LapTrain: multi-modality training curriculum for laparoscopic cholecystectomy—results of a randomized controlled trial

  • K. F. Kowalewski
  • C. R. Garrow
  • T. Proctor
  • A. A. Preukschas
  • M. Friedrich
  • P. C. Müller
  • H. G. Kenngott
  • L. Fischer
  • B. P. Müller-Stich
  • F. Nickel
Article
  • 6 Downloads

Abstract

Background

Multiple training modalities for laparoscopy have different advantages, but little research has been conducted on the benefit of a training program that includes multiple different training methods compared to one method only. This study aimed to evaluate benefits of a combined multi-modality training program for surgical residents.

Methods

Laparoscopic cholecystectomy (LC) was performed on a porcine liver as the pre-test. Randomization was stratified for experience to the multi-modality Training group (12 h of training on Virtual Reality (VR) and box trainer) or Control group (no training). The post-test consisted of a VR LC and porcine LC. Performance was rated with the Global Operative Assessment of Laparoscopic Skills (GOALS) score by blinded experts.

Results

Training (n = 33) and Control (n = 31) were similar in the pre-test (GOALS: 13.7 ± 3.4 vs. 14.7 ± 2.6; p = 0.198; operation time 57.0 ± 18.1 vs. 63.4 ± 17.5 min; p = 0.191). In the post-test porcine LC, Training had improved GOALS scores (+ 2.84 ± 2.85 points, p < 0.001), while Control did not (+ 0.55 ± 2.34 points, p = 0.154). Operation time in the post-test was shorter for Training vs. Control (40.0 ± 17.0 vs. 55.0 ± 22.2 min; p = 0.012). Junior residents improved GOALS scores to the level of senior residents (pre-test: 13.7 ± 2.7 vs. 18.3 ± 2.9; p = 0.010; post-test: 15.5 ± 3.4 vs. 18.8 ± 3.8; p = 0.120) but senior residents remained faster (50.1 ± 20.6 vs. 25.0 ± 1.9 min; p < 0.001). No differences were found between groups on the post-test VR trainer.

Conclusions

Structured multi-modality training is beneficial for novices to improve basics and overcome the initial learning curve in laparoscopy as well as to decrease operation time for LCs in different stages of experience. Future studies should evaluate multi-modality training in comparison with single modalities.

Trial registration: German Clinical Trials Register DRKS00011040

Keywords

Laparoscopy Training Education Laparoscopic cholecystectomy Curriculum GOALS 

Notes

Acknowledgements

The current study was supported by the Heidelberg Surgery Foundation. The full registered trial protocol can be accessed under http://www.drks.de (Registration No. DRKS00011040).

Author contributions

Study conception and design: Kowalewski, Nickel, Müller-Stich, Fischer. Acquisition of data: Friedrich, Garrow, Preukschas, Müller. Statistical analysis: Proctor, Kowalewski, Kenngott. Analysis and interpretation of data: Kowalewski, Proctor, Nickel, Preukschas, Garrow. Drafting of manuscript: Garrow, Kowalewski, Kenngott, Nickel, Friedrich. Critical revision: Müller-Stich, Nickel, Kenngott, Fischer, Müller.

