Development and validation of a comprehensive program of education and assessment of the basic Fundamentals of Laparoscopic Surgery

Article (PDF Available)inSurgery 135(1):21-7 · February 2004with84 Reads
DOI: 10.1016/S0039-6060(03)00156-9 · Source: PubMed
This study explores the volume-outcome relationship for gastric bypass surgery for obesity to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated fewer adverse outcomes. The Pennsylvania state discharge database was used to identify 4685 cases of gastric bypass surgery for obesity between 1999 and 2001. Statistical modeling analyses were used to determine whether mortality or adverse outcome rate was significantly related to hospital and surgeon volume; the data were controlled for risk factors such as age, gender, comorbidities, and others. There were 28 deaths (0.6%) and 813 adverse outcomes (17.4%). There was a significant risk-adjusted relationship between surgeon volume and adverse outcome, and the same trend was observed for deaths. Surgeons who performed fewer than 10 procedures per year had a 28% risk of adverse outcome and a 5% risk of death, compared with 14% (P<.05) and 0.3% (P=.06), respectively, for high-volume surgeons. Hospital volume did not reach significance, but there was a striking interaction between surgeon and hospital volume; surgeons who performed 10 to 50 cases per year operating in low-volume hospitals had a 55% risk of adverse outcome (P<.01). Risk-adjusted in-hospital adverse outcome is significantly lower when gastric bypass is performed by higher-volume surgeons.


Development and validation of
a comprehensive program of education
and assessment of the basic fundamentals
of laparoscopic surgery
Nathaniel J. Soper, MD, Lelan F. Sillin, MD, Bruce Schirmer, MD, Kaaren Hoffman, PhD,
and the SAGES FLS Committee, Los Angeles, Calif
From The Society of American Gastrointestinal Endoscopic Surgeons, Los Angeles, Calif
IN THE LATE 1990STHE Society of American
Gastrointestinal Endoscopic Surgery (SAGES)
formed a committee (Fundamentals of Laparo-
scopic Surgery or FLS) and charged it to develop
educational materials covering the basic funda-
mentals of laparoscopic surgery. Four major
principles guided the committee’s developmental
process. First, comprehensive coverage of the
domain of basic laparoscopy was seen as involving
two components: one cognitive (declarative knowl-
edge); and the other psychomotor (procedural
skill). Second, the focus of the program was to be
on the educational material considered unique to
laparoscopy and not on material normally encoun-
tered during open surgical training. Third, in
accordance with the idea of basic fundamentals,
any content specific to a particular anatomic
location or to a specific laparoscopic procedure
was to be avoided. And fourth, the program was to
contain mechanisms for assessment as well as for
didactic instruction.
The overall goal of the FLS program was to
‘teach a standard set of cognitive and psychomotor
skills to practitioners of laparoscopic surgery’ in
the belief that knowledge and application of these
fundamentals would help ‘ensure a minimal stan-
dard of care for all patients undergoing laparo-
scopic surgery.’’ The didactic learning modules are
CD-ROM based and teach the underlying physiol-
ogy, fundamental concepts, and component man-
ual skills involved in laparoscopic surgery. The
assessment instruments were designed to be in
accord with the competency movement and the
American Board of Medical Specialties recommen-
dation for maintenance of practice and practice-
based learning and improvement,
and to that end
they were rigorously developed.
It was not SAGES intent to develop a certifying
examination but rather to provide tools for the
teaching and assessment of the cognitive knowl-
edge, technical skills, and clinical judgment related
specifically to basic laparoscopic surgery. These
tools could then be used in any number of ways as
determined by the intent and purpose of the
organization desiring to use them. The assessment
tools consist of both a paper-and-pencil examina-
tion (cognitive in orientation) and a hands-on,
performance-based, technical skills examination.
The processes involved in designing both these
measurement tools relied heavily of the Test
Standards prepared by the Joint Committee on
Standards of the American Educational Research
Association, The American Psychological Associa-
tion, and The National Council on Measurement in
Throughout the development process, the FLS
committee and other subject matter experts con-
tinually reviewed the learning modules for ap-
propriateness. Several studies were performed to
ensure the effectiveness of the manual skills model,
based on the McGill Inanimate Systems for Training
and Evaluation of Laparoscopic Skills (MISTELS)
system. An initial pilot test of the assessment and
learning materials was conducted in the spring of
2000, and several modifications were undertaken.
