Effectiveness of box trainers in laparoscopic training

Using Wilcoxon matched-paired signed-ranks test, 2­ tailed P-value<0.0001 which is extremely significant. Rationale and Objectives: Various devices are Conclusion: This study confirms that a short-term, used to aid in the education of laparoscopic skills intensive, focused course does improve laparoscopic ranging from simple box trainers to sophisticated skills of trainees. Box-trainers can be used to change virtual reality trainers. Virtual reality system is an the present day didactic training into objective and advanced and effective training method, however competency-based. Global rating scale and checklist it is yet to be adopted in India due to its cost and provide an inexpensive and effective way of objective the advanced technology required for it.Therefore, assessment of performance of laparoscopic skills. box trainers are being used to train laparoscopic skills. Hence this study was undertaken to assess


INTRODUCTION
laparoscopic surgery before; attending the workshop were evaluated.Each participant was given a list Recognizing the growing role of laparoscopy in of tasks to perform before beginning the box-training course on day one and was evaluated quantitatively modern surgery, residency programs have rapidly by rating the successful completion of each test.

incorporated it into their training regimen. Various
Evaluation began when the subject placed the first devices ranging from simple box trainers, animal tool into the cannula and ended with task completion.models to sophisticated virtual reality trainers [1][2][3][4] Two evaluation methods used to score the subject, used to aid in this education of laparoscopic skills.
including a global rating scale and a task-specific Virtual reality system is an advanced and effective checklist.After the subject completed all sessions of the workshop, they were asked to perform the training method, however it is yet to be adopted in Abstract are same tasks and were evaluated in the same manner.For each task completed by the subjects, the difference in the scores between the second and first runs were calculated and interpreted as an improvement as a percentage of the initial score.Statistical Analysis: Wilcoxon matched-paired signed-ranks test was applied to find out the statistical significance of the results obtained.Results: The mean percentage improvement in scores for both the tasks, using global rating scale, was 44.5% + 6.930 (Mean + SD).For task 1, using the global rating scale mean percentage improvement was 49.4% + 7.948 (Mean + SD).For task 2, mean percentage improvement using global rating scale was 39.6% + 10.4 (Mean + SD).
India due to its cost and the advanced technology required for it. [5]Therefore, box trainers are being used to train laparoscopic skills. [6]The question that is often raised, by both surgeons and the public, is whether these training sessions are effective in actually improving one's skills enough to become proficient at performing laparoscopic surgery [3,7,8] In this paper, we explore an inexpensive and easy method of objective evaluation and test it on surgeons who attend a training workshop.The aim of this paper is to assess improvement in dexterity of surgical trainees and overall effectiveness of the box-training exercises.

Pre-training evaluation
Each participant was given two tasks; one from basicskills and other from advanced-skills to perform.The evaluation was done by a senior faculty member and a trained observer.
Task 1. Bead transfer: The task consisted of picking up of either sex (male 19, female 6), who had no prior and transferring first the pink, then yellow and then laparoscopic experience or were not exposed to white bead one by one; from one cotton pad to another laparoscopy were included in the study after due and arranging then in a straight line [Figure 3].consent.Surgeons had not personally performed or assisted or handled the equipment or instruments Task 2. Suture drill: The task consisted of repairing prior to attending this course.
the incision on the glove with a single suture using 3-0 silk sutures on a curved tapered needle and to Study procedure make an intra-corporeal knot and secure each knot.Set-Up: The department of Surgical Gastroenterology, Attention was paid to the basic skills involved in K.E.M. Hospital has an Endo-lab that consists of an suturing like tracing, needle holding, taking proper isolated room with box-trainers.Laparoscopic training bites, tying knot and cutting off the extra suture to a course is a six-day course.Each day there are lectures, short length [Figure 4].operative demonstrations and a three hour training session on the box-trainer that included one hour of Each participant was asked to perform these tasks supervised performance and two hours of practice before beginning the training course on day one.They (The two hours of practice time also includes the time were evaluated quantitatively by rating the successful when one candidate held the camera for the other completion of each test.Evaluation began when the person to get the feel of how a camera person is subject placed the first tool into the cannula and ended Important in laparoscopic surgery as he/she is eyes when the task was complete.Two evaluation methods of the surgeon and success of a procedure is a team were used to score the participants, including a global effort).Participants perform six tasks on six rating scale [9,10] (maximum score =20) [Table 1] and a consecutive days in the following order: day 1-bead task-specific checklist [9] (maximum score=13) [

Post-training evaluation
After the participants completed all sessions of the workshop, they were asked to perform the same tasks and were evaluated in the same manner.For each task completed by the subjects, Wilcoxon matchedpaired signed-ranks test was used to find the statistical significance between the pretraining and posttraining scores.

