Validation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique

doi:10.1016/j.urology.2018.07.035

Urology

Volume 120, October 2018, Pages 125-130

https://doi.org/10.1016/j.urology.2018.07.035 Get rights and content

Abstract

Objective

To develop and validate a training model for the robotic intracorporeal bowel anastomosis.

Methods

For simulation, surgeons with varying levels of experience were instructed about bowel anastomosis robotic surgical simulation in a short educational video. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. The procedure consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenteric angle (2), insertion of the stapler into the 2 bowel limbs for the side-to-side anastomosis (3), and transverse closure of the anastomosis with the stapler (4). All simulations were performed using the daVinci SI robotic system. Face and content validity were assessed using a standardized questionnaire. Construct validity was evaluated using the Global Evaluative Assessment of Robotic Skills, a validated global performance rating scale.

Results

Twenty-two surgeons participated including 6 robotic experts and 16 trainees. The expert participants rated the bowel anastomosis model highly for face validity (median 4/5; 64% agree or strongly agree), and all participants rated the content as a training model very highly (median 4.5/5; 100% agree or strongly agree). Discrimination between experts and trainees using Global Evaluative Assessment of Robotic Skills demonstrated construct validity (novice 17.6 vs expert 24.7, P = .03).

Conclusion

We demonstrate that the bowel anastomosis robotic surgical simulator is a reproducible and realistic simulation that allows for an objective skills assessment. We establish face, content, and construct validity for this model. This step-by-step technique may be utilized in training surgeons desiring to acquire skills in robotic intracorporeal urinary diversion.

Section snippets

Development of Training Model

In order to develop a bowel anastomosis training model, a group of experts deconstructed robotic intracorporeal bowel diversion into a set of fundamental steps predicated on the following: atraumatic handling and manipulation of bowel, positioning and orienting the bowel for stapling, and effectively directing the bedside assistant for stapler firing. In terms of material, initially, synthetic material was used; however, the rigidity of available materials was prohibitive with regards to

Demographics

The demographics of the 22 surgeons who participated in the porcine bowel anastomosis simulation are shown in Table 1. Trainees included residents in their PGY-3 (n = 1), PGY-4 (n = 1), PGY-5 (n = 4), and PGY-6 (n = 2) years, fellows in Pediatric Urology (n = 2), Female/Voiding Dysfunction (n = 1), and Urologic Oncology (n = 1), and surgeons in practice with minimal robotic experience (n = 4). The expert group was comprised of 6 urologic faculty who had extensive robotic experience with a

DISCUSSION

While robotic radical cystectomy has become an increasingly utilized procedure, the majority of urinary diversions are still performed in an extracorporeal fashion.⁵ Despite the potential benefits and the promising initial outcomes of completely intracorporeal urinary diversions,6, 7, 8, 9 there remains a reluctance to adopt this technique. While reasons for this are multifactorial, a lack of familiarity with laparoscopic bowel work and the inherent technical challenges (with the potential

CONCLUSION

This model of the robot-assisted intracorporeal bowel anastomosis is a reproducible, inexpensive, and realistic training model. Utilizing previously validated assessment tools for robotic surgical performance, we demonstrated face, content, and construct validity for this simulation. This model appears to realistically prepare surgeons and their surgical assistant for robotic intracorporeal urinary diversion.

References (18)

JJ Leow et al.
Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States
Eur Urol
(2014)
B Yuh et al.
Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy
Eur Urol
(2015)
SJ Raza et al.
Oncologic outcomes following robot-assisted radical cystectomy with minimum 5-year follow-up: the Roswell Park cancer institute experience
Eur Urol
(2014)
MN Jonsson et al.
Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder
Eur Urol
(2011)
MM Desai et al.
Robotic intracorporeal orthotopic neobladder during radical cystectomy in 132 patients
J Urol
(2014)
AC Goh et al.
Global evaluative assessment of robotic skills: validation of a clinical assessment tool to measure robotic surgical skills
J Urol
(2012)
DJ Scott et al.
The new ACS/APDS skills curriculum: moving the learning curve out of the operating room
J Gastrointest Surg
(2008)
KA Richards et al.
Does initial learning curve compromise outcomes for robot-assisted radical cystectomy? A critical evaluation of the first 60 cases while establishing a robotics program
J Endourol
(2011)
AB Smith et al.
Multi-institutional analysis of robotic radical cystectomy for bladder cancer: perioperative outcomes and complications in 227 patients
J Laparoendosc Adv Surg Tech
(2012)

There are more references available in the full text version of this article.