Accepted for publication April 6, 2003.
Reprint requests: Jeffrey H. Peters, MD, Professor of Surgery,
1510 San Pablo St, Los Angeles, CA 90033.
Surgery 2004;135:21-7.
0039-6060/$ - see front matter
Ó 2004 Elsevier Inc. All rights reserved.
Most recently a beta or field-testing of the didactic
and manual skills assessment tools was undertaken
in eight specially designated testing centers across
the United States and Canada. Each center tested
from 10-15 randomly selected participants from the
defined geographic area. Participants were strati-
fied across defined levels of training and experi-
ence. Pertinent data from the previous studies and
the beta-test investigation are presented in the
discussion of the FLS program that follows.
The overall educational component was de-
veloped as two CD-ROM based study guides. The
first CD contains a multimedia didactic presenta-
tion of cognitive material organized into 10 content
Each chapter includes printable textual review,
references, practice questions, and a practice clin-
ical scenario. The intent is to provide verbal and
visual instruction and interactive patient scenarios.
The 10 chapters cover 13 major content areas
(Table I). The content outline was formulated
collaboratively by the FLS committee and consists
of the basic principles, procedures, and man-
agement considerations deemed important when
undertaking any laparoscopic operation. The com-
mittee defined the 13 major content categories and
identified 66 subject areas/concepts that fell within
these categories.
The content outline also served as a framework
for the development of the cognitive assessment.
To validate that the didactic outline and test
blueprint effectively covered the domain of basic
laparoscopy, samples of practicing laparoscopic
surgeons attending the 2001 SAGES Annual
Meeting were asked to rate the importance of the
66 content areas. Participants were asked: ‘In order
to provide quality patient care, how essential is it for
the laparoscopic surgeon to have knowledge and/
or clinical judgment in the listed content area?’
Ratings were made on a scale of 1 to 5, where 1 was
‘essential for laparoscopic surgery,’ 3 was ‘desir-
able but not essential,’ and 5 was ‘not applicable to
laparoscopic surgery.’ The relative importance of
content areas was determined both by examining
average content area ratings and by having the
participants directly assign percentage weights to
the 13 major content areas. Finally, participants
were asked to add any content areas or concepts
they felt were essential but were not included in the
One hundred and seventeen surveys were
evaluated, involving 77% from SAGES members
and 21% from non-SAGES fellows and practicing
surgeons attending the conference. Seventy-two
of respondents practiced basic, intermediate, and
advanced laparoscopic surgery; the remaining
(28%) were involved in either basic or intermediate
laparoscopy or both, but not advanced. In general,
rating variations between respondents with differ-
ing backgrounds were more those of degree rather
than kind. Data were analyzed both by separate
groups and as a whole. No significant differences
that would influence conclusions were found. The
vast majority of content areas were judged as
essential with most receiving ratings less than 2.0.
Nine content areas were judged as more ‘desir-
able’ than ‘essential’ (ie, their rating was greater
than 2.0). These areas were reviewed and revised by
the FLS committee as appropriate. In addition,
participants listed some 14 areas as being not
present but appropriate for the examination. The
examination committee reviewed these areas and
either integrated them into the blueprint or
eliminated them based on their appropriateness
to the examination’s definition and purpose (ie,
their uniqueness to laparoscopic surgery and their
basic, procedure-free nature).
1. Tools 6. Abdominal access
2. Energy sources 7. Abdominal examination
3. Patient considerations 8. Lap suturing
4. Anesthesia and
9. Biopsy and hemostasis
5. Pneumoperitoneum
10. Exiting and postop
Table I. Content areas for basic laparoscopic
1. Equipment: tools of the trade
2. Energy sources: electrosurgery, ultrasound, and laser
3. Patient considerations: patient selection,
contraindications, preparation
4. Anesthesia: types, complications
5. Patient positioning
6. Establishment and physiology of pneumoperito-
neum: gas biologic characteristics, pressure and flow
7. Abdominal access and trocar placement: techniques,
8. Tissue handling, exposure, and examination of
abdomen and pelvis
9. Biopsy techniques
10. Hemorrhage and hemostasis
11. Tissue approximation: indications, techniques
12. Exiting the abdomen: drains, site closures
13. Postoperative care
January 2004
22 Peters et al
Weights for each of the major categories were
obtained both by averaging the ratings in a given
category and by direct estimates of weights by
the respondents. For both methods of obtaining
relative weights, the differences among the
categories were minor. Data indicated all areas
seemed equally important with slightly less weight
falling to anesthesia, biopsy techniques, and site
closures. The final test blueprint outlines the major
content areas and the weights applied among them
(Table II).
