Widespread acceptance of laparoscopic urology techniques has posed many challenges to training urology residents and allowing postgraduate urologists to acquire often difficult new surgical skills. Several factors in surgical training programs are limiting the ability to train residents in the operating room, including limited-hours work weeks, increasing demand for operating room productivity, and general public awareness of medical errors. As such, surgical simulation may provide an opportunity to enhance residency experience and training, and optimize post-graduate acquisition of new skills and maintenance of competency. This review article explains and defines the various levels of validity as it pertains to surgical simulators. The most recently and comprehensively validity tested simulators are outlined and summarized. The potential role of surgical simulation in the formative and summative assessment of surgical trainees, as well as, the certification and recertification process of postgraduate surgeons will be delineated. Surgical simulation will be an important adjunct to the traditional methods of surgical skills training and will allow surgeons to maintain their proficiency in the technically challenging aspects of minimally invasive urologic surgery.

Laparoscopic surgery is gaining popularity among the surgical community. While its prevalence expands, the need for reliable training and assessment tools is becoming increasingly important. Laparoscopic skills are not an innate behavior, nor can they be easily mimicked, and can only be acquired through hands-on training. A consensus exists among physicians that establishment and evaluation of technical skill in surgical training programs are inadequate and in need of improvement. A validated, reliable bench model that could train and assess could be standardized and provide numerous benefits including determination of which medical students should consider a career in surgery, valuable feedback to residents, a tracking mechanism of resident performance, a possible certification and recertification tool, and to allow for interinstitutional comparison. To this end, several potentially successful bench models testing dexterity, hand-eye coordination, and depth perception have been developed. A few models have been proven to be both valid and reliable indicators of technical skill. Although the future remains uncertain, enough groundwork has been laid to begin incorporating technical skill training and assessment into surgical training programs.

Background and purpose

Ureteroscope breakage is commonly related to laser fiber damage. Often, the damage is mechanical and not energy related. As such, we evaluated a novel laser fiber and sheath system in preventing mechanical ureteroscope damage during fiber insertion.

Materials and methods

We assessed 200-μm/272/3-μm laser fibers with the laser sheath in a flexible ureteroscope. Diminishment of active deflection and irrigation flow rates were compared with a standard laser fiber alone. Eight nonassembled working channel components were tested in a 0-degree/90-degree/210-degree deflection model. After insertion cycles, external and endolumenal damage to the working channel were classified. We also tested the sheath system in a 0-degree/90-degree/210-degree deflection model for fiber failure and laser damage.

Results

In all test trials with the sheath and for standard laser fibers in the 0-degree model, there were no channel perforations or damage. With standard laser fibers, in the 210-degree model, superficial scratches and demarcated abrasions were visible after 10 and 60 to 70 insertions for the 273-μm laser fiber and after 30 insertions (superficial scratches) for the 200-μm laser fiber. In the 90-degree model, superficial scratches occurred after 20 insertions for the 273-μm fibers and after 40 insertions for the 200-μm laser fibers. No demarcated abrasions were seen after 100 insertions. In the 210-degree model, there was one perforation with the 272-μm fiber, but none with 200-μm fiber. There were no fiber failures with sheath use; however, the sheath did not prevent laser energy damage. The laser sheath resulted in a 4.7-degree/3.8-degree (1.2%/1.5%) diminishment in deflection (up/down) for the 200 μm and a 3.5-degree/4.3-degree (1.8%/1.5%) diminishment for 272-μm laser fiber compared with standard 200/272-μm laser fiber. Irrigation flow was diminished with the sheath on both the 200-μm and 272-μm laser fiber by 28.7% and 32.6%, respectively.

Conclusion

The Scope Guardian Sheath prevented mechanical working channel damage with minimal diminishment of deflection and irrigation flow.

Background

The human cadaver remains the gold standard for anatomic training and is highly useful when incorporated into minimally invasive surgical training programs. However, this valuable resource is often not used to its full potential due to a lack of multidisciplinary cooperation. Herein, we propose the coordinated multiple use of individual cadavers to better utilize anatomical resources and potentiate the availability of cadaver training.