Statistical analysis
For each task completed by the subjects, Wilcoxon

RESULTS
All twenty-five surgeons completed the study.The mean percentage improvements in scores by global rating scale stratified by task are listed in Table 3.
test, 2-tailed P-value<0.0001which is extremely significant and Non-parametric spearman correlation coefficient is 0.6363.

Procedural step
For task 1 [

DISCUSSION
In the mid to late 1980s, the advent and widespread demand for laparoscopic cholecystectomy disrupted the fundamentals of traditional surgical training.It was not only subjects who needed training but now dimensional images on the video screen and work with proper hand-eye co-ordination.Since the participants had not performed laparoscopic surgery before they demonstrated extremely significant improvement in this basic task.The post-training scores for this task were between 75%-100% for almost all the participants.This can be attributed to the training.
Suture drill, the advanced and specific skill that was individual variability with respect to skill acquisition.
tested was the ability to place a suture and make an also practicing surgeons who did not have the luxury intra-corporeal knot.Though using sutures to of time to acquire these new and deceptively difficult approximate tissues in laparoscopic procedures can skills.This MIS revolution eventually led surgeons be ver y difficult and time-consuming, surgeons to rethink how best to train surgical skills.
should always be prepared for the unexpected need to use sutures in situations where clips fail.In One approach to skills acquisition was use of addition as the application of laparoscopy expands simulation, proposed by Satava [11] in the early 1990s.
to include more complex procedures, suturing and Over the past decade evidence has progressively knot tying on a video screen will be an important accumulated in favor of use of simulation as a means part of surgery in the future. [12]In suture drill task, of training and as an evaluation tool in the field of the subjects were asked to place a single stitch on an laparoscopy.Before it is incorporated in the already incision on a glove using 3-0 silk suture on a curved hectic regular curriculum, training and evaluation tapered needle.Attention was paid to the basic skills methodology needs to be standardized, internal involved in suturing like tracing, needle holding, validity established and usefulness of such training taking proper bites, tying knot and cut off the extra proven beyond doubt.
suture to a short length.They formed a standard surgeon's knot intracorporeally.The participants While surgical skills simulators are being produced demonstrated extremely significant improvement in in ever-increasing numbers, there is still confusion suturing and tying, also evident from the percentage about how to use simulators to teach surgical skills.
improvement in the global rating scale and checklist The underlying assumption seems to be that scores for suturing.However the posttraining scores individuals, who have performed the required for suturing were not as high as those for bead number of procedures will be a safe practitioner.A transfer.This may be because suturing is a difficult fundamental flaw with this approach is that it ignores task and three hours of practice on the box trainer Setting a fixed number of procedures or number of training hours is not an optimal approach to learning.Thus the various methods of surgical skills training till now were so much knowledge-oriented and subjective.So there is a need to make training objective and competency-based.
In this study, the subjects were made to perform two tasks [one basic skill (bead transfer) and one advanced skill (suture drill)].Bead transfer was designed to emphasize basic skills like instrument handling, use of assistant, getting orientation to the two -may not be enough to bring the scores to 75% to 100%.
By using both, global rating scale and task specific checklist for assessment, Regehr et al. [9,13] have shown that checklists do not add any additional value to the assessment process and that their reliability is lower than that for the global rating scale. [14,15]We have found both the scales useful.The most ideal method of gaining real operative experience outside the operating room would be practicing complete procedures like laparoscopic cholecystectomy or Nissen fundoplication on live animals such as the domestic swine, [14] but this is costly and requires an  formats according to the performance of participants.Past experiences such as video watching usually improves only cognitive skills of the participants such as understanding and comprehension of the procedures.To improve psychomotor skills and dexterity, box training or actual performance is essential.Surgeons may have seen the procedures but not personally performed or assisted to understand the difference of two-dimensional vision and haptics.This study proves that short-term; intensive, focused courses do improve laparoscopic Munz and colleagues [16] did a study to compare the skills of surgical trainees.Follow-up studies will be virtual reality simulator with the classical box trainer done to assess whether this really improves the and determine whether one has advantage over the clinical skills of surgeons.This would be evaluated other.Twenty-four novices were tested to determine by sending a questionnaire to the trainees after one their baseline laparoscopic skills and then randomized year, enquiring whether it really improved their into the following three groups: Lap Sim, box trainer clinical skills during laparoscopic surgery.The boxand no training (control).After three weekly training trainers can be used to change the present day didactic sessions lasting 30 minutes each, all subjects were training into objective and competency-based.reassessed.Assessment included motion analysis and error scores.Nonparametric tests were applied and Based on our study, we can conclude that physical P<0.05 was deemed significant.Both trained groups laparoscopic simulators certainly have a role as a tool made significant improvements in all parameters for training and evaluation in the near future.The measured (P<0.05).Compared to the controls, the cost factor, which is particularly relevant in the Indian box trainer group performed significantly better on context, should not be an impediment in the most of the parameters, whereas the LapSim group widespread usage of this novel tool.Low-cost performed significantly better on some parameters.
substitutes like mirrored-box simulators have been There were no significant differences between the shown to provide a reasonable reflection of relative LapSim and box trainer groups performance of laparoscopic skills. [18]bjective of practical and effective laparoscopic skills Scott et al. [15] have shown that inexperienced subjects training and assessment can be realised without the (undergraduate students) benefit more from training need for expensive equipment.on the simulators as compared to the more experienced post graduate students.Maximum ) .
n o w P u b l i c a t i o n s Dhariwal, et al.: Effectiveness of box trainers ( w w w

