Intracorporeal Suturing: Economy of Instrument Movements Using a Box Trainer Model

doi:10.1016/j.jmig.2011.04.003

Journal of Minimally Invasive Gynecology

Volume 18, Issue 4, July–August 2011, Pages 494-499

https://doi.org/10.1016/j.jmig.2011.04.003 Get rights and content

Abstract

Study Objective

To determine whether economy of instrument movement can differentiate between skills levels during intracorporeal suturing using a box trainer model.

Design

Prospective cohort study (Canadian Task Force classification II-2).

Setting

Skills laboratory of a university teaching hospital.

Subjects

Forty-two volunteers participated including 19 medical students without previous laparoscopic experience (novices), 12 residents in obstetrics and gynecology (intermediates), and 11 practitioners of intracorporeal suturing who had performed at least 200 laparoscopic procedures including advanced surgery (experts).

Interventions

Each participant performed 3 consecutive standardized intracorporeal sutures using a box trainer, and instrument movements were recorded using the TrEndo tracking device.

Measurements and Main Results

Time, path length, motion in depth, and motion smoothness of the instrument tips were recorded. Performance in the 3 groups differed significantly (p <.001 for all parameters; Kruskal-Wallis test). Experts outperformed novices in all 4 parameters (p <.01; Bonferroni test).

Conclusion

The construct validity has been suggested for time, path length, motion in depth, and motion smoothness for assessment of the laparoscopic suturing task using a box trainer. An expert level has been set for training and assessment purposes. The addition of economy of movement to time to complete the task has the potential to refine acquisition of skills.

Section snippets

Materials and Methods

Measurements were performed in the skills laboratory of Leiden University Medical Centre (LUMC, Leiden, the Netherlands).

Results

In total, 19 novices, 12 intermediates, and 11 expert laparoscopic surgeons participated in the study. All 19 novices who had responded to the advertisement denied previous surgical experience and completed the entire study protocol of 3 trials. Of the 22 residents who received an e-mail, 12 agreed to participate in the study: 4 in PGY 1, 2 in PGY 2, 3 in PGY 3, 2 in PGY 4, and 1 in PGY 5. All completed the entire study protocol. Of the 11 participating laparoscopic experts, 4 were consultants

Discussion

This study confirmed the hypothesis that the 4 motion-analysis parameters are able to discriminate between groups with different levels of experience during an intracorporeal suturing task using a physical box trainer. This indicates the construct validity of these objective assessment parameters for psychomotor skills for intracorporeal suturing.

Although experts outperformed intermediates during the first and second trials for all parameters, no significant difference was present during the

Conclusion

The construct validity of time and 3 parameters of economy of movement (path length, motion in depth, and motion smoothness) have been strongly suggested for the intracorporeal suturing task performed using a box trainer. An expert standard has been set. Economy-of-movement parameters should be added to the assessment package to form a framework of specified feedback and to enable continuous refinement of psychomotor skills during training, and can be used for assessment and for certification

Acknowledgment

We thank the students, residents, gynecologists, and surgeons who participated in the study.

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Cited by (29)