Cognitive item/question development. The cogni-
tive assessment was designed to be computer-based
and highly visual, and to test the understanding and
application of the basic fundamentals of laparoscopy
placing as much emphasis as possible on clinical
judgment or intraoperative decision making. Two
question formats were used: single multiple choice,
and a newer format called scenarios involving sets
of multiple choice questions integrated within the
context of a case scenario. Guidelines for item writing
were developed for both formats, and emphasis was
placed on writing questions that required examinees
to problem solve and apply or use (rather than simply
recall) their knowledge of the fundamentals of
laparoscopic surgery. The scenario-type question
format, in particular, was designed to capture the type
of sequential decision making or judgment found
in the operating room. As an aid for creating
scenarios, a generic surgical case was broken down
into 4 sections that summarized the order of events
during a laparoscopic procedure. The guidelines for
writing scenarios then listed the types of essential steps,
considerations, or decisions ordinarily made within
each of the sections. Each of these decision points was
seen as a potential question within a case scenario
format. These problems are based on a visually docu-
mented case history to create a simulated, ‘real-life’
Three such scenarios (involving 45 questions
in all) were pilot tested using 86 residents and
practitioners. Several scoring systems were
employed. Based on data from the pilot test, the
questions within a scenario were modified to
a multiple choice format in which the examinee
selects the one best (or two best, etc.) alternatives.
The current format is a cross between ‘context-
dependent’ questions and ‘patient management
problems.’ A scenario-type format begins with the
presentation of a brief case vignette followed by 3
to 7 questions. The computerized administration
requires test takers to answer a question before
the next question is presented. Examinees cannot
return to previous questions but are able to access
previously given information. Dependency among
questions within a scenario is often reduced by
informing the examinee which of the possible
alternative decisions or actions were actually un-
dertaken on previous questions.
Question review and preliminar y standard
setting. After development, questions were re-
viewed by small groups of laparoscopic surgeons.
To avoid bias, these review groups were selected to
be geographically diverse and to represent a variety
of practice patterns: academic; private practice
urban; or rural. Seven review sessions were held
over the course of a year. In addition to answering
the questions, participants were asked to designate
the subject area of each question, rate its relevance
to the area of laparoscopic surgery, and ascertain
if the question required problem solving or the
application of basic knowledge of laparoscopic
surgery. Data from such judgments provided an
independent review of the clarity and relevance/
importance of each proposed question to the field
of laparoscopic surgery and verified that the
questions fulfilled the objectives of the blueprint
for the examination.
Preliminary standard setting judgments were
also collected during the review process. Partici-
pants were introduced to the concept of a ‘just
qualified candidate’ and engaged in a discussion of
its definition. Using a modified Angoff method,
participants estimated the likelihood that the just
qualified candidates would answer each question
correctly. Participants had the opportunity to
practice this methodology and engage in a group
Table II. Fundamentals of laparoscopic surgery;
subject area weights
Subject area Weight (%)
Equipment: tools of the trade 11
Energy sources; electrosurgery, ultrasound,
and laser
Patient considerations: patient selection,
contraindications, and preparation
Anesthesia: types and complications 4
Patient postioning 7
Establishment and physiology of the
Abdominal access and trocar placement 11
Tissue handling, exposure and examination
of the abdomen and pelvis
Biopsy techniques 5
Hemorrhage and hemostasis 7
Tissue approximation: indication and
Exiting the abdomen: drains, site closure 4
Postoperative care 4
Volume 135, Number 1
Peters et al 23
discussion on a series of questions that had statis-
tical data derived from previous pilot testing.
The data from each review session were summa-
rized and integrated with the participants’ sug-
gested question modifications from the review
sessions. Poorly performing questions were in-
spected and either eliminated or revised in accord-
ance with the data and participants’ suggestions.
