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Video: Cognitive training for technical and non‐technical skills in robotic surgery

Cognitive training for technical and non‐technical skills in robotic surgery: a randomised controlled trial

Abstract

Objective

To investigate the effectiveness of motor imagery (MI) for technical skill and non‐technical skill (NTS) training in minimally invasive surgery (MIS).

Subjects and Methods

A single‐blind, parallel‐group randomised controlled trial was conducted at the Vattikuti Institute of Robotic Surgery, King’s College London. Novice surgeons were recruited by open invitation in 2015. After basic robotic skills training, participants underwent simple randomisation to either MI training or standard training. All participants completed a robotic urethrovesical anastomosis task within a simulated operating room. In addition to the technical task, participants were required to manage three scripted NTS scenarios. Assessment was performed by five blinded expert surgeons and a NTS expert using validated tools for evaluating technical skills [Global Evaluative Assessment of Robotic Skills (GEARS)] and NTS [Non‐Technical Skills for Surgeons (NOTSS)]. Quality of MI was assessed using a revised Movement Imagery Questionnaire (MIQ).

Results

In all, 33 participants underwent MI training and 29 underwent standard training. Interrater reliability was high, Krippendorff’s α = 0.85. After MI training, the mean (sd) GEARS score was significantly higher than after standard training, at 13.1 (3.25) vs 11.4 (2.97) (P = 0.03). There was no difference in mean NOTSS scores, at 25.8 vs 26.4 (P = 0.77). MI training was successful with significantly higher imagery scores than standard training (mean MIQ score 5.1 vs 4.5, P = 0.04).

Conclusions

Motor imagery is an effective training tool for improving technical skill in MIS even in novice participants. No beneficial effect for NTS was found.

Article of the week: Cognitive training for technical and non‐technical skills in robotic surgery: a randomised controlled trial

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a video produced by the authors.

If you only have time to read one article this week, it should be this one.

Cognitive training for technical and non‐technical skills in robotic surgery: a randomised controlled trial

Nicholas Raison* , Kamran Ahmed*, Takashige Abe*, Oliver Brunckhorst*, Giacomo Novara, Nicolo Buf§, Craig McIlhenny, Henk van der Poel**, Mieke van Hemelrijck††, Andrea Gavazzi‡‡ and Prokar Dasgupta*

 

*Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, Kings College London, UK, ††Division of Cancer Studies, Kings College London, UK, Department of Urology, Forth Valley Royal Hospital, Larbert, UK, Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan, Department of Urology, University of Padua, Padua, §Department of Urology, Humanitas Clinical and Research Centre, Rozzano, Milan, ‡‡Department of Urology, Azienda USL Toscana Centro, Florence, Italy, and **Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands

 

Visual Abstract created by Rebecca Fisher @beckybeckyfish

Abstract

Objective

To investigate the effectiveness of motor imagery (MI) for technical skill and non‐technical skill (NTS) training in minimally invasive surgery (MIS).

Subjects and Methods

A single‐blind, parallel‐group randomised controlled trial was conducted at the Vattikuti Institute of Robotic Surgery, King’s College London. Novice surgeons were recruited by open invitation in 2015. After basic robotic skills training, participants underwent simple randomisation to either MI training or standard training. All participants completed a robotic urethrovesical anastomosis task within a simulated operating room. In addition to the technical task, participants were required to manage three scripted NTS scenarios. Assessment was performed by five blinded expert surgeons and a NTS expert using validated tools for evaluating technical skills [Global Evaluative Assessment of Robotic Skills (GEARS)] and NTS [Non‐Technical Skills for Surgeons (NOTSS)]. Quality of MI was assessed using a revised Movement Imagery Questionnaire (MIQ).

Results

In all, 33 participants underwent MI training and 29 underwent standard training. Interrater reliability was high, Krippendorff’s α = 0.85. After MI training, the mean (sd) GEARS score was significantly higher than after standard training, at 13.1 (3.25) vs 11.4 (2.97) (P = 0.03). There was no difference in mean NOTSS scores, at 25.8 vs 26.4 (P = 0.77). MI training was successful with significantly higher imagery scores than standard training (mean MIQ score 5.1 vs 4.5, P = 0.04).

Conclusions

Motor imagery is an effective training tool for improving technical skill in MIS even in novice participants. No beneficial effect for NTS was found.