Cited by (6)

AUTHOR REPLY
2019, Urology
Development, manufacture and initial assessment of validity of a 3-dimensional-printed bowel anastomosis simulation training model
2021, Canadian Journal of Surgery
It is critical that junior residents be given opportunities to practise bowel anastomosis before performing the procedure in patients. Three-dimensional (3D) printing is an affordable way to provide realistic, reusable intestinal simulators. The aim of this study was to test the face and content validity of a 3D-printed simulator for bowel anastomosis.
The bowel anastomosis simulator was designed and assembled with the use of desktop 3D printers and silicone solutions. The production cost ranges from $2.67 to $131, depending on which aspects of the model one prefers to include. We incorporated input from a general surgeon regarding design modifications to improve the realism of the model. Nine experts in general surgery (6 staff surgeons and 3 senior residents) were asked to perform an anastomosis with the model and then complete 2 surveys regarding face and content validity. Items were rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”).
The overall average score for product quality was 3.58, indicating good face validity. The average score for realism (e.g., flexibility and texture of the model) was 3.77. The simulator was rated as being useful for training, with an overall average score of 3.98. In general, the participants agreed that the simulator would be a valuable addition to current simulation-based medical education (average score 4.11). They commented that the model would be improved by adding extra layers to simulate mucosa.
Experts found the 3D-printed bowel anastomosis simulator to be an appropriate tool for the education of surgical residents, based on the model’s texture, appearance and ability to undergo an anastomosis. This model provides an affordable way for surgical residents to learn bowel anastomosis. Future research will focus on proving educational efficacy, effectiveness and transfer that can be adapted for laparoscopic anastomosis training, hand-sewing and stapling procedures.
Il est crucial que les résidents juniors aient l’occasion de s’exercer à l’anastomose intestinale avant d’intervenir sur des patients. L’impression en 3 dimensions (3D) est une façon abordable de produire des simulateurs intestinaux réalistes et réutilisables. Le but de cette étude était de vérifier la validité apparente et de contenu des simulateurs obtenus par impression 3D pour l’anastomose intestinale.
Le simulateur d’anastomose intestinale est conçu et assemblé avec des imprimantes de bureau 3D et des solutions de silicone. Le coût de fabrication varie de 2,67 $ à 131 $, selon le nombre de composants désiré. Suite aux commentaires d’un chirurgien général nous avons modifié le modèle afin de le rendre plus réaliste. Nous avons demandé à 9 experts en chirurgie générale (6 chirurgiens en poste et 3 résidents séniors) d’effectuer une anastomose sur le modèle, puis de répondre à 2 questionnaires sur sa validité apparente et de contenu. Les questions étaient notées sur une échelle de Likert en 5 points, allant de 1 (« en désaccord total ») à 5 (« tout à fait d’accord »).
Le score moyen global pour la qualité du produit a été de 3,58, soit une bonne validité apparente. Le score moyen pour le réalisme (p. ex., flexibilité et texture du modèle) a été de 3,77. Le simulateur a été jugé utile pour la formation, avec un score moyen global de 3,98. En général, les participants ont convenu que le simulateur serait un ajout précieux à la formation actuelle par simulation (score moyen 4,11). Ils ont formulé un commentaire à l’effet que le modèle gagnerait à comporter des couches supplémentaires pour simuler la muqueuse.
Les experts ont jugé que le simulateur d’anastomose intestinale 3D constitue un outil approprié pour la formation des résidents en chirurgie, du point de vue de la texture et de l’aspect du modèle et de la capacité de pratiquer l’anastomose. Ce modèle constitue une façon abordable d’apprendre comment effectuer une anastomose intestinale pour les résidents en chirurgie. La recherche à venir portera sur la détermination de son efficacité didactique, son efficacité et de son applicabilité à l’enseignement de la technique d’anastomose laparoscopique, de la suture à la main et des techniques d’agrafage.
Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review
2024, British Journal of Surgery
Simulation-based education in urology – an update
2023, Therapeutic Advances in Urology
Current status of simulation training in urology: A non-systematic review
2020, Research and Reports in Urology
Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer
2019, International Journal of Urology

: Funding Support: Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number T32GM088129. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

¹: These authors contributed equally to the preparation of this manuscript.

View full text

Laparoscopy and RoboticsValidation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Development of Training Model

Demographics

DISCUSSION

CONCLUSION

Eur Urol

Eur Urol

Eur Urol

Eur Urol

J Urol

J Urol

J Gastrointest Surg

Does initial learning curve compromise outcomes for robot-assisted radical cystectomy? A critical evaluation of the first 60 cases while establishing a robotics program

J Endourol

Multi-institutional analysis of robotic radical cystectomy for bladder cancer: perioperative outcomes and complications in 227 patients

J Laparoendosc Adv Surg Tech

Laparoscopy and Robotics
Validation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique