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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 202-205

The effectiveness of box trainers in improving laparoscopic suturing skills in surgery


1 Department of Surgery, J.N. Medical College, Wardha, Maharashtra, India
2 Department of Pharmacology, J.N. Medical College, Wardha, Maharashtra, India
3 Department of Anatomy, J.N. Medical College, Wardha, Maharashtra, India

Date of Submission20-Feb-2019
Date of Decision20-Jul-2019
Date of Acceptance10-Aug-2019
Date of Web Publication2-May-2020

Correspondence Address:
Dr. Varsha Gajbhiye
Department of Pharmacology, J.N. Medical College, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_88_19

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  Abstract 


Background: Simulation training is an integral part of the laparoscopic training curriculum. To recognize the role of laparoscopy in modern surgery, residency programs rapidly incorporated it into their training regimen. Box trainers are useful to practice laparoscopic skills. Laparoscopy requires a long-learning curve. The simulation training model gives opportunities to practice the procedures efficiently until competency is achieved without exposing the live patient to undue risk. Hence, this study was conducted to assess the overall effectiveness of the box training to improve the skills in laparoscopic suturing. Materials and Methods: This was a prospective and observational study conducted over a period of 6 months including 30 residents of the surgery department. The department of surgery has an indoor laboratory that consists of an isolated room with two box-trainers. Participants were given a task to perform suturing by using box trainers for 2 h/week for 6 months. For the quantitative and qualitative assessment, a direct observation checklist was prepared, i.e., task-specific checklist having a maximum score of 15. Each participant performed a suturing task. Pre- and posttraining score was calculated and was compared to see the efficacy of the box trainers. Results: Around 30 participants’ surgery, residents were enrolled. Twenty-six male and 4 female residents were included in the training, with the age of all residents ranges from 26 to 30 years. The mean pretraining score was 3.1667, and it is improved significantly to 12.3667 after training. The unpaired t-test was calculated (20.5050). The two-tailed P is less than 0.0001; hence, it is statistically significant. Conclusions: This study proves the efficacy of box trainers in improving laparoscopic suturing skills.

Keywords: Box trainers, laparoscopic suturing, simulation skill


How to cite this article:
Lamture Y, Gajbhiye V, Gajbe U. The effectiveness of box trainers in improving laparoscopic suturing skills in surgery. J Datta Meghe Inst Med Sci Univ 2019;14:202-5

How to cite this URL:
Lamture Y, Gajbhiye V, Gajbe U. The effectiveness of box trainers in improving laparoscopic suturing skills in surgery. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 May 28];14:202-5. Available from: http://www.journaldmims.com/text.asp?2019/14/3/202/283606




  Introduction Top


When first introduced, laparoscopic surgery was associated with many complications. Surgeons, who were experts in their relative fields, found that when they performed the same operations laparoscopically, their open surgery skills did not transfer to the new technique. This led to the development of skill laboratories that allowed surgeons to develop basic laparoscopic skills without putting patients at risk. Simulation training has been used within the aviation industry, with similar requirements for high levels of technical skill, small margins for error, and significant consequences for decades with obvious benefits.[1]

It is important for a trainee to develop maneuvers required to manipulate instruments and tissue to the desired effect. Laparoscopic surgery demands very specific skills and capabilities that require initial learning of cognitive and motor skills followed by the refinement of those skills. The prerequisites for skilled laparoscopies work are as follows: (1) Depth perception – the surgeon is required to maneuver tissues and instruments in a three-dimensional environment with a two-dimensional view; (2) adjustment to fulcrum effect that creates conflict between the visual and proprioceptive feedback; (3) hand–eye coordination; (4) bimanual manipulation; (5) handling of laparoscopic instruments; and (6) ambidexterity.[2]

The methods to develop these skills outside the operating theater would enhance training, safety, and reduce operator stress. Although in the past patient-based training with a mentor had been an acceptable way of learning, with the pressure of service, reduced training and shallow learning curve of laparoscopic surgery require novel, nonmentor-based training. Simulators such as virtual reality (VR) and box trainers allow this to happen. VR training has been proven to be an effective form of training; however, the cost of VR trainers and their maintenance limit the availability to trainees.[3] Hence, laparoscopic simulation training must be effective and efficient in developing skills that translate into improved operative performance.[4]

One of the problems for the widespread use of laparoscopy surgery is a long-learning curve in laparoscopic surgery. The learning curve for laparoscopic radical prostatectomy ranged from 250 to 750 cases. For laparoscopy pyeloplasty, minimum 51 cases operated in the presence of the experienced surgeon. With a view to becoming more skillful without exposing humans to undue risk, various simulations, including the simple box trainer, animal, and VR simulators, are used. A VR system is considered an effective training method to surgical skills on a live patient. Similarly, simple box training also improves the technical skills compared with no training in trainees without previous laparoscopic experience.[5]