Read more Articles of the week

 

Should we abandon live surgery: reflections after Semi-Live 2017

Prokar_v2Ever since 2002, I have performed live surgery almost every year where it is transmitted to an audience eager to learn. This year I was invited by Markus Hohenfellner to the unique conference, Semi Live 2017 in Heidelberg. To say that it was an eye opener is perhaps stating the obvious. One look at the program will show you that the worlds most respected Urological surgeons had been invited to participate, but with a difference. There was no live surgery. Instead videos of operations – open, laparoscopic and robotic were shared with the attendees “warts and all” as a learning experience. These were not videos designed to show the best parts of an operation. There were plenty of difficult moments, do’s and don’ts and troubleshooting, but all this was achieved without causing harm or potential harm to a single patient.

My highlights were laparoscopic sacrocolpopexy (Gaston), robotic IVC thrombectomy up to the right atrium (Zhang) and reconstructive surgery for the buried penis (Santucci). The event takes place every 2 years and the videos are all available on the meeting app which can be downloaded here and is an outstanding educational resource.

We were treated to a heritage session which included the superstars Walsh, Hautmann, Clayman, Mundy, Schroder and Ghoneim. This was followed by our host Markus Hohenfellner comparing and contrasting the art of Cystectomy and reconstruction by Ghoneim, Stenzl and Studer.

 

Open surgery is certainly not dead yet. The session ended with Seven Pillars of Wisdom from Egypt which turned out to be a big hit on Twitter.

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The editor’s choice session, a new innovation for 2017, allowed me to showcase the Best of BJUI Step by Step, a section that has now replaced Surgery Illustrated with fully indexed and citable HD videos and short papers.

Has live surgery had its day?

Many on Twitter seemed to agree that in 20 years time we might look back and say that it was not the right thing to do.

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Surgeons do not operate “live” every day. Most doctors in a survey, would not subject themselves or their families to be patients during live surgery. Talk about hypocrisy!! Why should it be any different for our patients? Live surgery is NOT a blood sport practised in Roman times….

The counterpoint is that patients often have the services of the best surgeons during live surgery, recorded, edited videos are not quite the same and that the whole affair has become safer thanks to patient advocates and strict guidelines from some organisations like the EAU. Others have banned the practice for good reason. While the debate continues, I for one came away feeling that Semi-Live was as educational, less stressful and much safer for our patients.

 

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

 

RSM Urology Winter Meeting 2017, Northstar, California

rsm-2017-blogThis year’s Annual RSM Urology Section Winter Meeting, hosted by Roger Kirby and Matt Bultitude, was held in Lake Tahoe, California.

A pre-conference trip to sunny Los Angeles provided a warm-up to the meeting for a group of delegates who flew out early to visit Professor Indy Gill at the Keck School of Medicine.  We were treated to a diverse range of live open, endourological and robotic surgery; highlights included a salvage RARP with extended lymph node dissection and a robotic simple prostatectomy which was presented as an alternative option for units with a robot but no/limited HoLEP expertise.

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On arrival to Northstar, Dr Stacy Loeb (NYU) officially opened the meeting by reviewing the social media urology highlights from 2016. Next up was Professor Joseph Smith (Nashville) who gave us a fascinating insight into the last 100 years of urology as seen through the Journal of Urology. Much like today, prostate cancer and BPH were areas of significant interest although, in contrast, early papers focused heavily on venereal disease, TB and the development of cystoscopy. Perhaps most interesting was a slightly hair-raising description of the management of IVC bleeding from 1927; the operating surgeon was advised to clamp as much tissue as possible, close and then return to theatre a week later in the hopes the bleeding had ceased!

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With the promise of beautifully groomed pistes and stunning views of Lake Tahoe, it was hardly surprising that the meeting was attended by a record number of trainees. One of the highlights of the trainee session was the hilarious balloon debate which saw participants trying to convince the audience of how best to manage BPH in the newly inaugurated President Trump. Although strong arguments were put forward for finasteride, sildenafil, Urolift, PVP and HoLEP, TURP ultimately won the debate. A disclaimer: this was a fictional scenario and, to the best of my knowledge, Donald Trump does not have BPH.

The meeting also provided updates on prostate, renal and bladder cancer. A standout highlight was Professor Nick James’ presentation on STAMPEDE which summarized the trial’s key results and gave us a taste of the upcoming data we can expect to see in the next few years.

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We were fortunate to be joined by prominent American faculty including Dr Trinity Bivalacqua (Johns Hopkins) and Dr Matt Cooperberg (UCSF) who provided state-of-the-art lectures on potential therapeutic targets and biomarkers in bladder and prostate cancer which promise to usher in a new era of personalized therapy.