The revised questions were then re-reviewed at
a later session. In all, the subject-specific experts
reviewed approximately 203 multiple choice
questions and 138 scenario-type questions, some
of these being revised questions from earlier ses-
sions. In general, a question was considered ap-
propriate for beta testing if at least 60% of the
reviewers answered it correctly, at least 70% agreed
it was highly relevant to laparoscopic surgery, and at
least 70% felt it required clinical problem solving
rather than simple recall of information.
Psychometric properties (metrics). Questions
that passed the review process were finalized and
entered into the computer system for field testing.
To accommodate limited testing time, questions
ready for beta testing were assigned to two separate
assessments—Test A and B. A common set of 21
questions with an ‘‘equating’’ section that included
both multiple-choice and scenario formats was
embedded into both Test A and B. The field testing
process involved 8 testing centers in the United
States and Canada, so that the appropriateness of
both question content and the administration
mode could be investigated. Between October
and December 2002, each center randomly se-
lected 10-15 participants from lists of residents and
practicing laparoscopic surgeons in the defined
geographic area. Demographic and biographic
data were gathered on all participants and used to
investigate the relationships between the examina-
tion scores and variables of interest to establish the
construct validity of the examination scores.
Data from field testing showed that skilled
laparoscopic surgeons performed similarly on the
questions assigned to each test with an expected
average score of 81%. The average relevancy rating
was 2.5 (on a scale of l = low to 3 = high) for
questions in Test A and 2.6 for those in Test B.
Questions in both tests were judged as requiring
problem solving rather than simple recall (an
average of 73% for Test A and 77% for Test B).
Finally, the projected score for a ‘minimally quali-
fied’ laparoscopic surgeon (obtained from the
preliminary standard setting judgments) was esti-
mated to be 67% for Test A and 68% for Test B.
Validity anal yses. Data from the field testing
verified that the questions in the tests were relevant
to the domain of laparoscopic surgery and appro-
priate to the purpose of the test and the test
blueprint. Although this is a necessary aspect of any
assessment, it is not sufficient evidence for judging
overall validity. Evidence is needed to verify that the
decisions and inferences made from the assessment
are reasonable and valid in terms of their conse-
quences. In other words, does the assessment really
measure what you want it to measure (ie, knowl-
edge of the fundamentals of laparoscopic surgery
that has an influence on competence in this area)?
Such ‘construct’ evidence is often indirect and
must be gathered over time from a variety of
analyses. The beta testing process was designed to
provide some of this evidence.
Demographic and biographic data were gath-
ered on all beta testing participants and, along with
the performance data, were used to investigate the
following 4 construct validity questions:
1. Are there expected differences in performance
score between groups of participants with
varying training levels or credentials?
2. Are the assessment components related to
external data such as supervisory ratings, expe-
rience variables, or self-estimates of ability in an
expected manner?
3. Are the test scores free from any geographic or
administrative location bias?
4. Are the assessment components (multiple
choice, scenarios, and performance-based
scores) related in an expected or theoretically
sound manner?
As expected, preliminary results from the beta
testing showed significant differences in cognitive
performance for participants with different levels
of training, specifically among second-year resi-
dents, fifth-year residents, and a combined group
of fellows and practicing surgeons who are SAGES
members. These differences were noted for both
Test A and B and for the overlapping sections.
Significant differences in performance were also
noted for different experience levels as determined
by a self-report of number of various laparoscopic
procedures performed. The correlation between
the two variables was around 0.81 in the beta testing
sample. From a validity standpoint, one would
hope that performance/differences in training
level would be less than those noted for laparo-
scopic experience levels, as differences in training
could be due to a progressive increase in general
surgical knowledge rather than an increase in the
specific knowledge of laparoscopic surgery. To
examine this point, differences in laparoscopic
experience was controlled statistically (ie, entered
January 2004
24 Peters et al
as a covariate), and another analysis of cognitive
performance across training levels was performed.
When experience level was controlled, the dif-
ferences in cognitive performance across training
levels were no longer statistically significant. The
reverse situation, which is controlling for training
level and then examining differences among
experience levels, still showed statistically signifi-
cant differences. These findings help ensure that
the cognitive assessment is sensitive to changes in
laparoscopic knowledge and not just to increases in
general surgical knowledge.
Further evidence that the cognitive assessment is
measuring laparoscopic knowledge was sought by
examining the relationship between assessment
scores and self-ratings of competence. Self-ratings
of competence in performing basic and advanced
laparoscopic procedures independently and in
performing general laparoscopic technical skills
were all significantly correlated with performance
on the cognitive assessment (.62, .63, and .56,
respectively). Participants who rated themselves
above the median in competence scored signifi-
cantly higher on the cognitive assessment.