The rationale of the study

Recognizing the growing role of laparoscopy in modern surgery, residency programs rapidly incorporate it into their training regimen. Various devices ranging from simple box trainers and animal models to sophisticated VR trainers are used to aid in this education of laparoscopic skills. As already stated above, VR system is not available in India. Hence, box trainers are widely available to train laparoscopic skills. 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 the laparoscopy surgery. Laparoscopy requires the skill to perform as it is having a long learning curve. It needs a number of patients. The simulation training model gives opportunities to practice the procedures efficiently until the competency is achieved without exposing a live patient to undue risk. Hence, this study was conducted to assess the overall effectiveness of the box training to improve the skills in laparoscopic suturing.[6]


  Materials and Methods Top


This was a prospective and observational study. This study was conducted at the Department of Surgery of Acharya Vinoba Bhave Rural Hospital, Wardha, Maharashtra, with a duration of 6 months. Thirty residents of the surgery department were included in the study. All residents of the surgery department of either sex. Residents who perform laparoscopic surgery before this study were excluded from the study.

Study procedure

Setup

The department has an indoor laboratory that consists of an isolated room with two boxes trainers. Participants were given a task to perform suturing by using box trainers for 2 h/week for 6 months.

Box trainers

A box trainer manufactured by Meril [Figure 1] contains a board placed in a black training box fitted with rubber gaskets to accommodate cannulae for the scope and tools. A fiberoptic light source and camera equipment were used, and a video monitor was used to display the image. The following instruments were used: (1) atraumatic grasping forceps, both jaws opening; (2) grasping/dissecting forceps, curved left, both jaws opening (Maryland Dissector); (3) scissors, curved left, both blade opening (Metzenbaum); and (4) modular needle holder, straight with carbide insert with top lock.
Figure 1: Box trainers

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Data collection method

For the quantitative and qualitative assessment, a direct observation checklist is prepared, i.e., task-specific checklist having a maximum score of 15. Each participant had to perform a task, advanced skills, i.e., suturing. The evaluation was done by a senior faculty member and a trained observer. The task consisted of repairing the incision on the board with a single suture using 3-0 silk sutures on a curved tapered needle and to make an intracorporeal knot. Attention was paid to the basic skills involved in suturing such as tracing, needle holding, taking proper bites, tying knots, and cutting off the extra suture to a short length.

Pretraining evaluation

The evaluation method to be used to assess the participant's suturing skill was used to calculate the task-specific checklist [Table 1]. A task-specific checklist score (maximum score = 15) was recorded for each participant who performed suturing before training on simulation.
Table 1: Task.based checklist – Suturing in box trainers: Interrupted end.to.end suturing

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Posttraining evaluation

After the participants completed all sessions of the training, they were performing the same task and was scored in the same manner. The pre- and posttraining scores were recorded.

Statistical analysis

An unpaired t-test was used to find the statistical significance between the pre- and posttraining scores, and P < 0.05 considered to be statistically significant.


  Results Top


Two box trainers were used to train 30 residents.

Around 26 male and 4 female residents were included in the study.

The age of residents who participated in the study ranges from 26 to 30 years.

P value and statistical significance – the two-tailed P < 0.0001. As it is <0.05; hence, it is considered as statistically significant. Results are depicted in [Table 1] and [Table 2].
Table 2: Pre- and posttraining score and unpaired t-test results

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  Discussion Top


In 1980s decade, the invention and large need for laparoscopic cholecystectomy demanded to change the fundamentals of traditional surgical training. It was not the only resident who needed training but now also practicing the surgeons who did not have the luxury of time to acquire these new and deceptively difficult skills. These eventually led surgeons to think to search for a way to train laparoscopic skill. One way is to get that skill with the use of simulation as demonstrated by Satava in early 1990. Suture drill, the advanced and specific skill that was tested was the ability to place a suture and make an intracorporeal knot. Using sutures to approximate tissues in laparoscopic procedures can be very difficult and time-consuming. A surgeon should always be prepared for the unexpected need to use sutures in situ ations where clips fail. Suturing by using a task-specific checklist was used for the assessment. Dhariwal et al.[6] shows the tremendous improvement in suture skill format according to the performance of the participants. Specific past experiences such as video watching usually improve only the cognitive skills of the participants such as understanding and comprehension of the procedures. To improve psychomotor skills, box training or actual performance is essential. Surgeons may have seen the procedures but not personally performed or assisted to understand the difference between two-dimensional vision and touch skill.