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A personal highlight was Tuesday’s session on learning from complications. It was great to hear some very senior and experienced surgeons speaking candidly about their worst complications. As a trainee, it served as a reminder that complications are inevitable in surgery and that it is not their absence which distinguishes a good surgeon but rather the ability to manage them well.

There was also plenty for those interested in benign disease, including topical discussions on how to best provide care to an increasingly ageing population with multiple co-morbidities. This was followed by some lively point-counterpoint sessions on robot-assisted versus open renal transplantation (Ravi Barod and Tim O’Brien), Urolift vs TURP (Tom McNicholas and Matt Bultitude) and HOLEP vs prostate artery embolization for BPH (Ben Challacombe and Rick Popert). Professor Culley Carson (University of North Carolina) concluded the session with a state-of-the art lecture on testosterone replacement.

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In addition to the excellent academic programme, delegates enjoyed fantastic skiing with perfect weather and unparalleled views of the Sierra Nevada Mountains. For the more adventurous skiiers, there was also a trip to Squaw Valley, the home of the 1960 Winter Olympics. Another highlight was a Western-themed dinner on the shores of Lake Tahoe which culminated in almost all delegates trying their hand at line dancing to varying degrees of success! I have no doubt that next year’s meeting in Corvara, Italy will be equally successful and would especially encourage trainees to attend what promises to be another excellent week of skiing and urological education.

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Miss Niyati Lobo
ST3 Urology Trainee, Brighton and Sussex University Hospitals NHS Trust

@niyatilobo

 

That’s what’s wrong with you and your ‘Star Wars’ generation

NathanJust a few years ago whilst operating, I was curious to find out about one of our unit’s patients on the ward. We still had a bit of time to go in the current case, a retroperitoneal lymph node dissection. There was a chance the patient on the ward would require surgery and being at that time of the day an earlier ‘heads up’ is always best. One of the theatre staff kindly paged our resident. It was 5.05pm. No response. The other resident who was scrubbed directed them to get the resident’s mobile phone and call direct. This did not seem unreasonable – perhaps they were tied up. Maybe the phone could rouse him?  Ring ring… Finally an answer. It’s the urology team wanting an update from the ward. “Sorry I’m in the car”. Have you rounded yet? Sort of. Is there a handover? Silence. We’ll call you back later!’

I was astounded at two things – the resident having clearly left without giving a handover in person (or verbally) and the fact that they appeared to have left without the customary afternoon ward round being conducted. I grumbled and sent the other resident up to check on the patient. Was I becoming one of those ‘grumpy old surgeons ‘ whining at the ‘youth of today’? I didn’t think so as what was expected was probably the minimum expected.

Fast forward two weeks. Same time being 5.05pm and the same resident actually appears in person to give handover (were they learning?) I couldn’t miss the chance to poke at him “What a surprise – you’re still here and it’s after 5pm!” The scrub nurse and registrar and Anaesthetist all laughed having been there when he was in the car on the prior occasion. Clearly smarting he quipped “That’s what’s wrong with you and your ‘Star Wars’ generation”… “What do you mean? what’s wrong?” I quizzed. He thought… then responded: “You all think you are the only ones who have worked hard and that all Gen Y doctors are lazy… You guys shoe-box all of us… .”. I pointed out I was miffed that he had left without handover. He claimed all was fine with the ward and had no real excuse for not giving handover but no ill effects happened and the patient in question avoided theatre. “Only just” I added.

All the while the ‘Star Wars’ jibe had gotten under my skin. His blatant and underhand use of the name of a movie that was perhaps the “God amongst Gods” being a classic tale of good and evil that had delivered many new words and ideas and music to at least one generation…

I took my time. So wanting to get it out of my system I chose my words carefully: “So you say ‘I’m part of the ‘Star Wars’ generation’ so that must make you… part of the ‘Avatar’ generation?” He paused… “That’s right – you are exactly right”. This was potentially going to be fun.

OK. “So remind me, who were the lead characters on Avatar? The female lead Avatar?” Deafening silence…. “What about the actors’ names?” … Silence…… I then pointed out it was embarrassing given one was Australian and I couldn’t help but point out the other I quickly recalled being Sigourney Weaver!