Compliance with ethical standards

Disclosure

Felix Nickel reports receiving travel support for conference participation as well as equipment provided for laparoscopic surgery courses by KARL STORZ, Johnson & Johnson, and Medtronic. Karl-Friedrich Kowalewski, Carly R. Garrow, Tanja Proctor, Anas A. Preukschas, Mirco Friedrich, Philip Müller, Hannes Kenngott, Lars Fischer, and Beat Müller-Stich have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Gallagher AG et al (1999) Virtual reality training in laparoscopic surgery: a preliminary assessment of minimally invasive surgical trainer virtual reality (MIST VR). Endoscopy 31(4):310–313CrossRefPubMedGoogle Scholar
  2. 2.
    Madan AK et al (2003) Assessment of individual hand performance in box trainers compared to virtual reality trainers. Am Surg 69(12):1112–1114PubMedGoogle Scholar
  3. 3.
    Schijven J, Broeders, Tseng (2005) The Eindhoven laparoscopic cholecystectomy training course—improving operating room performance using virtual reality training: results from the first E.A.E.S accredited virtual reality trainings curriculum. Surg Endosc 19(9):1220–1226CrossRefPubMedGoogle Scholar
  4. 4.
    de Ruijter V et al (2015) The Business Engineering Surgical Technologies (BEST) teaching method: incubating talents for surgical innovation. Surg Endosc 29(1):48–54CrossRefPubMedGoogle Scholar
  5. 5.
    Fried GM (2008) FLS assessment of competency using simulated laparoscopic tasks. J Gastrointest Surg 12(2):210–212CrossRefPubMedGoogle Scholar
  6. 6.
    Saeger HD et al (2010) Course system of the Working Group for Gastro-intestinal Surgery Davos. Chirurg 81(1):25–30CrossRefPubMedGoogle Scholar
  7. 7.
    Lucas S, Tuncel A, Bensalah K, Zeltser I, Jenkins A, Pearle M, Cadeddu J (2008) Virtual reality training improves simulated laparoscopic surgery performance in laparoscopy naive medical students. J Endourol 22(5):1047–1051CrossRefPubMedGoogle Scholar
  8. 8.
    Chipman JG, Schmitz CC (2009) Using objective structured assessment of technical skills to evaluate a basic skills simulation curriculum for first-year surgical residents. J Am Coll Surg 209(3):364–370CrossRefPubMedGoogle Scholar
  9. 9.
    Arikatla VS, Sankaranarayanan G, Ahn W, Chellali A, De S, Caroline GL, Hwabejire J, DeMoya M, Schwaitzberg S, Jones DB (2013) Face and construct validation of a virtual peg transfer simulator. Surg Endosc 27(5):1721–1729CrossRefPubMedGoogle Scholar
  10. 10.
    Nickel F et al (2015) Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices. Medicine (Baltimore) 94(20):e764CrossRefGoogle Scholar
  11. 11.
    Nickel F, Kowalewski KF, Rehberger F, Hendrie JD, Mayer BF, Kenngott HG, Bintintan V, Linke GR, Fischer L, Müller-Stich BP (2016) Face validity of the pulsatile organ perfusion trainer for laparoscopic cholecystectomy. Surg Endosc. 31:714–722CrossRefPubMedGoogle Scholar
  12. 12.
    Szinicz B, Zerz, Bodner (1997) Role of the pulsatile organ perfusion surgical simulator in surgery education. Langenbecks Archiv Surg 114:687–693Google Scholar
  13. 13.
    Rossum V (1990) Schmidt’s Schema theory: the empirical base of the variability of practice hypothesis: a critical analysis. Huma Mov Sci9(3):387–435CrossRefGoogle Scholar
  14. 14.
    Schulz K, Altman D, Moher D (2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. J Pharmacol Pharmacother 1(2):100–107CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Altman DG, Simera I (2010) Responsible reporting of health research studies: transparent, complete, accurate and timely. J Antimicrob Chemother 65(1):1–3CrossRefPubMedGoogle Scholar
  16. 16.
    Vassilou MC, Feldman LS, Andrew CG, Bergman S, Leffondré K, Stanbridge D, Fried GM (2005) A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg 190(2005):107–113CrossRefGoogle Scholar
  17. 17.
    Gumbs AA, Hogle NJ, Fowler DL (2007) Evaluation of resident laparoscopic performance using global operative assessment of laparoscopic skills. J Am Coll Surg 204:308–313CrossRefPubMedGoogle Scholar
  18. 18.
    Kramp KH, van Det MJ, Hoff C, Lamme B, Veeger NJ, Pierie JP (2015) Validity and reliability of global operative assessment of laparoscopic skills (GOALS) in novice trainees performing a laparoscopic cholecystectomy. J Surg Educ 72(2):351–358CrossRefPubMedGoogle Scholar
  19. 19.
    Chang L, Hogle NJ, Moore BB, Graham MJ, Sinanan MN, Bailey R, Fowler DL (2007) Reliable assessment of laparoscopic performance in the operating room using videotape analysis. Surg Innov 14(2):122–126CrossRefPubMedGoogle Scholar
  20. 20.
    Gumbs AA, Hogle NJ, Fowler DL (2007) Evaluation of resident laparoscopic performance using global operative assessment of laparoscopic skills. J Am Coll Surg 204(2):308–313CrossRefPubMedGoogle Scholar
  21. 21.
