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Langenbeck's Archives of Surgery

, Volume 403, Issue 2, pp 271–278 | Cite as

Conception of the Lübeck Toolbox curriculum for basic minimally invasive surgery skills

  • Tilman Laubert
  • Hamed Esnaashari
  • Paul Auerswald
  • Anna Höfer
  • Michael Thomaschewski
  • Hans-Peter Bruch
  • Tobias Keck
  • Claudia Benecke
ORIGINAL ARTICLE

Abstract

Purpose

Difficulties at the beginning of the learning curve in minimally invasive surgery (MIS) can well be overcome by simulation outside the operating room. Despite a great number of available devices, standardized, structured, and validated training curricula for video simulators are scarce.

Methods

The Lübeck Toolbox (LTB) video trainer provides six training modules and online video tutorials. Proficiency levels for the tasks were defined by performance analysis of MIS experts (n = 15). Mean values of the best performed repetitions were set as benchmarks for a validation study with n = 30 MIS novices and the learning curves calculated. The novices performed a cholecystectomy on a pig organ model before and after the curriculum which were analyzed using the GOALS score.

Results

Benchmarks defined by expert performance for the task Nos. 1 to 6 were 72 s (± 8) (Pack Your Luggage), 49 s (± 9) (Weaving), 66 s (± 10) (Chinese Jump Rope), 89 s (± 28) (Triangle Cut), 138 s (± 44) (Hammer Cut), and 98 (± 22) (Suturing). The median numbers of required repetitions by the novices to reach the proficiency level were n = 42 (7–80), n = 26 (9–55), n = 32 (14–77), n = 44 (15–59), n = 19 (6–68), and n = 26 (15–60). These values were all located at the beginning of the plateau phase of the learning curves. GOALS score improved significantly after completion of the curriculum (18.0 (± 2.6) vs. 10.9 (± 1.6), p < 0.0001).

Conclusion

The LTB curriculum constitutes a new highly standardized and proficiency level-based training program for basic skills in MIS. Transferability of the task content to a (sub)-realistic environment could be demonstrated. Still, future trials will have to further validate the effectiveness of the LTB curriculum.

Keywords

Laparoscopy Training Simulation Lübeck Toolbox Education Minimally invasive surgery 

Notes

Acknowledgements

We thank Freya Zielke for her tedious and reliable work throughout the study.

Authors’ contributions

Study conception and design: TL, HE, AH, H-PB; acquisition of data: HE, PA, AH, MT; analysis and interpretation of data: TL, PA, AH, TK; drafting of the manuscript: TL, CB; critical revision of the manuscript: all authors

Compliance with ethical standards

Conflict of interest

Tilman Laubert and Hamed Esnaashari are co-founders of LTB Ltd.

Paul Auerswald, Anna Höfer, Hans-Peter Bruch, Tobias Keck, and Claudia Benecke declare that they have no conflicts of interest or financial ties to disclose.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in this study.

