Is it all about the money? : The effects of low and high cost simulator training scenarios in surgical training

Sammanfattning: Background: The learning process is complex and dependent on several factors such as for instance, the environment to learn, prior knowledge and distinct abilities, motivation, goal-orientation as well as the effects of instructor feedback. Medical education, in particular within surgical domains is imperative due to its influence on patient safety. The demand for training surgeons has shifted from the “master-apprentice/practice on patients”, towards a safer modality, involving simulators. The positive effects laparoscopic simulator training has on laparoscopic performance is extensive, as well as its impact on operating room performance. Nonetheless, the difference in learning effect using either low-cost or high-fidelity laparoscopic simulators were not totally clear prior to study start. Aims 1. To examine whether laparoscopic surgical training may be offered at a lower cost, with maintained equivalent level of training and effect in knowledge/learning using a low-cost laparoscopic Blackbox (Paper I). 2. To study the impact of PC-gaming experience, visuospatial ability and gender on the various parameters of the MIST-VR simulator and its effect on the score (Paper II). 3. To further investigate the Blackbox, and if different adjuncts (video analysis) could provide more information regarding the effects of training (Paper III). 4. To study the effects on time to learn laparoscopic knot- and suturing skills in novices using two different laparoscopic needle holders in a more advanced Blackbox, evaluate outcomes regarding performance, ergonomic discomfort and time to perform laparoscopic knot- and suturing skills, as well as to evaluate an objective video evaluation scoring table (OVEST) (Paper IV). Materials and Methods: The participants were medical students from the surgical semester at Karolinska Institutet, Stockholm (Studies I-III) and medical students at Athens University Medical School in Athens, Athens, Greece (Study IV). The studies were conducted at CAMST (Center for Advanced Medical Simulation and Training), Karolinska University Hospital, Stockholm (Studies I-III), and at MPLSC (Medical Physics-Lab Simulation Center), Athens University Medical School, Athens, Greece (Study IV). In conjunction with inclusion, the students (Studies I-II) performed a test (MRT-A; Mental Rotation Test – A) for the assessment of their visuospatial ability, and questionnaires including baseline questions (Studies I-IV). The simulator training/tests were done using different laparoscopic simulators; Blackbox (Studies I and III); LapMentor (Study I); MIST-VR (Studies I-III); Simball box (Study IV). The participants’ simulator performance analyzed; time to completion and economy of movement (Studies I-IV); optical flow metrics (path-length and total number of particles) as displayed by the automated video analysis software (Study III); knot- and suturing skills (Study IV). Results: Studies I and II showed, as previous studies, that the visuospatial ability correlated with the initial simulator training sessions. Study I showed no significant difference in performance between laparoscopic basic skills training regardless of simulator used; low-cost or high-fidelity laparoscopy simulator. Studies I, II and III showed discrepancies between prior PC-gaming experience and the simulator performance, as well as some gender-specific differences. Study III also showed that the use of a low-cost automated video analysis software may be feasibly comparable to the build-in software of the MIST-VR simulator. Study IV presented a shortened time to learn for novices performing laparoscopic knot- and suturing tasks in a simulated environment when using the newly designed laparoscopic needle holder compared to a conventional market needle holder. Conclusions: Laparoscopic simulator training clearly facilitates laparoscopic skills performance. Improved prerequisites of training opportunities for surgeons could potentiate patient safety, especially since enhanced surgical performance improves patient safety. Subsequently, as depicted in this thesis, there is not one single truth or solution, rather different angles and several factors that affect learning in general and surgical performance in particular. Therefore, considerations of for instance individual differences, gender, and motivation, should all be included when producing laparoscopic skills training curriculum for future surgical trainees.