Comparing Simulator Metrics and Rater Assessment of Laparoscopic Suturing Skills
2023, Journal of Surgical Education
Citation Excerpt :
Therefore, most of the novices were experienced in handling laparoscopic instruments (median number of independently performed procedures = 60) compared to if we had chosen, e.g. medical students with no laparoscopic experience and no prerequisites for achieving a more advanced laparoscopic task such as suturing. In addition to the laparoscopic experience, all participants had the opportunity of a warm-up session of a maximum of 45 minutes, which also gave the novices the benefit of a higher performance level compared to a setup where a warm-up session was not accessible.13,29-31 We expected that the novices would benefit from a warm-up session, leading to a higher score of the novices and thus demanding a more robust and more sensitive assessment tool to show a significant difference between novices and experienced.
Laparoscopic intracorporeal suturing is important to master and competence should be ensured using an optimal method in a simulated environment before proceeding to real operations. The objectives of this study were to gather validity evidence for two tools for assessing laparoscopic intracorporeal knot tying and compare the rater-based assessment of laparoscopic intracorporeal suturing with the assessment based on simulator metrics.
Twenty-eight novices and 19 experienced surgeons performed four laparoscopic sutures on a Simball Box simulator twice. Two surgeons used the Intracorporeal Suturing Assessment Tool (ISAT) for blinded video rating.
Composite Simulator Score (CSS) had higher test-retest reliability than the ISAT. The correlation between the number performed procedures including suturing and ISAT score was 0.51, p<0.001, and 0.59 p<0.001 for CSS. We found an inter-rater reliability (0.72, p<0.001 for test 1 and 0.53 p<0.001 for test 2). The pass/fail rates for ISAT and CSS were similar.
CSS and ISAT provide similar results for assessing laparoscopic suturing but assess different aspects of performance. Using simulator metrics and raters’ assessments in combination should be considered for a more comprehensive evaluation of laparoscopic knot-tying competency.
Assessment of technical skills based on learning curve analyses in laparoscopic surgery training
2021, Surgery (United States)
Citation Excerpt :
Recently, much effort was devoted to the development of performance parameters that reflect efficient and safe tissue interaction. For example, force exertion parameters (eg, MaxForce) indicate if tissue damage occurs during manipulation, and instrument motion parameters, such as “Path length” and “Volume of motion,” indicate any risk of unintended interaction with tissue out of the camera’s scope.11–17 Despite the development and validation of tools for objective assessment of technical skills acquisition over the past decades, structural implementation and adoption into surgical curricula are still lacking.
Objective force- and motion-based assessment is currently lacking in laparoscopic skills curricula. This study aimed to evaluate the added value of parameter-based assessment and feedback during training.
Laparoscopy-naïve surgical residents that took part in a 3-week skills training curriculum were included. A box trainer equipped with the ForceSense system was used for assessment of tissue manipulation- (MaxForce) and instrument-handling skills (Path length and Time). Learning curves were established using linear regression tests. Pre- and post-course comparisons indicated the overall progression and were compared to predefined proficiency levels. A post-course survey was carried out to assess face validity.
In total, 4,268 trials, executed by 24 residents, were successfully assessed. Median (interquartile range) MaxForce outcomes improved from 2.7 Newton (interquartile range 1.9–3.8) to 1.8 Newton (interquartile range 1.2–2.4) between pre- and post-course assessment (P ≤ .009). Instrument Path length improved from 7,102.2 mm (interquartile range 5,255.2–9,025.9) to 3,545.3 mm (interquartile range 2,842.9–4,563.2) (P ≤.001). Time to execute the task improved from 159.8 seconds (interquartile range 119.8–219.0) to 60.7 seconds (interquartile range 46.0–79.5) (P ≤ .001). The learning curves revealed during what training phase the proficiency benchmarks were reached for each trainee. In the survey outcomes, trainees indicated that this curriculum should be part of a surgical residency program (mean visual analog scale score of 9.2 ± 0.9 standard deviation).
Force-, motion-, and time-parameters can be objectively measured during basic laparoscopic skills curricula and do indicate progression of skills over time. The ForceSense parameters enable curricula to be designed for specific proficiency-based training goals and offer the possibility for objective classification of the levels of expertise.
Performance assessment - The knowledge, skills and attitudes of surgical performance
2020, Seminars in Pediatric Surgery
Citation Excerpt :
These include: in-built systems (i.e., the Toronto laparoscopic surgery simulator with motion-tracking capability),52 systems within a simulator (i.e., Pro- MISTM),53,54 or separate devices enabling flexible use (i.e., Imperial College Surgical Assessment Device, ICSAD).49,55 Motion tracking sensors can be attached to surgical instruments, to trocars in laparoscopic surgery, to the hand or head of the surgeon,50,56,57 and can be used to assess performance both on a simulator as well as in the operative field. Motion tracking analysis has been shown to be an objective and valid tool for assessing surgical skills in terms of precision and economy of movement (path length and number of hand movements).11,48,58
Pediatric surgical education has traditionally focused on the hard cognitive and psychomotor (technical) skills. While more and more attention is being paid to softer skills such as communication, collaboration, leadership, health advocacy, professionalism and scholarship, the bulk of curricula remain focused on the hard skills. An intricate part of education is the assessment of performance. This article reviews the current literature on the assessment of cognitive and psychomotor skills, focusing particularly on the assessment of technical skills in the realm of simulation.
