Showing papers by "Rajesh Aggarwal published in 2008"

Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery.

Abstract: Background: Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience. Methods: Randomized clinical trials addressing this issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, grey literature and reference lists. Standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis. Results: Twenty-three trials (mostly with a high risk of bias) involving 622 participants were included in this review. In trainees without surgical experience, VR training decreased the time taken to complete a task, increased accuracy and decreased errors compared with no training. In the same participants, VR training was more accurate than video trainer (VT) training. In participants with limited laparoscopic experience, VR training resulted in a greater reduction in operating time, error and unnecessary movements than standard laparoscopic training. In these participants, the composite performance score was better in the VR group than the VT group. Conclusion: VR training can supplement standard laparoscopic surgical training. It is at least as effective as video training in supplementing standard laparoscopic training.

Toward feasible, valid, and reliable video-based assessments of technical surgical skills in the operating room.

Abstract: Objective To determine the feasibility, validity, inter-rater, and intertest reliability of 4 previously published video-based rating scales, for technical skills assessment on a benchmark laparoscopic procedure. Summary background data Assessment of technical skills is crucial to the demonstration and maintenance of competent healthcare practitioners. Traditional assessment methods are prone to subjectivity through a lack of proven validity and reliability. Methods Nineteen surgeons (6 novice and 13 experienced) performed a median of 2 laparoscopic cholecystectomies each (range 1-5) on 53 patients within 2 Academic Surgical Departments. All patients had a diagnosis of biliary colic. Surgical technical skills were rated posthoc in a blinded manner by 2 experienced observers on 4 video-based rating scales. The different scales used had been developed to assess generic or procedure-specific technical skills in a global manner, or on a procedure-specific checklist. Results Six of 53 procedures were excluded on the basis of intraoperative difficulty. Of the remaining 47 procedures, 14 were performed by 6 novice surgeons and 33 by the 13 experienced surgeons. There were statistically significant differences between performance of the 2 groups on the generic global rating scale (median 24 vs. 27, P = 0.031), though not on procedural or checklist-based scales. All scales demonstrated inter-rater reliability (alpha = 0.58-0.76), though only the global rating scales exhibited intertest reliability (alpha = 0.72). Conclusions Video-based technical skills evaluation in the operating room is feasible, valid and reliable. Global rating scales hold promise for summative assessment, though further work is necessary to elucidate the value of procedural rating scales.

Validation of orthopaedic bench models for trauma surgery

Abstract: The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device. The video scores were significantly different for the three groups in all three procedures (p 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment. This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.

Laparoscopic skills suffer on the first shift of sequential night shifts: program directors beware and residents prepare.

Abstract: Objective: Research evaluating fatigue-induced skills decline has focused on acute sleep deprivation rather than the effects of circadian desynchronization associated with multiple shifts. As a result, the number of consecutive night shifts that residents can safely be on duty without detrimental effects to their technical skills remains unknown. A prospective observational cohort study was conducted to assess the impact of 7 successive night shifts on the technical surgical performance of junior residents. Methods: The interventional strategy included training 21 residents from surgery and allied disciplines on a virtual reality surgical simulator, towards the achievement of preset benchmark scores, followed by 294 technical skills assessments conducted over 1764 manpower night shift hours. Primary outcomes comprised serial technical skills assessments on 2 tasks of a virtual reality surgical simulator. Secondary outcomes included assessments of introspective fatigue, duration of sleep, and prospective recordings of activity (number of “calls” received, steps walked, and patients evaluated). Results: Maximal deterioration in performance was observed following the first night shift. Residents took significantly longer to complete the first (P = 0.002) and second tasks (P = 0.005) compared with baseline. They also committed significantly greater numbers of errors (P = 0.025) on the first task assessed. Improved performance was observed across subsequent shifts towards baseline levels. Conclusions: Newly acquired technical surgical skills deteriorate maximally after the first night shift, emphasizing the importance of adequate preparation for night rotas. Performance improvements across successive shifts may be due to ongoing learning or adaptation to chronic fatigue. Further research should focus on assessments of both technical procedural skills and cognitive abilities to determine the rotas that best minimize errors and maximize patient safety.

Short‐phase training on a virtual reality simulator improves technical performance in tele‐robotic surgery

Abstract: Background The da Vinci tele-robot necessitates the acquisition of new skills and surgical educators must develop standardized training programmes. It is possible that virtual reality (VR) computer simulation maybe used and it is necessary to define whether a simulator is an appropriate tool. Methods Ten surgical novices performed a series of five tasks, ten times on a commercially available VR robotic simulator. Two experts repeated the series of tasks twice in an attempt to validate the simulator. Results Each of the five tasks displayed statistically significant learning curves. Error scores did not improve significantly over successive repetitions except in one task. The experts completed two of the tasks in a significantly faster time. Conclusions Practice sessions on a VR simulator improve technical performance. The simulator enables surgeons to mount the early part of the learning curve within a laboratory environment, which may lead to a more effective training programme. Copyright © 2008 John Wiley & Sons, Ltd.