Finally, the components of the assessments
relate to each other in an appropriate manner.
Within the cognitive assessment, the multiple-
choice questions are correlated with the scenario
questions, but not so much that the two formats can
be seen as duplicative (r = ;.60).
As noted previously, the FLS committee felt that
a component that addresses the training and
evaluation of technical skill is essential to any
curriculum on the fundamentals of laparoscopic
surgery. Basic manual skills must be acquired for
a surgeon to be competent in laparoscopy. There
are several domains in which the skills required for
laparoscopy are quite distinct from those that must
be attained to perform open surgery,
differences in visual spatial perception and the use
of very long instruments constrained through
a fixed trocar in the abdominal wall. Using
a monocular optical system, a surgeon must be
able to develop new cues to enable depth percep-
tion, manipulate objects within the abdomen or
thorax, and use both hands in a complementary
manner to cut, dissect, control tubular structures,
and suture.
A series of human learning experiments on both
practicing surgeons and nonsurgeons was per-
formed in the early 1990s by Tendick et al.
studies demonstrated that 10% of practitioners had
an innate ability to perform complex maneuvers
endoscopically, 80% of practitioners had a slow, but
steady learning curve to gain mastery, and some
l0% of the population had a fundamental inability
to work in the 2-dimensional ‘‘video’’ environment.
The endoscopic abilities were not associated with
open surgical skill or experience—it was more
a factor of neuromotor and spacial/perception
functions. Although these skills can be learned,
learning is best achieved in an environment outside
the operating room.
Development of the FLS manual skills
exercises. The development process involved iden-
tifying a set of simulations that incorporated a large
number of the psychomotor skills required during
laparoscopic surgery. These exercises could then be
used for training as well as for assessment. After
a skill-oriented review of a series of videotapes of
laparoscopic operations, seven exercises represent-
ing common elements of laparoscopic procedures
were developed using a physical simulator.
A phy-
sical simulator was chosen over a computer-based or
virtual reality simulator because of the advantages of
being inexpensive, portable, and reproducible, and
because it included an optical system and instru-
mentation similar to those used in the operating
room (Fig 1). Previous studies
showed that 2 of
the exercises (clipping a tubular structure and
placing and securing a mesh over a defect) failed
to contribute any additional discriminatory value to
the training or assessment, and so for simplicity they
were eliminated from the FLS program. The 5 re-
maining exercises included peg transfer, pattern
cutting, ligating loop, suturing with an intracorpo-
real knot, and suturing with an extracorporeal knot.
An instructional CD in a ‘watch and do’ manner
demonstrates the 5 exercises being carried out in
a simple laparoscopy box. The exercises are non-
procedure-specific and designed to improve the
technical facility of a basic laparoscopic skill set.
Manual skills test metrics. Intrinsic to any
educational system is feedback. To provide useful
feedback to the trainee, each exercise was ac-
companied with metrics, which provided a score
for performing the exercise based on time and
accuracy. Thus, the trainee is rewarded by per-
forming an exercise efficiently and without error.
To ensure that the measurements attained were
objective and reproducible, the reliability of the
measuring system was tested by measuring inter-
rater reliability and test-retest reliability. All tasks
proved to be highly reliable with interclass corre-
lation coefficients of 0.99 and 0.89, respectively, for
the entire manual skills test.
Volume 135, Number 1
Peters et al 25
Test validity. The use of the exercises for
training or assessment requires evidence that they
are representative of the domain of manual skills in
basic laparoscopy. Experienced laparoscopic sur-
geons assembled a list of 14 skills commonly
required in basic laparoscopic procedures. Parti-
cipants in the beta testing (n = 44) were asked after
completing manual skills assessment to indicate
which of the listed skills was required for success-
fully completing each of the FLS exercises. The
majority of participants felt that 11 of the listed
skills were incorporated in 1 or more of the exer-
cises. Four of the skills were viewed as required by
all the exercises, and 3 of the skills seemed to be
only required by 1 of the exercises. Global ratings
on the exercises revealed that beta test respondents
felt they would be useful for training and that the
skills required were similar to those required by
actual laparoscopic surgery.
