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Bellows et al. Laparoscopic training for surgical residents

The on-site “standard” conventional trainer (Karl Storz independent training period. After training completion,
Endoscopy, Culver City, CA) used in this study included all participants underwent repeated evaluation (post-
a 15 inch video monitor (Sony Corporation, New York, test) on the same initial two laparoscopic tasks using
NY), Xenon-nova light source, Telecam SL camera the on-site “standard” video-trainer.
system, Hopkins II laparoscope and a Plexiglas box
trainer. Tasks were carried out using a 0° Strorz 10-mm Questionnaire
laparoscope connected to a light source and with the Each participant completed a questionnaire on the
images directed to the Sony television monitor. educational experience, at the completion of the study
investigating the perceived benefit of the training
Training and testing protocol method. One set of issues concerned the opportunity
After an orientation and viewing a introductory video for practice during the study period while another
on the “Fundamentals of Laparoscopic Surgery” (FLS) concerned the usefulness of the home training device
peg board transfer and intra-corporal suturing and in term of the learning of surgical skills. Participants
knot tying tasks, all trainees completed a baseline in the home group were asked to evaluate using
[15]
assessment (pre-test) on these tasks using the on- 10-point Likert scale (1-10) their satisfaction regarding
site “standard” video-trainer. The peg transfer and an the home training with higher numbers being more
FLS-type video-trainer laparoscopic suturing model positive responses.
were used to assess their baseline skills. Performance
scores were calculated and recorded for each peg Statistics
transfer attempt using time (s) and for each laparoscopic Data are expressed as means ± standard error of the
suturing and knot tying attempt using the previously mean. Comparisons of the pre-training and the post-
published formula: 600 – [time (s) + 10* accuracy training continuous variables for each domain within
error + 10* security error]. If there was failure to groups were performed using a Wilcoxon matched
[16]
complete the later task (i.e. tie a functional knot) pairs test. Comparisons of continuous variables
within the time limit (10 min), the task was terminated between groups were conducted by using an un-
and the participant was given a score of 0. Baseline paired two-tailed t-test. Categorical variables were
performance was defined as the mean score of the compared using Fisher’s exact or chi square test.
first three repetitions at the beginning of training (in Computer software (GraphPad Instat software, San
the absence live, proctored instruction). Subjects were Diego CA) was used for all statistical analyses. A P
then ranked according to the sum of the overall scores value of less than 0.05 was considered significant.
for the three attempts, stratified into blocks of two and
randomized into two groups. On-site group received RESULTS
unlimited 24-h access to the on-site skills laboratory
for independent practice. Home group received a self- Study population
contained, portable laparoscopic - minimally invasive Seventeen subjects were enrolled, but one subject
training system box (Joystick SimScope™; 3D Med, (medical student) dropped out secondary medical
Franklin, Ohio). reasons during the training period, and this individual
was not included in the final study analysis. Therefore,
Both groups were then allowed to self-direct their the subsequent analysis was per protocol. The mean
training for a three months period of time. During this age of the study population was 31.0 ± 1.5 years (range
independent training period, both groups were given 24-47 years). Nine subjects were female (52.9%) and
access and allowed unlimited viewing of the didactic 15 were right-hand dominant (88.2%). There were no
tutorials on the two tasks. The peg transfer model, an significant differences in age, gender, or self-reported
FLS-type video-trainer laparoscopic suturing model, laparoscopic experience, between groups. Moreover,
and 6-inch pre-cut 3-0 silk sutures were provided to trainee baseline simulator performances for the two
each participant. All participants were given previously groups were equal (P > 0.05).
established task specific proficiency levels for the peg
transfer (48 s) and the laparoscopic suturing model Training period
[17]
(score 512) at the start of the training period to guide As a group, only 56 % (n = 9/16) of the participants
[16]
practice. To further foster goal-directed learning, all actually practiced the laparoscopic tasks during the
participants were encouraged to train as long as they training period (n = 4 in on-site group, n = 5 in home
needed in their spare time until they reached the pre- group). Of the participants that practiced (50% of
defined proficiency criterion. Both groups were given medical students, 40% of PGY-1, and 33% of PGY-
a journal to record number of practice days, and 2 residents) only one subject (on-site group; medical
time spent practicing on each task over the 3-month student) practiced on a regular basis with a total
128 Mini-invasive Surgery ¦ Volume 1 ¦ September 30