Laparoscopic Training


Surgical education has struggled with the methods to objectively scrutinize surgical performance of house staff for many years. The methods of formal education have had some limited application, but as the complexity of modern laparoscopic surgery has manifested itself, departments across the country and around the world have begun to evaluate how to assess competency, skill development, teaching methodologies, and communication skills (67). The complexity of this task has resulted in a surprising number of papers in the surgical literature on trends in education. Extensive lists are beginning to be generated on measurable psychomotor skills, but the ability of young surgeons to communicate is significantly important, especially for advanced laparo-scopic procedures. Important aspects that deserve attention are psychomotor skills, cognitive decision making, incorporation of video-enhanced motor coordination, two-handed surgical maneuvering, and rhetorical ability. Students of advanced laparo-scopic surgery are themselves independent learners. There are various approaches each will take to gaining laparoscopic skills. A whole host of research endeavors have begun to focus on the surgeon's ability to learn (68). At least four factors can be attributed to learning orientation: concrete experiences, abstract conceptualization, active experimentation, and reflective observation. D.A. Kolb is widely quoted in research regarding learning orientation. It is these orientations that help research investigators study learning. They identify four dominant learning styles: convergence, divergence, assimilation, and accommodation. The convergence learner stresses abstract conceptualization and active experimentation. These learners stress hypothetical-deductive reasoning to analyze their problems. Divergers rely upon contrasting orientations of concrete experience and reflective observation. Their information processing can thus be protracted and often do not feel impelled to act. Assimilators tend to use inductive

Kolb's learning styles have been used successfully to evaluate medical students and evaluate the educational environment for medical learning.

development of concepts such as unifying theories to explain their observations. They tend to focus on the soundness or fitness of ideas and thus are less concerned about the practical value of observations. Last are the accommodators who emphasize orientations of active experimentation and concrete experience (69).

Kolb's learning styles have been used successfully to evaluate medical students and evaluate the educational environment for medical learning.

In addition, this theory has also recently been applied to third-year medical students rotating on their general surgery clerkships at the University of Nebraska. They identified that the majority of the of third year students were convergers (45%), assimi-lators (26%), accommodators (21%), and divergers (8%). They were primarily interested in how best to evaluate the performance of the students and not to predict methods to better teach psychomotor skills. But applications of the modern learning theory are evident. They stated that clinical performance requires additional cognitive skills and abilities that need to be further quantified (69).

The ability to measure and impart laparoscopic psychomotor skills is another area undergoing intense scrutiny. The ability to ascertain those individuals who have innate ability should also be possible.

Factors recognized as crucial in laparoscopic surgery include muscle strength, speed, precision, dexterity, balance, spatial resolution, as well as poise and endurance. Kaufman et al. at the University of West Virginia have begun an active program focusing on three aspects of surgical education. First, can prospective surgeons be screened with regard to their psychomotor skills? Second, can the application of modern educational psychomotor concepts help in the development of advanced skills? Third, can evaluation methods of psychomotor skill proficiency adequately gauge the acquisition and performance of complex surgical tasks? Their methodology is complex, but applies a wide battery of psychomotor tests at the initiation of training, during training, and following training to better evaluate skill acquisition. Their tests include the following: McCarron assessment of neuromuscular development to measure motor function and fatigue, Purdue pegboard to assess fine motor control, Minnesota rate of manipulation test to measure speed and precision, Minnesota paper form board to measure spatial perception, haptic visual discrimination test to measure spatial perception, and California psychological inventory to measure poise, confidence, and relaxation. During preliminary evaluations, they have developed an equation that balances psy-chomotor ability with the acquisition of motor skill factoring in the time of training.

Psychomotor ability X Amount of practice = Motor skill proficiency (70)

The United States Army represents another wealth of information regarding the ability to perform tasks and the ability to measure skill. Again, they have reported two major determinates for performance, length of time spent doing a given task, and aptitude. Using isoperformance curves, it is possible to explain the relationship between experience and aptitude mathematically. Now changes in the relationships can be measured and the effect of training can be calculated on isoperformance curves (71). As these studies continue, one can hope that directed methods of training will be possible for those interested in advanced laparoscopic surgery that will bring performance to a peak level and maintain it there (72-88).

Flight Simulators

The premise that the skill of the surgeons can be equated to the outcomes of the operations over time is a fundamental concept in modern surgery. Those surgeons who perform the most complex operations and have the lowest morbidity are encouraged. This concept is fundamental to other more intensively scrutinized professions as well, most notably commercial aviation. Flight simulation has a long and interesting history (89). Simulators have been attempted with surgical procedures such as laparoscopic cholecystectomy, laparoscopy-assisted vaginal hysterectomy, and laparoscopic inguinal hernia repair (Fig. 3) (73,77). But to date, they lack ability to function in the manner in which the aeronautics profession is capable. Current simulators are available in anesthesia, interventional radiology, and emergency medicine but these are far from clinical reality. Fidelity in haptic feedback has been an ongoing problem with surgical simulators. In addition, the ability of the computer to add nuances of human anatomical variability has not been achieved.

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