Around 30 participants, surgery residents not exposed to laparoscopic surgeries were enrolled in this study. Twenty-six male and four female residents were included in the training, with an age of all residents ranges [Figure 2] from 26 to 30 years. Task-based checklist [Table 2] suturing in box trainers [Figure 1] was performed interrupted end-to-end suturing done. Score one point was given for each correctly performed action and zero for an incorrectly performed task.
Figure 2: Age of the participants

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{Table 2}

The mean of pretraining score was 3.1667, and it is improved significantly to mean of 12.3667 after training with unpaired t-test was 20.5050. The two-tailed P value is less than 0.0001 [Table 2]; hence, it proves to be statistically significant. Similar results were observed in a study done by Sihombing et al.[5] and reported that pretraining score was 6.7 that was improved to 10.3, participated candidates were all urologists, and the mean age of the participants was higher than the present study. As already stated that Dhariwal et al.[6] also give a promising result and reported that pretraining score was 3.5 that was improved to 9.

van Hove et al.[7] reviewed and analyzed the studies for the evaluation of methods to test the objective skills of the surgery. They included 104 studies, and these studies were assessed according to a tool developed by the Oxford center for evidence-based medicine to determine the levels of evidence. They concluded that most methods of skills assessment are valid for feedback or measuring the progress of training. Korndorffer's study showed[8] that even home box training is effective and home training results in laparoscopic suturing skill, expertise in a more perfect manner leads to improved skill retention when compared with standard simulation center training.

Hunter et al.,[9] in their study, demonstrated that box trainers efficacy improves laparoscopic skill related to cholecystectomy.

Scott et al.,[10] in their study, reported that mean percentage improvement in scores for the task was 44.5%. The Wilcoxon matched-paired signed-rank test was calculated and 2-tailed P < 0.0001, which is extremely significant. This study was similar to the present study.

Mohan and Chaudhry's study was conducted[11] in the surgery department to prove the efficacy of simulator training on the improvement of psychomotor skills related to laparoscopic cholecystectomy. Twenty-four surgical residents (12 in each group) were included in their study. These residents had no prior exposure to laparoscopic surgery. These residents after getting sufficient information about the operative procedure were then included in either a group that received training on a simulator or a controlled group that did not receive such training. The residents who received training on a simulator demonstrated better psychomotor skills in the operation theater than those who did not. The results of this study were similar to the present study.

Saxena[12] also proves the efficacy of smartphone-tablet-based box trainers in his study.


  Conclusion Top


The present study proves that short-term, intensive, focused courses improved the laparoscopic skills of surgical trainees. Based on this study, we can conclude that our low-cost training box is effective to improve laparoscopic skills. This study also emphasizes a need for the objective assessment of laparoscopic skills and the use of box trainers to document the same. This will allow training centers to strive to improve the quality of teaching, ensure standardization, and change course formats according to the performance of the participants.

Acknowledgments

The authors would like to acknowledge the pharmacology, surgery department, and central laboratory for kind cooperation to complete this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vitish-Sharma P, Knowles J, Patel B. Acquisition of fundamental laparoscopic skills: is a box really as good as virtual reality trainer? Int J Surg 2011;9:659-661.  Back to cited text no. 1
    
2.
Duffy AJ, Hogle NJ, McCarthy H, Lew JI, Egan A, Christos P, et al. Construct validity for the LAPSIM laparoscopic surgical simulator. Surg Endosc 2005;19:401-5.  Back to cited text no. 2
    
3.
Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91:146-50.  Back to cited text no. 3
    
4.
Korndorffer JR, Bellows CF, Tekian A, Harris IB, Downing SM. Home laparoscopic simulation training. Am J Surg 2012;203:1-7.  Back to cited text no. 4
    
5.
Sihombing AT, Sibarani J, Sudigdo A. Effectiveness of low-cost laparoscopic training box to increase laparoscopic skills in urology training centre universitas padjadjaran/hasan sadikin general hospital. Open Access Libr J 2017;4:3412.  Back to cited text no. 5
    
6.
Dhariwal AK, Prabhu RY, Dalvi AN, Supe AN. Effectiveness of box trainers in laparoscopic training. J Minim Access Surg 2007;3:57-63.  Back to cited text no. 6
    
7.
van Hove PD, Tuijthof GJ, Verdaasdonk EG, Stassen LP, Dankelman J. Objective assessment of technical surgical skills. Br J Surg 2010;97:972-87.  Back to cited text no. 7
    
8.
Korndorffer JR. Home laparoscopic simulation training. Am J Surg 2012;203:1-7.  Back to cited text no. 8
    
9.
Hunter JG, Sackier JM, Berci G. Training in laparoscopic cholecystectomy. Quantifying the learning curve. Surg Endosc 1994;8:28-31.  Back to cited text no. 9
    
10.
Scott DJ, Young WN, Tesfay RN, Frawley WH, Rege RV, Jones DB. Laparoscopic skills training. Am J Surg 2001;182:137-42.  Back to cited text no. 10
    
11.
Mohan P, Chaudhry R. Laparoscopic simulators: Are they useful! Med J Armed Forces India 2009;65:113-7.  Back to cited text no. 11
    
12.
Saxena A. Smartphone-tablet based laparoscopy stimulation system. World J Laparosc Surg 2016;9:26-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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