Whether the simulated exercises are used for
training or assessment, the measurements obtained
must be a valid reflection of performance in the
operating room. Because there is no gold standard
for technical performance in the operating room,
validity of the skills training had to be demon-
strated in other ways. Performance scores were
assessed of residents at different levels of training,
assuming that the scores would show progressive
improvement, which was indeed confirmed.
data showed that the variance in performance
scores is large early in the residency program, but at
the chief resident level, not only were their scores
higher, but they also showed less variance, pro-
viding further evidence for the validity of the
Preliminary data from the recent beta testing
confirm that performance on the manual skills
assessment increases significantly with training.
Second-year residents had greater variance than
did fifth-year residents or fellows, but the variance
of practicing surgeons in the beta test sample was
nearly as large as that of the second-year residents.
Beta test sample scores were also positively related
to self-reports of laparoscopic surgical experience
and to self-ratings of competence in technical skills
and in handling an advanced case. And similar to
the cognitive assessment, differences in training
level were no longer present once laparoscopic
experience was controlled.
Investigators from McGill University compared
novice surgeons (surgical residents in their first
2 years) with a ‘‘competent’ group (chief residents,
fellows, and practicing laparoscopic surgeons). A
highly significant difference in performance scores
was found for each of the tasks and the sum of the
Frequency distribution curves were devel-
oped for performance of these 2 groups. From
these data, receiver operator curves were gener-
ated, allowing determination of a cutoff score to
Fig 1. Laparoscopic skills simulator used for practice and
for testing.
Fig 2. Receiver operator curve; prevalence of a passing
score for competent versus non-competent surgeons on
MISTELS skills test. (Reprinted with permission from
Fraser SA, Klassen DR, Feldman LS, Ghitulescu GA,
Stanbridge D, Fried GM. Evaluating laparoscopic skills:
setting the pass-fail score for the MISTELS system. Surg
Endosc 2003;17:964-7. Copyright Springer-Verlag.)
January 2004
26 Peters et al
maximize the sensitivity and specificity of the FLS
skills test in separating competent from non-
competent surgeons (Fig 2).
Using a passing score
generated by this means, the test provided sensitiv-
ity, specificity, and positive and negative predictive
values all in excess of .80.
The final step in validation of the FLS skills
program was provided by showing a correlation
between performance scores in the FLS manual
skills component and in-training evaluations per-
formed at the end of clinical rotations, which
address technical skills performance. These data
also showed very good separation in FLS scores
between resident surgeons that were more highly
rated in their technical skill performance in the
operating room versus poorer performers.
that the same exercises could be used for both
training and assessment, it is important to establish
that practice on the exercises leads to an increase in
performance in the operating room as well as in the
simulated tasks.
In summary, the FLS program was developed
because of an identified need to educate surgeons
in the underlying principles and basic skills of
laparoscopic surgery and because of the growing
demand to document competency in surgical
practice. The program was designed by a committee
of experts who first defined relevant content and
then created an educational program. Examina-
tions of both cognitive and manual skill were
developed to assess learning, and metrics were used
to value technical efficiency and accuracy. The
inclusion of a testing component ensures that
competence in laparoscopy is both taught and
evaluated. The program was shown to be reliable
and valid by a rigorous metrics process and from
the results of recently completed multi-institutional
beta testing. Ideally, measurements attained in the
FLS program can be shown to be a valid reflection
of performance in the operating room. SAGES
hopes to further document the validity and impact
of FLS by collection of longitudinal data and
performance comparisons. We believe the process
used to develop this program can be followed in
other areas where new procedures or new technol-
ogies are introduced.
