Showing papers by "Rajesh Aggarwal published in 2007"

Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery.

Abstract: Objective:The aim of this study was to compare learning curves for laparoscopic cholecystectomy (LC) after training on a proficiency based virtual reality (VR) curriculum with that of a traditionally trained group.Summary Background Data:Simulator-based training has been shown to improve technical p

An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room

Abstract: Recent publications of the rates of medical errors and adverse events within health care, and particularly during surgery, have drawn the spotlight toward the methods of credentialing surgeons to perform procedures independently.1–4 Training boards and certifying bodies are coming under increasing pressure to ensure individuals demonstrate the necessary skills to perform operations safely.5–9 This is not only important for patient safety but also underpins the development of a proficiency-based training curriculum. It is somewhat surprising then that there are no tools in widespread use that are feasible, valid, and reliable for assessment of technical surgical skill (Table 1).10 Current training outcomes are assessed by live evaluations of the trainee by the master surgeon, a process that is known to be biased and subjective.11 More objective data are available from morbidity and mortality data, although this is rarely a sole function of operative skill and thus does not truly reflect an individual's surgical competence.12 The majority of trainees also maintain a log of the procedures performed, but these are indicative merely of procedural performance rather than a measure of technical ability.13 TABLE 1. Qualities of the Ideal Surgical Assessment Tool Although a number of new tools have been developed to assess surgical technical performance, their use remains within the confines of surgical skills laboratories.10 These include virtual reality simulators and psychomotor training devices, which are designed primarily to assess performance during critical parts of a procedure, rather than a complete operation.14 The realism (or face validity) of such simulations is not perfect and the situations lack context, leading to a failure of operators to treat the models like real patients.15 The ideal device for objective assessment of real surgical procedures would be one that can automatically, instantly, and objectively provide feasible, valid, and reliable data regarding performance within the operating room.16 It is with this approach that our Department has developed the ROVIMAS motion tracking software, which enables surgical dexterity to be quantified and thus reported instantly by a computer program.17 Although automatic, objective, and instant, the data do not provide any information regarding the quality of the procedure performed. The system does, however, incorporate the ability to synchronously record video of the operative procedure, which can then be evaluated according to a valid and reliable rating scale. This can enable a definition of dexterity not only for whole procedures, but also for critical steps of a particular procedure. A preliminary publication has confirmed the feasibility of using the device within the operating room to assess laparoscopic skills.17 The primary aim of this study was to determine the validity and reliability of a new concept for technical skills assessment in the operating room, a combination of motion analysis and video assessment. Both approaches have been individually validated in the literature, although the introduction of a hybrid between the 2 modes of assessment has not been previously attempted.

Framework for Systematic Training and Assessment of Technical Skills

Abstract: K A s b he purpose of training programs for all medical specilities is to produce competent individuals who are able o meet the health-care needs of society. Recent editorils have commented on the crisis in medical education nd the requirement for defined competencies to assess erformance before new physicians begin independent edical practice. Effective since July 2002, the Acreditation Council for Graduate Medical Education ACGME) listed 6 categories of competence, defined as he ACGME Outcomes Project (Table 1). This article does not address the specific need for emonstration of proficiency in technical skills. This is ot an issue for the surgical specialities only but also for hysicians training in cardiology, anaesthesiology, gasrointestinal medicine, chest medicine, and intervenional radiology, together with allied health specialists. he introduction of new techniques and instruments to hese specialities requires training of not just residents, ut also of independent practitioners. This was clearly vident with the increased rate of complications associted with the introduction of laparoscopic cholecystecomy and has led to the development of training prorams at many centers around the globe. Although there is a transfer of skills to the trainee, urrent training programs have not been designed from background of scientific research to ensure the curriclum is valid, efficient, and competency based. The aim f a surgical residency program is to produce competent rofessionals, displaying the cognitive, technical, and ersonal skills required to meet the needs of society. ithin the context of surgical procedures, patients can xpect satisfactory outcomes in terms of cure, complicaion rates, and return to daily activities. Technical profi-

Skills acquisition for laparoscopic gastric bypass in the training laboratory: an innovative approach.

Abstract: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a technically demanding procedure, with a long learning curve.The aim of this study was threefold: to develop a task-based approach to training in LRYGBP, define a tool for objective technical skills assessments, and objectively determine the efficacy of this approach. Videos of expert and novice surgeons performing LRYGBP on patients and anesthetised porcine models were analyzed to define an appropriate task for skills assessment. Subsequently, a jejunojejunostomy model was developed using cadaveric porcine small bowel, placed into a video-box trainer. 27 surgeons of varying experience levels in advanced laparoscopic procedures performed the task. Assessments of technical skill were by hand motion analysis and video-based scoring. A further 16 surgeons inexperienced in LRYGBP attended a taskbased hands-on training course and performed the jejuno-jejunostomy task at start and end of the course. The jejuno-jejunostomy model differentiated between surgeons of varying experience levels for time taken (P<0.001), economy of movement (P=0.001) and video scores (P<0.001). Surgeons attending the training course made significant improvements in time taken (P=0.002) and economy of movement (P=0.006), although not for generic video scores (P=0.243) by the end of course. The structured, task-based approach for commencement of training in LRYGBP leads to objective improvements in the technical skills of inexperienced surgeons at the end of a short course. The next stage of the curriculum should be to achieve proficiency in the complete procedure on an anesthetised porcine model, prior to preceptorship on human cases.

Laparoscopic vertical banded gastroplasty. A multicenter prospective study of 200 procedures.