Maybe I was being a bit hard – “OK, what was the mineral they were mining on their planet?” Silence …….”unobtainium!” I yelped… “Who could forget that? Alright give me a line from the movie, any line?” Silence …. “Alright hum me the ‘Theme to Avatar'”… Again, silence.

I paused, then in a friendly way with a wry smile, I stated: “May the force be with you!” and gleefully hummed the well known Star Wars theme… as he ducked off….

So was this reinforcing the stereotypes that Gen Y is all flash and glamour with No Substance?

Probably not, but it teaches us that one generation is not that far from the next (the other resident a Gen Y knew more about Star Wars than I did!!). And subsequently I have had some of the best residents ever. So it is all about attitude and understanding what is required. The resident really lifted their game after this, which was excellent and they ended up with a great report – having taken on board the veiled but constructive “criticism”.

Honesty and communication is the best policy, sometimes laced with humour and by doing this “Help them, you will”.

 

Nathan Lawrentschuk @lawrentschuk

University of Melbourne, Department of Surgery and Ludwig Institute for Cancer Research, Austin Hospital and Peter MacCallum Cancer Centre, Department of Surgical Oncology, Melbourne, VIC, Australia

 

Article of the month: The surgical spectacle

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The surgical spectacle: a survey of urologists viewing live case demonstrations

Sammy E. Elsamra, Mathew Fakhoury, Hector Motato, Justin I. Friedlander, Daniel M. Moreira, Joel Hillelsohn, Brian Duty, Zeph Okeke and Arthur D. Smith

The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA

Read the full article
OBJECTIVE

• To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD).

METHOD

• A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris).

RESULTS

• Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training.

• Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P < 0.001, respectively). Nearly no one selected ‘not helpful’ and a few selected ‘minimally helpful’ for any of the three forms of demonstration.

• Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos.

• Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019).

• A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice.

CONCLUSIONS

• Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice.

• LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD.

• Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care.

 

Read more articles of the week

Editorial: Do live case demonstrations have a future in surgical education?

The ever increasing desire for instant access to information is a reflection of our times facilitated by social networks and by video and information technology. Nowadays, sport events are dissected and quantified from every possible perspective. We know almost real-time any detail of a soccer match: how many miles each player runs, how many good or bad passages of play, how many faults and so on, including if needed the details of heart rate and weight loss. The same and even more is available for example in formula one racing. Theoretically the same could easily be applied to surgical performance and it is foreseeable it will be applied, as a self-performance improvement method and as a development of one of the most popular ‘scientific and educational’ activities during surgical meetings, live case demonstrations (LCDs). All this, together with simulation, could in the near future have a tremendous impact on surgical performance and training. Twitter and Instagram show the power of the immediate real-time diffusion of events, as condensed as possible, so that the tweet or the instantaneous image can be visible and digested without losing time. Video clips follow the same concept and certainly BJUI is pioneering the use of short surgical video clips that are easily accessible and usable at any spare time of a busy day.

The core issue about LCDs is that at present there is no solid scientific evidence of their educational value, and this is outlined in the paper by Elsamra et al. [1] published in this issue of BJUI, which commendably attempts to evaluate the educational benefit of LCDs in terms of perception, clearly not a very strong criterion.

Data about the outcomes of live surgery operations are scant. Clearly patient’s safety is the first goal of any surgical activity, and this applies to LCDs. As mentioned in the paper, the European Association of Urology (EAU) Executive felt the urgent need to establish procedures and regulations in order to endorse live surgery events. The reader can find all related information on the EAU website. These regulations are meant to be in the best interest of patients, surgeons and organisers. Among others, one important innovation is the requisite of a ‘patient advocate’ present during the LCD, being an experienced medical doctor, independent from the organising committee of the educational event, in charge of advising in case of unexpected events, which can endanger patient’s safety.

Moreover, the EAU has established a prospective database of all endorsed live surgery events. This will hopefully allow in a few years an answer, with solid data, to the question of whether an intervention performed during a live surgery event has the same outcome compared with the same intervention executed by the same surgeon in his usual environment. The more challenging goal is to quantify the educational value of a live surgical event and the jump from perception to scientific evidence is far from being an easy task.

Walter Artibani
Urologia – Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy

Read the full article

Reference

  1. Elsamra SE, Fakhoury M, Motato H et al. The surgical spectacle: a survey of urologists viewing live case demonstrationsBJU Int 2014; 113: 674–678
 

Editorial: VR simulators can improve patient safety

You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.

Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.

Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.

Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.

Roger Kirby
The Prostate Centre, London W1G 8GT

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