Resident perceptions of advanced laparoscopic skills training
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- Palter, V.N., Orzech, N., Aggarwal, R. et al. Surg Endosc (2010) 24: 2830. doi:10.1007/s00464-010-1058-2
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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 χ2 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.
Laparoscopic intracorporeal suturing is one of the most difficult skills in minimally invasive surgery to master. At the same time, proficiency with intracorporeal suturing is of crucial importance as it not only allows for the performance of a wide range of complex operative scenarios, but also is an essential skill required for dealing with intraoperative complications. Learning and practicing laparoscopic intracorporeal suturing in the operating room is difficult for a wide variety of reasons. Indeed, residents frequently have insufficient exposure to advanced cases that require intracorporeal suturing . This is compounded by the current situation where both resident work hours and operating room time have substantially decreased. Therefore, there has been a recent push for trainees to learn this technique in a simulated environment.
Various models have been developed to simulate laparoscopic suturing. These include black box trainers, animal models, and virtual reality (VR) simulators. Studies have effectively demonstrated the efficacy of these models for teaching this advanced procedure [2–4]. Moreover, these skills have been shown to transfer to both the animate and human operating room [4–6]. In addition, Kanumuri et al.  demonstrated that training on either a VR simulator or a box trainer was equivalent for learning laparoscopic suturing. Despite the fact that evidence exists to support learning advanced laparoscopic skills in a simulated environment, recent work has shown that simulation centers are underutilized, with minimal voluntary use of the models outside the realm of research studies or a structured mandatory curriculum . When designing a curriculum for laparoscopic suturing, therefore, it is essential to explore not only what models will effectively teach the skills but also the perceptions of the residents utilizing the models.
Indeed, resident buy-in is essential in order to ensure optimal voluntary utilization of the accessible models in a surgical skills lab, as well as optimal participation within a structured curriculum. 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 our institution.
Materials and methods
This study utilized a cross-sectional survey design to solicit the opinions of senior general surgery trainees regarding the current methods of simulating laparoscopic suturing. A survey was created that consisted of 19 questions divided into three sections: demographics, laparoscopic experience to date, and opinions regarding the current methods of teaching laparoscopic suturing in a simulated environment (Appendix 1). The questions were structured as either single answer, multiple choice, or Likert Scale type. This survey was administered to 16 senior general surgery residents (PGY 3-5, median = PGY 4) participating in a workshop in advanced laparoscopy at the University of Toronto. The residents volunteered to participate in the workshop, and informed consent was obtained from all participants prior to data collection. Four training tools were utilized in the course curriculum. The Fundamentals of Laparoscopic Suturing (FLS) black box suturing model, a synthetic Nissen fundoplication model, a porcine jejuno-jejunostomy model, and a virtual reality suturing model (LapMentor). Study participants were able to practice laparoscopic suturing independently on all four models during the course of the curriculum. Each participant could individualize the amount of practice on each module, for a maximum of 1.5 h per model. Practice on each model was supervised by a member of the study team, who provided instructions on how to use the models as well as informal feedback. After having the opportunity to practice laparoscopic suturing on all four simulated models, the participants completed the survey anonymously.
Survey responses were coded and analyzed using SPSS v16.0 (SPSS, Inc., Chicago, IL, USA). Model rank was analyzed with one-way ANOVA, and χ2 analysis with Fisher’s exact test was used to analyze model effectiveness.
Rank of the laparoscopic suturing models
Laparoscopic suturing model
Mean rank score
Virtual reality simulator
The skill set required to perform laparoscopic surgery is significantly different from that required for open surgery. Effectively performing minimally invasive surgery requires adapting to altered depth perception, developing video–eye–hand coordination, and becoming accustomed to utilizing long instruments that diminish tactile feedback . As such, there has been an increasing trend for systematic training of both basic and advanced laparoscopic skills in a simulated environment .
This study effectively demonstrates that at our institution exposure to advanced minimally invasive procedures in the operating room is likely insufficient for residents to achieve proficiency with advanced techniques such as intracorporeal suturing. Indeed, while as a group the residents had experience either assisting in or performing basic cases such as laparoscopic cholecystectomy or appendectomy, they had very little experience with advanced procedures that require suturing, such as bariatric or foregut surgery. These results may be limited by several factors: First, participation in the course was voluntary, and the residents attending may have chosen to do so because they felt that their minimally invasive experience to be insufficient. Second, only two of the residents surveyed were PGY5, and perhaps the majority of the course attendees would gain more advanced minimally invasive training in their final year of residency. This lack of experience in advanced laparoscopy, however, is reflective of similar findings of studies that took place in both the United States and Canada [10–13]. This emphasizes the importance of residents learning and practicing advanced laparoscopic skills in the skills lab, before going into the operating room, in order to take maximum advantage of learning opportunities with real patients. The concerns expressed by the residents in the survey about the volume of experience and amount of practice that they are exposed to when learning advanced laparoscopic procedures are similarly reflected in the findings of Chaisson et al. . Although there have been significant developments in simulation techniques during the time period between these two studies, perhaps there has not been enough effort in implementing these techniques into a structured curriculum that is available to our surgical trainees. The efficacy of a short course in laparoscopic suturing was demonstrated by Aggarwal et al. . This group demonstrated that trainees at both junior and senior levels were able to learn intracorporeal suturing effectively, with objective improvements in dexterity and the quality of the procedure at the end of a 2-day period. This study emphasizes the fact that a certain baseline level of laparoscopic experience is not a prerequisite to learning a complex minimally invasive skill in a simulated environment.
