Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience

Background

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform the surgery under the supervision of a trained surgeon. This is costly, time consuming, and is of variable effectiveness. Laparoscopic surgery involves use of instruments using key-hole incisions and is generally considered more difficult than open surgery. Training using box models (physical simulation) is an option to supplement standard laparoscopic surgical training. The impact of box model training in surgical trainees with limited prior laparoscopic experience is unknown. We sought to answer the question of whether the box model training is useful in such trainees in terms of improving technical outcomes by performing a thorough search of the medical literature for randomised clinical trials. Randomised clinical trials are commonly called randomised controlled trials and are the best study design to answer such questions. If conducted well, they provide the most accurate answers to questions about intervention effects. Two authors searched the medical literature available to May 2013 and obtained the information from the identified trials. The use of two authors decreases the errors in obtaining the information.

Study characteristics

We identified and included seven trials in which 249 surgical trainees with limited previous laparoscopic experience received either box model training in addition to their standard apprenticeship training (122 trainees) versus standard apprenticeship training alone (127 trainees). The choice of whether the trainees received supplementary box model training was made in a random method similar to the toss of a coin. Six trials were conducted in USA and one trial in Canada. After supplementary box model training or standard training, the performance of the trainees was evaluated on their first operation after supplementary box model training and during the first operation in humans after an equivalent time after standard training. Different trials assessed the performance in different operations and all these operations were minor to moderate operations.

Key results

Three trials including 168 trainees reported the complications that the patients developed during or immediately after the operation. There were no deaths in either group in 168 operations performed by 168 trainees and we could not tell whether laparoscopic box model training led to major complications (one major complication in one patient operated by a trainee who underwent standard training out of 86 operations performed by trainees who underwent standard training as compared with no major complications in 82 operations performed by trainees who underwent box model training). None of the trials reported patient quality of life. One trial reported a small reduction in operating time of just over six minutes in the supplementary box model training group. The remaining trials did not report operating time. In one trial, the proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group (24/24 (100%)) compared with the standard training group (15/26 (57.7%)). The remaining trials did not report the proportion of people who stayed overnight. None of the trials reported trainee satisfaction. The operating performance as assessed by surgical experts was significantly better in the supplementary box model training group compared with the standard training group. None of the trials compared box model training compared with animal model training or compared with different methods of box model training. Laparoscopic box model training appears to improve technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and decrease the proportion of patients who require overnight stay in the first hernia repair operation that the trainee performed after box model training. However, the duration of the benefit of box model training (ie, whether such benefit continues in subsequent operations) is unknown.

Quality of evidence

Only one trial including 50 trainees was at low risk of bias (no risk of arriving at wrong conclusions because of favouritism by the researchers). Overall, the quality of evidence was very low.

Future research

Further well-designed trials with less risk of bias because of poor study design or because of chance are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes.

Authors' conclusions: 

There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Read the full abstract...
Background: 

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown.

Objectives: 

To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

Selection criteria: 

We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training.

Data collection and analysis: 

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

Main results: 

We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.

There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).

None of the trials compared box model training versus animal model training or versus different methods of box model training.

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