competent use of instruments but
occasionally appeared stiff or awkward
Fluid moves with
instruments and no
awkwardness
1 2 3 4 5
Knowledge of
instruments Frequently asked for wrong instrument or
used inappropriate instrument
Knew names of most instruments and used
appropriate instruments
Obviously familiar
with the
instruments and
their names
1 2 3 4 5 Flow of operation
Frequently stopped operating and seemed
unsure of the next move
Demonstrated some forward planning with
reasonable progression of procedure
Obviously planned
course of operation
with effortless flow
from one move to
the next
1 2 3 4 5 Use of assistants
Consistently placed assistants poorly or
failed to use assistants
Appropriate use of assistants most of the
time
Strategically used
assistants to the
best advantage at
all times
1 2 3 4 5
Knowledge of
specific procedure Deficient knowledge. Needed specific
instruction at most steps
Knew all important steps of operation Demonstrated
familiarity with all
aspects of
operation
Would you feel confident in allowing this trainee to perform this procedure in the operating room?
Yes
No
- CitationsCitations9
- ReferencesReferences20
- This includes using both task-specific performance goals and a training setup resembling where the practiced skills is going to be used [23] . This is consistent with two randomised trials' findings that using a model with higher functional resemblance may yield a better end result and increase transferability [7,24,25]. The same observation has been made in sports; for example , different types of throws exist in badminton and there may be a high degree of specificity when learning a specific skill or type of movement [21,26,27].
[Show abstract] [Hide abstract] ABSTRACT: The use of structured curricula for minimally invasive surgery training is becoming increasingly popular. However, many laparoscopic training programs still use basic skills and isolated task training, despite increasing evidence to support the use of training models with higher functional resemblance, such as whole procedural modules. In contrast to basic skills training, procedural training involves several cognitive skills such as elements of planning, movement integration, and how to avoid adverse events. The objective of this trial is to investigate the specificity of procedural practice in laparoscopic simulator training. A randomised single-centre educational superiority trial. Participants are 96 surgical novices (medical students) without prior laparoscopic experience. Participants start by practicing a series of basic skills tasks to a predefined proficiency level on a virtual reality laparoscopy simulator. Upon reaching proficiency, the participants are randomised to either the intervention group, which practices two procedures (an appendectomy followed by a salpingectomy) or to the control group, practicing only one procedure (a salpingectomy) on the simulator. 1:1 central randomisation is used and participants are stratified by sex and time to complete the basic skills. Data collection is done at a surgical skills centre. The primary outcome is the number of repetitions required to reach a predefined proficiency level on the salpingectomy module. The secondary outcome is the total training time to proficiency. The improvement in motor skills and effect on cognitive load are also explored. The results of this trial might provide new knowledge on how the technical part of surgical training curricula should be comprised in the future. To examine the specificity of practice in procedural simulator training is of great importance in order to develop more comprehensive surgical curricula. Trial registration ClinicalTrials.gov: NCT02069951- [Show abstract] [Hide abstract] ABSTRACT: We determined the status of Canadian training during senior residency in laparoscopic, robotic and endourologic surgery. Fifty-six residents in their final year of urology residency training were surveyed in person in 2007 or 2008. All residents completed the survey. Most residents (85.7%) train at centres performing more than 50 laparoscopic procedures yearly and almost all (96.4%) believe laparoscopic radical nephrectomy is the gold standard. About 82% of residents participated in a laparoscopic partial nephrectomy in 2008, compared to 64.7% in 2007. Of the respondents, 66% have participated in a laparoscopic prostatectomy and 54% believe the procedure has promising potential. Exposure and training in robotic-assisted laparoscopic procedures seem to be increasing as 35.7% of 2008 residents have access to a surgical robot and 7% consider themselves trained in robotic-assisted procedures. Most residents (71.4%) train at centres that perform percutaneous ablation. However, 65% state the procedure is performed solely by radiologists. Percutaneous nephrolithotomy is widely performed (98.2%), but only 37.5% of residents report training in obtaining primary percutaneous renal access. Despite only 12.5% of residents ranking their laparoscopic experience as below average or poor, an increasing proportion of graduating residents are pursuing fellowships in minimally-invasive urology. Laparoscopic nephrectomy is commonly performed and is considered the standard of care by Canadian urology residents. Robotic-assisted surgery is becoming more common but will require continued evaluation by educators who will ultimately define its role in the urological residency training curriculum. Minimally-invasive surgical fellowships remain popular, as Canadian residents do not feel adequately trained in certain advanced procedures. Urologists must strive to learn and adapt to new technologies or risk losing them to other specialties.
- [Show abstract] [Hide abstract] ABSTRACT: Any discussion of the future of medicine should include a discussion of prostate cancer surgery, which is presently one of the most rapidly evolving and technologically advanced areas of medicine. Prostate cancer is the most common cancer in men for which the surgical treatment is radical prostatectomy (RP). RP affords a high chance of cure for localized prostate cancer and has a demonstrated survival benefit. RP has been around for more than a century and has undergone a dramatic evolution culminating in modern techniques that allow for excellent oncologic control and quality of life. A variety of surgical approaches exist for RP including open, laparoscopic, and laparoscopic with robotic assistance. Outcomes, cost, learning curves and usage trends for these approaches are discussed. Conservative options that may precede surgery are also discussed.
- [Show abstract] [Hide abstract] ABSTRACT: Learning laparoscopic urethrovesical anastomosis is a crucial step in laparoscopic radical prostatectomy. Previously we noted that practice on a low fidelity urethrovesical model was more effective for trainees than basic suturing drills on a foam pad when learning laparoscopic urethrovesical anastomosis skills. We evaluated learner transfer of skills, specifically whether skills learned on the urethrovesical model would transfer to a high fidelity, live animal model. A total of 28 senior residents, fellows and staff surgeons in urology, general surgery and gynecology were randomized to 2 hours of laparoscopic urethrovesical anastomosis training on a urethrovesical model (group 1) or to basic laparoscopic suturing and knot tying on foam pads (group 2). All participants then performed timed laparoscopic urethrovesical anastomosis on anesthetized female pigs. A blinded urologist scored subject videotaped performance using checklist, global rating scale and end product rating scores. Group 1 was significantly more adept than group 2 at the laparoscopic urethrovesical anastomosis pig task when measured by the checklist, global rating scale and end product rating (each p <0.05). Time to completion was similar in the 2 groups. No statistically significant difference was noted in global rating scale and checklist scores for laparoscopic urethrovesical anastomosis performed on the urethrovesical model vs the pig. Training on a urethrovesical model is superior to training with basic laparoscopic suturing on a foam pad for performing laparoscopic urethrovesical anastomosis skills on an anesthetized female pig. Skills learned on a urethrovesical model transfer to a high fidelity, live animal model.
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