Objective Measurement of Impact of Bench Laparoscopic Training in Novices

Prashanth Annayyanapalya Thimmegowda1, Krish Lakshman2, Rajashekara Reddy1, Sachin Nale1, Ravishankar1

1. Department of General Surgery, Sagar Hospital, Jayanagar, Bangalore, Karnataka, India
2. Department of General Surgery, Shanthi Hospital and Research Centre (SHRC), Jayanagar, Bangalore, Karnataka, India               

Correspondence to: Dr. Prashanth Annayyanapalya Thimmegowda; email: at.prashanth@gmail.com

Received: 19th September 2020 ; Revised: 13th April 2021 ; Accepted: 15th April 2021 ; Available online: 23rd April 2021 

Abstract

Background: We are currently in the era of laparoscopic surgery. It has gained popularity in the last few decades because of its well-known advantages. Laparoscopy requires different skills from those of open surgery. In a paradigm shift, learning basic surgical skills is now performed more in the skills laboratory than in the operation theater. However, there is a lack of reliable training and assessment tools for laparoscopic surgical skills. This study aimed to objectively assess the effect of bench laparoscopic training in novices. Methods: This prospective study was conducted at the Clinical Skills Centre of Bangalore Medical College and Research Institute (BMCRI) in Bangalore, India. Sixty interns with no previous experience in laparoscopy were included. They underwent supervised training on the box trainer for 3 days, 2 hours a day, in basic surgical tasks, including pointing dots, joining straight lines, joining curved lines, picking objects, peg transfer, and circle cut. All participants were assessed objectively in a virtual reality (VR) simulator before and after training. The objective outcomes measured were time taken, distance traveled, and error scores given by the VR simulator metrics. Results: The novices showed statistically significant improvement in all the tasks after the training compared with their skill levels before the training. Conclusion: Structured short-term training significantly improves basic laparoscopic surgery skills.

Keywords: Bench laparoscopic training; Box trainer; Virtual reality simulator; Novices training; Endo training


Ann Afr Surg. 2021 ; 18(3): 170-175
DOI : http://dx.doi.org/10.4314/aas.v18i3.8
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 

Introduction

Laparoscopic surgery has gained popularity in the last few decades and has been steadily replacing open standard techniques in several procedures because of its advantages such as minimal surgical trauma, early post-operative recovery, shorter hospital stays, and better cosmesis (1-3). Learning laparoscopic surgical skills require a different set of skills due to diminished tactile feedback, need for hand-to-eye coordination, the fulcrum effect caused by trocars and long instruments, and accommodation for lack of depth perception with 2D vision (4).
Acquiring basic surgical skills outside the operation theater (OT) is ideal (5) because valuable OT time is not wasted and concerns for patient safety are avoided. The old dictum “see one, do one, teach one” does not apply anymore. Simulation modules play a very important role in mastering these skills, thereby flattening the learning curve. Different simulation models are currently available, such as box trainer, virtual reality (VR) simulator, augmented reality (AR) simulator, animal models, and cadaver models. Among them, only VR and AR simulators provide objective metrics and real-time feedback to trainees (6).
Box trainers are relatively cheap and have realistic haptic feedback, which VR simulators lack. Compared with VR simulators, box trainers have the advantage of using standard laparoscopic instruments. The biggest advantage of a VR simulator is that it provides objective metrics, which helps train students better. However, in evaluating laparoscopic surgical skills, both the box trainer and VR simulator correlate positively with each other (7). In this prospective trial, we investigated the impact of bench laparoscopic training on basic laparoscopic surgical skills using the box trainer, and objective assessment of the said training was carried out in a VR simulator


Methods

This prospective study was conducted at a clinical skills center in Bangalore, India, from January to March 2018.The study protocol was approved by the hospital ethics committee. Informed consent was obtained from all individual participants included in the study.
We included 60 interns from Bangalore Medical College and Research Institute (BMCRI) with no experience in laparoscopic surgeries. The novices were assessed on a VR simulator before they started their training on the box trainer. The VR trainer is an indigenously designed and built trainer (BIGSOLV Laparo simulator; Sri Dutt Technologies, Bangalore, India) that has been validated to measure basic laparoscopic skills (8).
The interns underwent supervised training on the box trainer for 3 days, 2hours each day. The training included standardized basic surgical tasks, including pointing dots, joining straight lines, joining curved lines, picking objects, peg transfer, and circle cut. The tasks were of progressive complexity. The participants standardized skills were assessed in a VR simulator immediately after the training. The primary outcomes of interest were time taken to complete the tasks, total path length, and error scores. These data were objectively given by the VR trainer used in the study.
Pre-training assessment in the VR simulator 
Figure 1 shows the images of the various tasks as seen in the VR simulator.

 

Click to view Figure 1


In task 1, pointing dots, trainees had to move the tool sequentially from 1 to 10. In task 2, joining straight lines, the tool had to be moved sequentially from 1 to 10 along the straight path provided. In task 3, joining curved lines, the tool had to be moved along the curved path provided. For tasks 1, 2, and 3, a needle tool was used, and these tasks were mainly aimed at improving the hand-to-eye coordination. The points have to be traversed in an incremental manner starting from 1 and ending at 10. Any effort to follow a non-incremental approach was counted as an error.
Task 4, picking objects, the trainee was supposed to pick up the cube using the tool and transfer it into the bowl. While transferring the cube, care was to be taken to see that the cube was not dropped outside the bowl. Picking up the cube with the tool and releasing it elsewhere apart from the bowl was counted as an error.
Task 5, peg transfer, consisted of a torus and a peg, and the trainee was asked to pick up the torus using the tool and transfer it over the peg. While transferring the peg, care was to be taken to see that the torus will not touch the peg, and doing so resulted in an error. Picking up the torus with the tool and releasing it elsewhere apart from the peg was counted as an error.
For tasks 4 and 5, a grasper tool was used, and these tasks were aimed at giving the user a higher degree of hand-to-eye coordination than that in tasks 1