Could variations in technical skills acquisition in surgery be explained by differences in cortical plasticity

Abstract: Variations in technical performance in surgery are known to exist but are poorly understood. Gaining an appreciation of these differences may have implications for technical skills training, assessment, and selection. Investigators attempting to correlate technical skill with visuospatial or percept

Re-stocking the resuscitation trolley: how good is compliance with checking procedures?:

Abstract: This study retrospectively reviewed compliance with the checking policy for resuscitation trolleys on medical, surgical and paediatric wards in a large UK city-based teaching hospital. Successful advanced life support (ALS) relies on the availability of a resuscitation trolley that provides the required equipment and recommended drugs. Missing or faulty equipment can significantly compromise ALS. Local policy stipulates periodic checking, and re-stocking as required, of resuscitation trolleys, and checklists are provided for this purpose. The checklist forms located on each trolley were examined between January and December 2005. The frequency of checking was compared with the arrest calls made within that period. The medical, surgical and paediatric wards had a mean checking rate of 72.2%, 68.8% and 65.9%, respectively. In December one ward checked their trolley on 11/31 (35.5%) days of the month, during which there were two cardiac arrest calls. In this hospital, basic trolley checking procedure...

New Technologies for the Surgical Curriculum

Abstract: The aim of a surgical residency program is to produce competent professionals displaying the cognitive, technical, and personal skills required to meet the needs of society. Current changes to the delivery of healthcare necessitate the development of new models of training. These can be supported with the development of new technologies to train and assess surgical practitioners. This article describes recent developments within Imperial College London with regard to eye tracking, noninvasive brain imaging, and an innovative mentoring scheme for the new surgical curriculum. The concept of eye tracking is described, together with surgical application for this technique in terms of dexterity analysis during minimally invasive procedures. We have also begun to understand spatial localization within the brain cortex during surgical knot-tying tasks. The aim is to develop a map of the cortex with regard to surgical novices and experienced surgeons and then to develop the hypothesis that a translational process of cortical plasticity occurs during training. Finally, the article is intended to describe a training scheme that goes beyond dexterity, and moves toward the development of a successful surgeon through surgical mentoring. It is hoped that some of these tools will enhance the training of future surgeons in order to continue to provide a high-quality service to our patients.

Symposium on surgical simulation for training and certification.

Abstract: The publication of this Symposium on Surgical Simulation for Training and Certification marks an important event with regard to the development of the surgical curriculum. A number of key authors worldwide have contributed a summary of works to this issue, resulting in an up-to-date and concise cluster of information for the surgical reader. The issue opens with a historical review of surgical simulation from Dr. Satava, himself one of the leading lights in the world of surgical simulation since the mid1980s. The early work of Dr. Gaba in pioneering anesthesia-based manikin simulators was the precursor to the development of virtual reality simulation for training and assessment of technical skills in minimally invasive surgery. In the past 20 years, the surgical simulation market has grown at a progressive rate. However, it is of utmost importance to ensure that we as a surgical community are not inappropriately seduced by the vision that these new technologies can offer. As Dankelman states, the design and development of surgical simulators for integration within a surgical curriculum necessitates that they are effective (i.e., learning objectives are met), and efficient (i.e., minimization of costs and time taken to achieve proficiency). This entails an understanding of the behaviors that are to be trained, whether skills-based, rules-based, or knowledge-based, in accordance with Rasmussen’s model of human behavior. It is thus important for simulator developers to be guided by surgeons who are going to use the tool—from trainees to educators. One of the main objects of developing simulation tools is the ability to assess technical skill objectively, leading to the notion of a competency-based curriculum, whereby performance is measured according to actual skill developed (expertise) rather than the number of years in practice (experience). Gerald Fried has extensively and comprehensively led the development of tools for certification in basic laparoscopic skills, dubbed Fundamentals of Laparoscopic Surgery (FLS), a program that has been supported by both the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American College of Surgeons (ACS). Performance on the didactic and handson skills training modules has been shown to be valid, reliable, and predictive of in vivo laparoscopic skills performance. The expansion of tools specifically for assessment of technical skill (such as rating scales and motion-tracking systems) is now being pursued by the development of measures for nontechnical skills, such as communication, leadership, and decision making. However, the simulation set-up for real-world team training is expensive, resource heavy, and difficult to organize. It is with this background that Heinrichs et al. describe their experience with the development and use of virtual worlds simulation for team training and assessment in acute care medicine, ranging from in-hospital trauma management to pre-hospital disaster training. The simulations enabled repeated practice opportunities for uncommon, life-threatening trauma cases in a reproducible and flexible setting. The integration of the aforementioned tools within the surgical curriculum, in a sequential, modular, and criterionbased framework, is the basis of the article by McClusky and Smith. They provide an exemplary five-stage curriculum detailing the development of knowledge, technical skill, and judgment, each stage of which is proficiency R. Aggarwal (&) A. Darzi Department of Biosurgery & Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St. Mary’s Hospital, Praed Street, London W2 1NY, United Kingdom e-mail: rajesh.aggarwal@imperial.ac.uk