Methods

Twenty-two postgraduate surgeons participated in a robot-assisted surgical training course that utilized shared cadavers. All participants completed a Likert 4-scale satisfaction questionnaire after their training session. Cadaveric tissue quality and the quality of the training session related to this material were assessed.

Results

Nine participants rated the quality of the cadaveric tissue as excellent, 7 as good, 5 as unsatisfactory, and 1 as poor. Overall, 72% of participants who operated on a previously used cadaver were satisfied with their training experience and did not perceive the previous use deleterious to their training.

Conclusion

The coordinated use of cadavers, which allows for multiple cadaver use for different teaching sessions, is an excellent training method that increases availability of human anatomical material for minimally invasive surgical training.

Background and purpose

Surgery is a high-stakes "performance." Yet, unlike athletes or musicians, surgeons do not engage in routine "warm-up" exercises before "performing" in the operating room. We study the impact of a preoperative warm-up exercise routine (POWER) on surgeon performance during laparoscopic surgery.

Materials and methods

Serving as their own controls, each subject performed two pairs of laparoscopic cases, each pair consisting of one case with POWER (+POWER) and one without (-POWER). Subjects were randomly assigned to +POWER or -POWER for the initial case of each pairing, and all cases were performed ≥ 1 week apart. POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer. For each case, cognitive, psychomotor, and technical performance data were collected during two different tasks: mobilization of the colon (MC) and intracorporeal suturing and knot tying (iSKT). Statistical analysis was performed using SYSTAT v11.0.

Results

A total of 28 study cases (14+POWER, 14-POWER) were performed by seven different subjects. Cognitive and psychomotor performance (attention, distraction, workload, spatial reasoning, movement smoothness, posture stability) were found to be significantly better in the +POWER group (P ≤ 0.05) and technical performance, as scored by two blinded laparoscopic experts, was found to be better in the +POWER group for MC (P=0.04) but not iSKT (P=0.92). Technical scores demonstrated excellent reliability using our assessment tool (Cronbach ∝=0.88). Subject performance during POWER was also found to correlate with intraoperative performance scores.

Conclusions

Urologic trainees who perform a POWER approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive, psychomotor, and technical performance.

Introduction

Laparoscopic techniques are difficult to master, especially for surgeons who did not receive such training during residency. To help urologists master challenging laparoscopic skills, a unique 5-day mini-residency (M-R) program was established at the University of California, Irvine. The first 101 participants in this program were evaluated on their laparoscopic skills acquisition at the end of the 5-day experience.

Methods

Two urologists are accepted per week into 1 of 4 training modules: (1) ureteroscopy/percutaneous renal access; (2) laparoscopic ablative renal surgery; (3) laparoscopic reconstructive renal surgery; and (4) robot-assisted prostatectomy. The program consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal and cadaver laboratory sessions, and observation or participation in human surgeries. Skills testing (ST) simulating open, laparoscopic, and robotic surgery is assessed in all of the M-R participants on training days 1 and 5. Tests include ring transfer, suture threading, cutting, and suturing. Performance is evaluated by an experienced observer using the Objective Structured Assessment of Technical Skill (OSATS) scoring system. Statistical methods used include the paired sample t test and analysis of variance at a confidence level of PResultsBetween July 2003 and June 2005, 101 urologists participated in the M-R program. The mean participant age was 47 years (range, 31 to 70). The open surgical format had the highest ST scores followed by the robotic and then the laparoscopic formats. The final ST scores were significantly higher than the initial ST scores (P<0.05) for the laparoscopic (58 vs. 52) and the robotic (114 vs. 95) formats. Open surgical ST scores did not change significantly during the training program (191 vs. 194) (P=0.17).

Conclusion

Laparoscopic and robotic ST scores, but not open ST scores, improved significantly during this intensive 5-day M-R program. The robotic ST scores demonstrated greater improvement than did the laparoscopic ST scores, suggesting that the transfer of laparoscopic skills may be improved using the robotic interface.