    Friedrich M, Kowalewski K-F, Proctor T, Garrow C, Preukschas AA, Kenngott HG et al (2017) Study protocol for a randomized controlled trial on a multimodal training curriculum for laparoscopic cholecystectomy−LapTrain. Int J Surg Protoc 5:11–14Google Scholar
  22. 22.
    Stefanidis D et al (2010) Initial laparoscopic basic skills training shortens the learning curve of laparoscopic suturing and is cost-effective. J Am Coll Surg 210(4):436–440CrossRefPubMedGoogle Scholar
  23. 23.
    Aggarwal R et al (2006) Training junior operative residents in laparoscopic suturing skills is feasible and efficacious. Surgery 139(6):729–734CrossRefPubMedGoogle Scholar
  24. 24.
    Zendejas B et al (2013) State of the evidence on simulation-based training for laparoscopic surgery: a systematic review. Ann Surg 257(4):586–593CrossRefPubMedGoogle Scholar
  25. 25.
    Diesen DL et al (2011) Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices. J Surg Educ 68(4):282–289CrossRefPubMedGoogle Scholar
  26. 26.
    Munz Y et al (2007) Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: objective assessment of the transfer of skill from virtual reality to reality. Am J Surg 193(6):774–783CrossRefPubMedGoogle Scholar
  27. 27.
    Coleman RL, Muller CY (2002) Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial. Am J Obstet Gynecol 186(4):836–842CrossRefPubMedGoogle Scholar
  28. 28.
    Chandra V et al (2010) A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery 147(6):830–839CrossRefPubMedGoogle Scholar
  29. 29.
    Hassan I et al (2008) Simulation of endoscopic procedures—an innovation to improve laparoscopic technical skills. Tunis Med 86(5):419–426PubMedGoogle Scholar
  30. 30.
    Sanders R (1987) The Pareto principle: its use and abuse. J Serv Mark 1(2):37–40CrossRefGoogle Scholar
  31. 31.
    Pusic M, Pecaric M, Boutis K (2011) How much practice is enough? Using learning curves to assess the deliberate practice of radiograph interpretation. Acad Med 86(6):731–736CrossRefPubMedGoogle Scholar
  32. 32.
    Stolzenburg J-U et al (2007) Training in laparoscopy. EAU-EBU Update Series 5(2):53–62CrossRefGoogle Scholar
  33. 33.
    Pape-Koehler C et al (2013) Multimedia-based training on Internet platforms improves surgical performance: a randomized controlled trial. Surg Endosc 27(5):1737–1747CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Pape-Kohler C et al (2013) Learning success of students in surgery with a multimedia-based manual. A prospective randomized trial. Chirurg 84(10):875–880CrossRefPubMedGoogle Scholar
  35. 35.
    Nickel F et al (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 15:137CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Hsu K et al (2008) Experienced surgeons can do more than one thing at a time: effect of distraction on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surg Endosc 22(1):196–201CrossRefPubMedGoogle Scholar
  37. 37.
    Stefanidis D et al (2012) Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency-based training: a randomized controlled trial. Ann Surg 255(1):30–37CrossRefPubMedGoogle Scholar
  38. 38.
    Stefanidis D et al (2007) Redefining simulator proficiency using automaticity theory. Am J Surg 193(4):502–506CrossRefPubMedGoogle Scholar
  39. 39.
    van Velthoven RF, Hoffmann P (2006) Methods for laparoscopic training using animal models. Curr Urol Rep 7(2):114–119CrossRefPubMedGoogle Scholar
  40. 40.
    Maeda T et al (2010) Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision. Surg Endosc 24(11):2850–2854CrossRefPubMedGoogle Scholar
  41. 41.
    Nickel F, Kowalewski K, Müller-Stich B (2015) Risk awareness and training for prevention of complications in minimally invasive surgery. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 86(12):1121–1127Google Scholar
  42. 42.
    Smith CD et al (2001) Assessing laparoscopic manipulative skills. Am J Surg 181(6):547–550CrossRefPubMedGoogle Scholar
  43. 43.
    Grantcharov TP et al (2003) Learning curves and impact of previous operative experience on performance on a virtual reality simulator to test laparoscopic surgical skills. Am J Surg 185(2):146–149CrossRefPubMedGoogle Scholar
  44. 44.
    Chaudhry A et al (1999) Learning rate for laparoscopic surgical skills on MIST VR, a virtual reality simulator: quality of human-computer interface. Ann R Coll Surg Engl 81(4):281–286PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • K. F. Kowalewski
    • 1
  • C. R. Garrow
    • 1
  • T. Proctor
    • 2
  • A. A. Preukschas
    • 1
  • M. Friedrich
    • 1
  • P. C. Müller
    • 1
  • H. G. Kenngott
    • 1
  • L. Fischer
    • 1
  • B. P. Müller-Stich
    • 1
  • F. Nickel
    • 1
  1. 1.Department of General, Visceral, and Transplantation SurgeryUniversity of HeidelbergHeidelbergGermany
  2. 2.Institute of Medical Biometry and InformaticsUniversity of HeidelbergHeidelbergGermany

Personalised recommendations