Figure 2 :
Figure 2: Box trainer with the endoscope and instruments

Table 2
]. transfer; day 2-transferring the sugar cubes; day 3-A global rating scale was recorded for each task the transferring the rings from one pin to another; day participant performed and checklist for the suture drill.4-bowel tracing; day 5-pattern cutting; day 6-suture drill.They were given two hours to practice each task.Box-Trainer: Locally manufactured box-trainer contains a board placed in a black training box fitted with rubber gaskets to accommodate cannulae for the scope and tools [Figures 1 and 2].A fiber-optic light source and camera equipment is used and the image is displayed on a video monitor.The following instruments are used 1.Atraumatic grasping forceps, both jaws opening 2. Grasping/dissecting forceps curved left, both jaws opening (Maryland Dissector)

Table 4 ]
, using the global rating scale mean percentage improvement was 49.4% (Pre 7.4 ± 1.97The mean improvement in suturing skills [Table 6] vs. Post 17.4 ± 1.41) with a standard deviation of using task-based checklist was 45.84% with a 7.948.Using Wilcoxon matched-paired signed-ranks standard deviation of 15.77 (Pre 3.52 ± 1.61 vs. Post

Table 4 : Task 1 (bead transfer): Pre and post training scores Table 6: Task 2 (suture drill): Pre and post training scores (out of 20) using global rating scale (out of 13) using checklist Pre-training score Post-training score Pre-training score Post-training score
Using Wilcoxon matched-paired signed-ranks test, 2-tailed P-value<0.0001UsingWilcoxonmatched-paired signed-ranks test, 2-tailed P-value<0.0001which is extremely significant.which is extremely significant.
Dhariwal, et al.:Effectiveness of box trainers experienced staff of an anesthetist, a veterinarian and a lab.technician.The advantage of box-training for objective evaluation of basic skills is twofold.First the scenario for testing is easily reproducible.The performance is not biased by the variations in anatomy or physiologic response found in animals.The exact same test can be repeated in identical fashion at any location at any time.Second the equipment is inexpensive, reusable and easy to set up quickly without an experienced staff.