One of the most common impediments to designing a surgical skills lab and curriculum is a lack of consensus on what equipment is appropriate . While evidence exists supporting the use of a variety of simulators to teach laparoscopic suturing, these models all possess a unique set of advantages and disadvantages. Animal models most closely approximate operating on a live patient and are the only models that can effectively simulate bleeding and complications; however, they are expensive are associated with infectious, moral, and ethical concerns . Video-box trainers are inexpensive, utilize real surgical instruments, and possess realistic haptics; however, they require an expert to be present for assessment and they are capable of simulating only specific skill sets rather than operations in their entirety . Finally, virtual reality simulators are very flexible, allowing for gradation of difficulty within a practice session, and they allow for the simulation of whole and partial operations. However, they are relatively expensive and although many possess devices to produce haptic feedback, the level of realism is still suboptimal . In this study, the approximate costs of the models used were as follows: $125,000 for the virtual reality simulator, $12,000 per animal model, $20.00 for the FLS model (although the black box itself costs $18,000), and $5.00 for the synthetic Nissen model. All prices are in US dollars. Although when designing a curriculum for advanced laparoscopic techniques such as suturing, taking into account these considerations with respect to the goals of the course is essential, it is also important to solicit the goals and opinions of the individuals who will be participating in this curriculum. This study demonstrates that as a group, senior general surgical residents prefer live animal or black box trainers compared to virtual reality simulators when learning an advanced laparoscopic maneuver. These findings are consistent with the work of Hamilton et al.  and Kanumuri et al. , both of whom found that residents tended to prefer black box trainers to virtual reality trainers. Moreover, Grober et al.  demonstrated that although trainees tend to prefer high-fidelity live animal models, training on a low-fidelity model conferred the same degree of benefit as training on a high-fidelity model. Considering the wide variation in the cost of the models to teach laparoscopic suturing and the fact that the residents’ preferred low-fidelity bench-top models as well as animal models, perhaps the most cost-effective way of teaching an advanced skill such as laparoscopic suturing is to teach the basics on a less expensive bench-top model and reserve the animal models for practicing advanced procedures.
The fact that surgical trainees seem the be less comfortable learning on virtual reality simulators could be reflective of the fact that residents in general have less exposure to these type of models. In 2006, only 46% of skills laboratories in the United States reported using VR trainers, whereas 99% had some form of video-trainer . With the high initial cost associated with the purchase of VR simulators, potential trainee resistance to engage in learning on these models is an important consideration when setting up a surgical skills curriculum. Indeed, results from this study suggest that it is necessary to educate residents and expose them early in their training to different simulated models in order to increase their familiarity and acceptance of various skills lab training systems.
Introduction of a new type of trainer to residents may face initial resistance and efforts should be made to take resident opinions into account when constructing a curriculum that will directly implicate them. Moreover, it is important to note that this survey simply solicited the opinions of more senior residents. Perhaps VR simulators are more useful for junior trainees who do not have a large amount of experience operating on live patients. Our study was not sufficiently powered to determine whether operative experience altered an individual’s perception of the utility of a specific simulator; however, it would be interesting to investigate whether experience to date dictates which simulator is preferred for practice.
In conclusion, this study demonstrates that operative experience among senior surgical residents in advanced laparoscopy is less than ideal. In addition, senior residents learning this skill in a simulated environment prefer animal or video-trainers as teaching models rather than virtual reality. Although more work needs to be done to investigate how specifically video-trainers and simulators should be utilized in a curriculum for advanced laparoscopy, it should be emphasized that resident perceptions regarding the utility of the simulation models are an important factor to take into consideration when designing a surgical skills curriculum for advanced endoscopy.
The authors gratefully acknowledge the time commitment given by the surgical residents involved in this study.
Dr. Vanessa Palter, Dr. Neil Orzech, Dr. Rajesh Aggarwal, Dr. Allan Okrainec, and Dr. Teodor Grantcharov all have no conflicts of interest or financial ties to disclose.