Use of simulators in vascular training

Abstract: Rapid advances in technology and the public and institutional demand to improve quality and safety have led to an increased use of simulation technology in medicine. What is simulation? It refers to the process of imitating a course of events and ranges from the use of standardised patient encounters to robot-manikins to computerised virtual environments. A simulator is the apparatus that reproduces a procedure that must be learnt and that incorporates assessment measures that allow progress and learning to be measured. In the medical context virtual reality (VR) simulation replaces an actual clinical episode with a simulated experience in a computer-generated environment, permitting doctors to acquire core skills in a safe environment without jeopardising patient safety.1 A cardiopulmonary patient simulator like “Harvey” was first presented at the American Heart Association Scientific programme in 1968. Medical students who used Harvey during their cardiology elective acquired more cognitive information and were better skilled in bedside cardiac examinations than their colleagues who were trained traditionally.2 In 1999 the American College of Cardiology’s Task Force on Teaching recommended Harvey for day-to-day training in bedside skills.3 Technical skills may be enhanced by using bench-top models or high-fidelity tissue-based simulators, but most research in VR simulation has focused on minimally invasive techniques such as laparoscopic and endovascular interventions. Training opportunities are restricted owing to the increased use of non-invasive imaging techniques and the diminishing working week of trainees. High-risk and complex endovascular interventions such as carotid artery stenting (CAS) and the primary concern for patients’ safety resulted in 2004 in the report of the Food and Drug Administration that simulation may be beneficial as part of a training package before allowing doctors to perform …

Laparoscopic Parastomal Hernia Repair: A Description of the Technique and Initial Results:

Abstract: In this study, the authors review their initial results with the laparoscopic approach for parastomal hernia repair. Between 2006 and 2007, 4 patients were treated laparoscopically at our institution. The hernia sac was not excised. A piece of Gore-Tex DualMesh with a central keyhole and a radial incision was cut so that it could provide at least 3 to 5 cm of overlap of the fascial defect. The mesh was secured to the margins of the hernia with circumferential metal tacking and trans-fascial sutures. No complications occurred in the postoperative period. After a median follow-up of 9 months, recurrence occurred in 1 patient. This was our first patient in whom mesh fixation was performed only with circumferential metal tacking. The laparoscopic repair of parastomal hernias seems to be a safe, feasible and promising technique offering the advantages of minimally-invasive surgery. The success of this approach depends on longer follow-up reports and standardization of the technical elements.

Surgical management of morbid obesity.

Abstract: Obesity affects 1.7 million people worldwide, and is a leading cause of morbidity and mortality. Outcomes of conservative management are generally poor. Surgery for morbid obesity has reported excellent results, leading to an exponential increase in numbers of procedures performed.

Endovascular simulation-based training.

Abstract: Th e purpose of training programmes for all medical specialties is to produce competent individuals who are able to meet the healthcare needs of society. Legislation of workforce hours, waiting list initiatives, ambulatory care centres and star ratings for hospitals have led to confl icts between service and training priorities. It is no longer acceptable, nor economically effi cient, to train surgeons using the age-old apprenticeship model. Th ese drivers for change make it necessary to develop a new, integrated solution to maintain the healthcare workforce, while enabling reconfi guration of hospital services.

Virtual reality simulation: prepared for training and assessment of endovascular skills?

Abstract: Evolving endovascular therapies have transformed the management of vascular disease and are rapidly gaining acceptance. Current opportunities for future interventionalists; to practice are limited by a number of factors including patient safety, budgetary constraints, reduction in length of residency programs, implementation of the European Working Time Directive and the increasing application of non invasive diagnostic strategies. Virtual reality simulation has been proposed as a means to train and objectively assess technical endovascular performance without risks to patient safety. This article reviews the evidence for this adjunctive tool to enhance current training programmes to ensure that the highest standards of care are sustained for treatment of vascular disease.