Novel application of the sewing machine principle; a new simplified intracorporeal suturing technique for pediatric inguinal hernia
2019, Journal of Pediatric Surgery
The desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES] and needlescopic surgery. Intracorporeal suturing and knot tying during SIPES remain challenging. The aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. It is an imitation of the principles of sewing machine.
The first author discussed the idea of the technique with the coauthors and a demonstration was done on a Silicon Pad before application of the technique on children with congenital inguinal hernia [CIH] for peritoneum closure after needlescopic disconnection of the hernia sac. The main outcome measures were feasibility of the technique, suturing and knotting time and recurrence rate.
The sutures were snugly applied to the ridges of Silicon Pad with good approximation and the knot was firmly tightened in all experiments. After applying and mastering the technique on a Silicon Pad, we shifted to use it on 373 children with 491 hernia defects. All operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. The time required for suturing of the peritoneum around internal inguinal ring [IIR] and knot tying, decreased considerably from 6 min 27 s in the first operation to less than 4 min after the fifth operation and stabilized at approximately 4 min 30 s. No major intraoperative complication. There was no recurrence during a mean follow-up period of 19.6 ± 1.2 months.
The closure of the peritoneum around the IIR using needles mimicking what is happening in sewing machine suturing is a feasible, safe and effective line of treatment of children with CIH. The cosmetic results are 42 outstanding without any recurrence.
Refinement in the analysis of motion within low-cost laparoscopic simulators of differing size: Implications on assessing technical skills
2018, Journal of Pediatric Surgery
Simulation is becoming more important in the teaching and assessment of technical skills. The purpose of this study was to refine the use of motion analysis parameters (MAPs) to assess performance of a defined task in low-cost pediatric laparoscopic simulators of differing size.
105 participants performed a defined intracorporeal suturing task in large and small pediatric laparoscopic simulators. Outcomes included MAPs — path length, extreme velocity events, and extreme acceleration events in all available degrees of freedom for novices, intermediates, and experts. ANOVA p < 0.05 was judged significant.
In the smaller simulator, all MAPs discriminated between expertise groups in all degrees of freedom. In the larger simulator, all but one MAP discriminated between expertise groups. Experts demonstrated the greatest variability in performance between the larger and smaller simulators.
Analysis of motion in the performance of a defined intracorporeal suturing task allowed discrimination between novices, intermediates, and experts in large and small low-cost pediatric laparoscopic simulators. Further refinement in MAPs will determine their role in surgical education.
Not applicable.
Intracorporeal knot tying in a box trainer: How proficient is in vitro evaluation in laparoscopic experts?
2014, Journal of Minimally Invasive Gynecology
Citation Excerpt :
First, during acquisition of the first competencies in (laparoscopic) surgical skills, monitoring of virtual reality or box trainer results provides useful information about the proficiency gaining curve and differentiates skillful novices from less competent residents. However, after reaching the nebulously termed and ill-defined expert level, surgeons tend to not show significant improvement over multiple attempts on a box trainer [13]. Second, we imply that, for experts, single-task observations in box trainers lack the complexity of actual advanced laparoscopic surgery and therefore fail to mimic results of these complex procedures.
To determine the applicability of motion analysis parameters of intracorporeal knot tying in box trainers in experts as predictors of surgical outcome.
Consecutive series of 1534 advanced laparoscopic hysterectomies (Canadian Task Force classification II-2).
Time, path length, and motion in depth of a standardized intracorporeal knot-tying task were compared with mean risk-adjusted primary clinical outcomes for each participant.
Although a large variety in proficient knot tying and surgical skills factors was observed; after correction for patient mix in 50 expert surgeons, motion analysis of intracorporeal knot tying could not significantly determine surgical outcome skills in advanced laparoscopic surgery.
Levels of proficiency in advanced laparoscopic surgery cannot be appropriately determined using motion analysis in box trainers. Therefore, box trainer assessments do not adequately differentiate proficient from suboptimal clinical performance.

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: The authors have no commercial, proprietary, or financial interest in the products or companies described in this article.

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Original ArticleIntracorporeal Suturing: Economy of Instrument Movements Using a Box Trainer Model

Abstract

Study Objective

Design

Setting

Subjects

Interventions

Measurements and Main Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Acknowledgment

J Am Coll Surg

Surgery

Sens Actuators A Physical

Am J Surg

Am J Surg

Randomized clinical trial of virtual reality simulation for laparoscopic skills training

Br J Surg

Virtual reality training improves operating room performance: results of a randomized, double-blinded study

Ann Surg

Skill acquisition and assessment for laparoscopic surgery

Arch Surg

Original Article
Intracorporeal Suturing: Economy of Instrument Movements Using a Box Trainer Model