References

  1. 1.
    Buckley CE, Kavanagh DO, Traynor O, Neary PC (2014) Is the skillset obtained in surgical simulation transferable to the operating theatre? Am J Surg 207(1):146–157.  https://doi.org/10.1016/j.amjsurg.2013.06.017 CrossRefPubMedGoogle Scholar
  2. 2.
    Zendejas B, Brydges R, Hamstra SJ, Cook DA (2013) State of the evidence on simulation-based training for laparoscopic surgery: a systematic review. Ann Surg 257(4):586–593.  https://doi.org/10.1097/SLA.0b013e318288c40b CrossRefPubMedGoogle Scholar
  3. 3.
    Seymour NE, Gallagher AG, Roman SA, O'Brien MK, Bansal VK, Andersen DK, Satava RM (2002) Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 236(4):458–463; discussion 463-454.  https://doi.org/10.1097/01.SLA.0000028969.51489.B4 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Fraser SA, Klassen DR, Feldman LS, Ghitulescu GA, Stanbridge D, Fried GM (2003) Evaluating laparoscopic skills: setting the pass/fail score for the MISTELS system. Surg Endosc 17(6):964–967.  https://doi.org/10.1007/s00464-002-8828-4 CrossRefPubMedGoogle Scholar
  5. 5.
    Ritter EM, Scott DJ (2007) Design of a proficiency-based skills training curriculum for the fundamentals of laparoscopic surgery. Surg Innov 14(2):107–112.  https://doi.org/10.1177/1553350607302329 CrossRefPubMedGoogle Scholar
  6. 6.
    Zendejas B, Ruparel RK, Cook DA (2016) Validity evidence for the Fundamentals of Laparoscopic Surgery (FLS) program as an assessment tool: a systematic review. Surg Endosc 30(2):512–520.  https://doi.org/10.1007/s00464-015-4233-7 CrossRefPubMedGoogle Scholar
  7. 7.
    Nousiainen M, Brydges R, Backstein D, Dubrowski A (2008) Comparison of expert instruction and computer-based video training in teaching fundamental surgical skills to medical students. Surgery 143(4):539–544.  https://doi.org/10.1016/j.surg.2007.10.022 CrossRefPubMedGoogle Scholar
  8. 8.
    Pape-Koehler C, Immenroth M, Sauerland S, Lefering R, Lindlohr C, Toaspern J, Heiss M (2013) Multimedia-based training on internet platforms improves surgical performance: a randomized controlled trial. Surg Endosc 27(5):1737–1747.  https://doi.org/10.1007/s00464-012-2672-y CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Laubert T EH, Höfer A, Renner L, Roblick UJ, Strik M, Bruch HP (2013) Entwicklung eines standardisierten Trainings curriculums für die minimalinvasive Chirurgie–Projekt Lübecker Toolbox Deutsche Gesellschaft für Chirurgie. www.egms.de/en/meetings/dgch2013/13dgch839.shtml
  10. 10.
    Vassiliou MC, Feldman LS, Andrew CG, Bergman S, Leffondre K, Stanbridge D, Fried GM (2005) A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg 190(1):107–113.  https://doi.org/10.1016/j.amjsurg.2005.04.004 CrossRefPubMedGoogle Scholar
  11. 11.
    Bilgic E, Watanabe Y, Nepomnayshy D, Gardner A, Fitzgibbons S, Ghaderi I, Alseidi A, Stefanidis D, Paige J, Seymour N, KM MK, Birkett R, Whitledge J, Kane E, Anton NE, Vassiliou MC, Simulation Committee of the Association for Surgical E (2017) Multicenter proficiency benchmarks for advanced laparoscopic suturing tasks. Am J Surg 213(2):217–221.  https://doi.org/10.1016/j.amjsurg.2016.07.033 CrossRefPubMedGoogle Scholar
  12. 12.
    Vanderbilt AA, Grover AC, Pastis NJ, Feldman M, Granados DD, Murithi LK, Mainous AG, 3rd (2014) Randomized controlled trials: a systematic review of laparoscopic surgery and simulation-based training. Glob J Health Sci 7 (2):310–327. doi: https://doi.org/10.5539/gjhs.v7n2p310
  13. 13.
    van Dongen KW, van der Wal WA, Rinkes IH, Schijven MP, Broeders IA (2008) Virtual reality training for endoscopic surgery: voluntary or obligatory? Surg Endosc 22(3):664–667.  https://doi.org/10.1007/s00464-007-9456-9 CrossRefPubMedGoogle Scholar
  14. 14.
    Lee TD, Genovese ED (1988) Distribution of practice in motor skill acquisition: learning and performance effects reconsidered. Res Q Exerc Sport 59(4):277–287.  https://doi.org/10.1080/02701367.1988.10609373 CrossRefGoogle Scholar
  15. 15.
    Mackay S, Morgan P, Datta V, Chang A, Darzi A (2002) Practice distribution in procedural skills training: a randomized controlled trial. Surg Endosc 16(6):957–961.  https://doi.org/10.1007/s00464-001-9132-4 CrossRefPubMedGoogle Scholar
  16. 16.
    Verdaasdonk EG, Stassen LP, van Wijk RP, Dankelman J (2007) The influence of different training schedules on the learning of psychomotor skills for endoscopic surgery. Surg Endosc 21(2):214–219.  https://doi.org/10.1007/s00464-005-0852-8 CrossRefPubMedGoogle Scholar
  17. 17.
    Scott DJ, Pugh CM, Ritter EM, Jacobs LM, Pellegrini CA, Sachdeva AK (2011) New directions in simulation-based surgical education and training: validation and transfer of surgical skills, use of nonsurgeons as faculty, use of simulation to screen and select surgery residents, and long-term follow-up of learners. Surgery 149(6):735–744.  https://doi.org/10.1016/j.surg.2010.11.010 CrossRefPubMedGoogle Scholar