Abstract: The commonest surgical procedure for management of morbid obesity in Europe is laparoscopic adjustable gastric banding (LAGB), even though laparoscopic vertical banded gastroplasty (LVBG) is still considered to be a gold standard restrictive option in bariatric surgery. A multicenter prospective study was designed to to assess the efficacy of LVBG in terms of weight loss and complication rates for obese patients who have indications for a restrictive procedure. Two-hundred morbidly obese patients (84.5% female) with a mean age of 41 years and mean body mass index (BMI) of 43.2 kg/m2 underwent LVBG as described by MacLean. Five trocars were placed in standard positions as per laparoscopic upper gastrointestinal surgery. A vertical gastric pouch (30 ml) was created with circular (21 or 25mm) and endolinear stapling techniques, enabling definitive separation of the two parts of the stomach. The gastric outlet was calibrated with either a polypropylene mesh (5.5 cm in length and 1cm in width) or a nonadjustable silicone band. The median follow-up period was 30 months (range, 1–72 months). One case had to be converted to open surgery (gastric perforation) and there was one death secondary to peritonitis of unknown etiology. The morbidity rate was 24%, comprising the following complications: gastric outlet stenosis (8%); staple line leak (2.5%); food trapping (1.5%); peritonitis (1%); thrombophlebitis (1.5%); pulmonary embolism (0.5%); and gastroesophageal reflux (9%). The excess weight loss achieved was 56.7% (1 year), 68.3% (2 years), and 65.1% (3 years). Laparoscopic vertical banded gastroplasty is an effective procedure for the surgical management of morbid obesity, especially for patients who present hyperphagia but are unable to manage the constraints of adjustable gastric banding. Laparoscopic vertical banded gastroplasty is safe, as demonstrated by an acceptable complication rate, of which gastric outlet stenosis, staple line leakage, and gastroesophageal reflux predominate.

Motion tracking systems for assessment of surgical skill.

Abstract: We read with interest the recent paper by Van Sickle et al. [4] regarding construct validity of the video-based motion tracking system on the ProMIS laparoscopic simulator. Indeed, our department has also reported the validity of this device for objective assessment of psychomotor skill [3]. As stated, the ultimate goal is to objectively assess surgical skill in a realistic environment (i.e., the operating room). In this vein, we have been working with electromagnetic motion systems, both with the use of standard bench models in the skills laboratory and in the operating room [1, 2]. As stated, a fundamental drawback to the use of electromagnetic systems is their susceptibility to noise within a metallic environment. This is an unavoidable product of using such a system. However, the Imperial College Surgical Assessment Device (ICSAD) incorporates application-specific software, which with adequate preand postprocessing and validated filters can minimize the effect of anomalous readings. We thus refer Van Sickle et al. to numerous studies published in the literature that have proven the use of the ICSAD electromagnetic device for motion tracking in both controlled and operating room environments. We have also attempted to assess video-based tracking for the operating room with the use of premarked gloves, in a similar manner to the system used by the ProMIS simulator. However, the cameras suffered from line-of-sight disturbances that could only be rectified by the use of multiple cameras at strategically placed sites. Motion analysis involves the placement of thimble-sized sensors on the dorsum of the surgeons hands, making it a feasible and portable device for skills assessment. The device has been shown to be consistent, reliable, and eminently practicable for motion tracking analysis in the operating room [2]. The use of vision tracking for motion analysis in the operating room necessitates further work, although it has been shown to be ideal for tracking instruments in a closed box trainer.

Laparoscopic surgery and corticoadrenalomas

Abstract: Nowadays, laparoscopic adrenalectomy is the “gold standard” procedure for the treatment of benign lesions. However, the situation is not so clearcut when the issue is laparoscopic excision of malignant adrenal tumors. We present our results of laparoscopic adrenalectomy for treating malignant tumors over the past decade. Between October 1995 and June 2004, 131 consecutive laparoscopic adrenalectomies were performed on 120 patients (11 synchronous bilateral procedures). All patients underwent a standardized investigation protocol during their workup for surgery. There were only two conversions to laparotomy (1.6%). Complications that occurred during the procedure were limited to six patients (5%). Postoperative 30-days mortality was nil. Postoperative complications occurred in five patients (4.7%) during the first 30 days of recovery. The median hospital stay for all patients was 2.5 days (range = 2–10 days). Twelve patients (9%) had a malignant tumor: nine corticoadrenalomas, one pleomorphic sarcoma, one metastastic deposit from a previously excised colonic cancer, and one malignant pheochromocytoma. At mean followup of 34 months, mean survival time was 42.3 months for corticoadrenalomas that had undergone laparoscopy versus 29.7 months for those who had had a laparotomy. Five of the nine patients are alive and well at a mean of 37 months following surgery. One patient developed pulmonary metastases one year postsurgery; they were responsive to mitotane. Five years later, the same patient had a reoperation for an intra-abdominal retrogastric recurrence of her tumor and continues to do well. Another patient developed pulmonary metastases 22 months following adrenalectomy. Two patients died of metastatic intra-abdominal disease 20 and 7 months postsurgery. When laparoscopic surgery is to used for cancer treatment, caution is the rule to maintain the primary objective of securing a survival rate at least as high as that for open surgery, without increased risk of recurrence. Considering the results presented within this study, it seems that the laparoscopic removal of a corticoadrenaloma should not worsen the prognosis, provided the surgeon respects the primary rules of oncologic resectional surgery. Any surgical conditions that would preclude the strict application of these criteria are contraindications to a laparoscopic procedure.