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3. Alarcom A, Berguer R. A comparison of operating room
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6. Derossis AM, Antoniuk M, Fried GM. Evaluation of
laparoscopic skills: a 2-year follow-up during residency
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Volume 135, Number 1
Peters et al 27
    • "The vulnerability to ergonomic risk is well confirmed in a literature stating that " performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery " [7]. In addition, it has been reported that MIS carries more complications than open surgery [8, 9]. Therefore, it is important to quantitatively measure ergonomic risks on performing surgeons, particularly muscle fatigue during MIS procedures. "
    [Show abstract] [Hide abstract] ABSTRACT: Due to its inherent complexity such as limited work volume and degree of freedom, minimally invasive surgery (MIS) is ergonomically challenging to surgeons compared to traditional open surgery. Specifically, MIS can expose performing surgeons to excessive ergonomic risks including muscle fatigue that may lead to critical errors in surgical procedures. Therefore, detecting the vulnerable muscles and time-to-fatigue during MIS is of great importance in order to prevent these errors. The main goal of this study is to propose and test a novel measure that can be efficiently used to detect muscle fatigue. In this study, surface electromyography was used to record muscle activations of five subjects while they performed fifteen various laparoscopic operations. The muscle activation data was then reconstructed using recurrence quantification analysis (RQA) to detect possible signs of muscle fatigue on eight muscle groups (bicep, triceps, deltoid, and trapezius). The results showed that RQA detects the fatigue sign on bilateral trapezius at 47.5 minutes (average) and bilateral deltoid at 57.5 minutes after the start of operations. No sign of fatigue was detected for bicep and triceps muscles of any subject. According to the results, the proposed novel measure can be efficiently used to detect muscle fatigue and eventually improve the quality of MIS procedures with reducing errors that may result from overlooked muscle fatigue.
    Full-text · Article · Jan 2016
    • "Fifty medical students without previous experience in laparoscopic surgery (novices) were randomly assigned to groups N2D (n = 25) and N3D (n = 25). Participating subjects were asked to perform five standardized tasks adopted from the Fundamentals of Laparoscopic Surgery (FLS) and European Training in Basic Laparoscopic Urological Skills (E-BLUS) curricula [17, 18]. A standardized instruction was given using a pre-recorded video manual that showed the five tasks. "
    [Show abstract] [Hide abstract] ABSTRACT: To compare task performances of novices and experts using advanced high-definition 3D versus 2D optical systems in a surgical simulator model. Fifty medical students (novices in laparoscopy) were randomly assigned to perform five standardized tasks adopted from the Fundamentals of Laparoscopic Surgery (FLS) curriculum in either a 2D or 3D laparoscopy simulator system. In addition, eight experts performed the same tasks. Task performances were evaluated using a validated scoring system of the SAGES/FLS program. Participants were asked to rate 16 items in a questionnaire. Overall task performance of novices was significantly better using stereoscopic visualization. Superiority of performances in 3D reached a level of significance for tasks peg transfer and precision cutting. No significant differences were noted in performances of experts when using either 2D or 3D. Overall performances of experts compared to novices were better in both 2D and 3D. Scorings in the questionnaires showed a tendency toward lower scores in the group of novices using 3D. Stereoscopic imaging significantly improves performance of laparoscopic phantom tasks of novices. The current study confirms earlier data based on a large number of participants and a standardized task and scoring system. Participants felt more confident and comfortable when using a 3D laparoscopic system. However, the question remains open whether these findings translate into faster and safer operations in a clinical setting.
    Article · Aug 2015
    • "The first mode performed was determined by the flip of a coin. The exercise consisted of cutting out a piece of gauze between two circles of 5 and 3.5 cm diameter [18]. Templates of the circles were printed with a rubber ink stamp on gauze. "
    [Show abstract] [Hide abstract] ABSTRACT: This study compares pain and tiredness experienced by a student and gynaecological surgeons of varying experience between straight sticks (SS) and single-incision laparoscopic surgery (SILS) in vitro. Data was collected prospectively with randomization of the mode sequence. Participants from two hospitals performed identical exercise of cutting circles using SS and SILS in vitro. Questionnaires (Borg CR10 scale scores) were completed at 0, 30 and 60 min, respectively. Wilcoxon’s signed ranked tests were performed on matched pairs of SS and SILS on the number of circles cut and the mistakes between 0-30 and 30-60 min, respectively. There were significant differences between the two groups at 30 min in arm discomfort, hand and finger discomfort, shoulder girdle tiredness, arm tiredness and most significantly in wrist discomfort with a matched median difference of 1.83, confidence interval (CI) 1.00 to 2.67 and P = 0.003. At 60 min, the significant differences between the two groups were in shoulder girdle pain, arm discomfort, hand and finger discomfort, neck tiredness, wrist tiredness, and hand and finger tiredness and the most significant was wrist discomfort with a matched median difference of 1.75, CI 0.50 to 3.25 and P = 0.011. SS causes less tiredness and discomfort in an in vitro setting than with SILS.
    Full-text · Article · Apr 2015
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