  18. 18.
    Madan AK, Harper JL, Taddeucci RJ, Tichansky DS (2008) Goal-directed laparoscopic training leads to better laparoscopic skill acquisition. Surgery 144(2):345–350.  https://doi.org/10.1016/j.surg.2008.03.016 CrossRefPubMedGoogle Scholar
  19. 19.
    Stefanidis D, Acker CE, Greene FL (2010) Performance goals on simulators boost resident motivation and skills laboratory attendance. J Surg Educ 67(2):66–70.  https://doi.org/10.1016/j.jsurg.2010.02.002 CrossRefPubMedGoogle Scholar
  20. 20.
    Feldman LS, Cao J, Andalib A, Fraser S, Fried GM (2009) A method to characterize the learning curve for performance of a fundamental laparoscopic simulator task: defining “learning plateau” and “learning rate”. Surgery 146(2):381–386.  https://doi.org/10.1016/j.surg.2009.02.021 CrossRefPubMedGoogle Scholar
  21. 21.
    Barsom EZ, Graafland M, Schijven MP (2016) Systematic review on the effectiveness of augmented reality applications in medical training. Surg Endosc 30(10):4174–4183.  https://doi.org/10.1007/s00464-016-4800-6 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Laubert TTM, Auerswald P, Zimmermann M, Brüheim L, Keck T, Benecke C (2017) Implementation of a laparoscopic simulation training in undergraduate medical education—the Lübeck Toolbox-Curriculum. Zentralbl Chir 142:1–7Google Scholar
  23. 23.
    Van Sickle KR, Gallagher AG, Smith CD (2007) The effect of escalating feedback on the acquisition of psychomotor skills for laparoscopy. Surg Endosc 21(2):220–224.  https://doi.org/10.1007/s00464-005-0847-5 CrossRefPubMedGoogle Scholar
  24. 24.
    Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC (2011) Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure. Postgrad Med J 87(1030):524–528.  https://doi.org/10.1136/pgmj.2010.109363 CrossRefPubMedGoogle Scholar
  25. 25.
    Kowalewski KF, Hendrie JD, Schmidt MW, Proctor T, Paus S, Garrow CR, Kenngott HG, Müller-Stick BP, Nickel F (2017) Validation of the mobile serious game application Touch Surgery™ for cognitive training and assessment of laparoscopic cholecystectomy. Surg Endosc 31(10):4058–4066.  https://doi.org/10.1007/s00464-017-5452-x CrossRefPubMedGoogle Scholar
  26. 26.
    Nickel F, Brzoska JA, Gondan M, Rangnick HM, Chu J, Kenngott HG, Linke GR, Kadmon M, Fischer L, Müller-Stich BP (2015) Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices. Medicine (Baltimore) 94(20):e763.  https://doi.org/10.1097/MD.0000000000000764
  27. 27.
    Stefanidis D, Korndorffer JR, Jr., Heniford BT, Scott DJ (2007) Limited feedback and video tutorials optimize learning and resource utilization during laparoscopic simulator training. Surgery 142 (2):202–206. doi: https://doi.org/10.1016/j.surg.2007.03.009
  28. 28.
    Nickel F, Kowalewski KF, Rehberger F, Hendrie JD, Mayer BR, Kenngott HG, Bintintan V, Linke GR, Fischer L, Müller-Stich BP (2017) Face validity of the pulsatile organ perfusion trainer for laparoscopic cholecystectomy. Surg Endosc 31(2):714–722.  https://doi.org/10.1007/s00464-016-5025-4 CrossRefPubMedGoogle Scholar
  29. 29.
    Nickel F, Jede F, Minassian A, Gondan M, Hendrie JD, Gehring T, Linke GR, Kadmon M, Fischer L, Müller-Stick BP (2014) One or two trainees per workplace in a structured multimodality training curriculum for laparoscopic surgery? Study protocol for a randomized controlled trial-DRKS00004675. Trials 15(1):137.  https://doi.org/10.1186/1745-6215-15-137 CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM (2010) Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial. Am J Surg 199(1):115–120.  https://doi.org/10.1016/j.amjsurg.2009.07.035 CrossRefPubMedGoogle Scholar
  31. 31.
    Nickel F, Hendrie JD, Stock C, Salama M, Preukschass AA, Senft JD, Kowalewski KF, Wagner M, Kenngott HG, Linke GR, Rischer L, Müller-Stick BP (2016) Direct observation versus endoscopic video recording-based rating with the objective structured assessment of technical skills for training of laparoscopic cholecystectomy. Eur Surg Res 57(1–2):1–9.  https://doi.org/10.1159/000444449 CrossRefPubMedGoogle Scholar
  32. 32.
    Probst P, Knebel P, Grummich K, Tenckhoff S, Ulrich A, Büchler MW, Diener MK (2016) Industry bias in randomized controlled trials in general and abdominal surgery: an empirical study. Ann Surg 264(1):87–92.  https://doi.org/10.1097/SLA.0000000000001372 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Tilman Laubert
    • 1
  • Hamed Esnaashari
    • 1
  • Paul Auerswald
    • 1
  • Anna Höfer
    • 1
  • Michael Thomaschewski
    • 1
  • Hans-Peter Bruch
    • 1
  • Tobias Keck
    • 1
  • Claudia Benecke
    • 1
  1. 1.Department of SurgeryUniversity Medical Center Schleswig-Holstein Campus LübeckLübeckGermany

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