N101-094 TITLE: Prevention of Laparoscopic Surgical Skill Attrition

TECHNOLOGY AREAS: Biomedical, Human Systems

ACQUISITION PROGRAM: Capable manpower

OBJECTIVE: Provide to U.S. Military new capabilities to support minimally invasive surgical (MIS) Laparoscopic surgery procedures, reducing the need for extensive retraining and providing new validation methodologies.

Provide US military health care providers and their Interagency partners with objective metrics and measurement techniques to conduct validation for immersive and simulate training environments (e.g., virtual).and with new training strategies that will prevent decay of these highly perishable skills.

DESCRIPTION: Minimally invasive surgery (MIS) has many benefits over traditional types of surgery. (MIS) results in less pain, less scarring, and shorter recovery times for patients, as well as significantly reduced costs. The skills required for laparoscopic surgery vary greatly from those involved in traditional surgical methods, and thus require extensive specialized training. However, research has indicated that MIS is associated with higher rates of complications than traditional surgery. A few studies have demonstrated that virtual reality training translates to improved laparoscopic skills in the operating room [1] [2] [3] [4]. However, the primary methods of assessment and evaluation are inherently subjective. For example, time to completion is a poor metric for the objective assessment of laparoscopic task performance [5], and that when untrained subjects are learning a laparoscopic manipulative task, measurement of time alone fails to account for the more protracted learning curve for accuracy; thus, devices and training programs that fail to consider objective assessments of accuracy may overestimate laparoscopic proficiency [6].

Over the past decade, attempts have been made to establish standards for MIS training and evaluation. Using virtual reality simulators to determine what constitutes surgical skill proficiency, and how it is to be objectively assessed within training [7], further validation of the specific metrics used is needed. These metrics must demonstrate reliability, validity, practicality, and consistency with measures of high quality surgery in the operating room in order to provide the basis for proficiency-based learning programs [8].

Moreover, little is known about the durability of acquired surgical skills. Some studies have shown the retention of laparoscopic surgical skills to be high over periods of up to 11 months, with practice impacting the rate of decay [9] [10] [11]. However, these studies have relied primarily on subjective simulator-based metrics for assessment, which have been shown to be unrelated to transferring skills over extended periods of time [12]. A successful candidate proposal would develop a conceptual model and objective measures to reliably assess surgical skill acquisition, proficiency, and decay/retention.

PHASE I: Execute a research program that includes the development of a skill decay model for (MIS) that identifies those skills that are the most perishable and their rate of decay. Identify objective methods and measures to reliably assess these skills. The primary research question is, are their differences in the skill decay rate for different types of skills (cognitive vs. psychomotor skills)? Are their individual differences across the continuum of novice to expert surgeons in the rate and types of skill decay?

PHASE II: Develop a simulation based prototype training module, refresher training, based on the research results of Phase1. Provide proof-of-concept demonstration of training module and reliability and validity estimates of measures of skills developed in Phase 1.The results of this project could also be used to develop initial simulation based training to train MIS skills that are resistant to decay. The prototype should be open architecture and open sources and scalable to meet future needs.

PHASE III: Provide US military health care providers and their Interagency partners with objective metrics and measurement techniques to conduct validation for immersive and simulate training environments (e.g., virtual).and with new training strategies that will prevent decay of these highly perishable skills.

PRIVATE SECTOR COMMERCIAL POTENTIAL/DUAL-USE APPLICATIONS: Has USG-wide and possibly Multinational and International application (United Nations, NATO).

REFERENCES:
1. James C. Rosser, MD; Ludie E. Rosser; Raghu S. Savalgi. (1997). Skill Acquisition and Assessment for Laparoscopic Surgery. Arch Surg. 132(2), 200-204.

2. Ahlberg G, Enochsson L, Gallagher AG, Hedman L, Hogman C, McClusky DA 3rd, Ramel S, Smith CD, Arvidsson D. (2007). Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg. 193(6), 797-804.

3. Van Sickle KR, Ritter EM, Baghai M, Goldenberg AE, Huang IP, Gallagher AG, Smith CD. (2008). Prospective, randomized, double-blind trial of curriculum-based training for intracorporeal suturing and knot tying. J Am Coll Surg. 207(4), 560-8.

4. J.Korndorffer, Jr, J.Dunne, R.Sierra, D.Stefanidis, C.Touchard, D.Scott. (2005). Simulator training for laparoscopic suturing using performance goals translates to the operating room. Journal of the American College of Surgeons. 201 (1), 23-29.

5. A. L. McCluney, M. C. Vassiliou, P. A. Kaneva, J. Cao, D. D. Stanbridge, L. S. Feldman, G. M. Fried. (2007).FLS simulator performance predicts intraoperative laparoscopic skill. Surgical Endoscopy. 21(11), 1991-5.

6. Nathaniel J. Soper, and Gerald M. Fried, MD, FACS (2008). The Fundamentals of Laparoscopic Surgery: Its time has come. Bulletin of the American College of Surgeons. 93 (9).

7. Cosman, Peter H; Cregan, Patrick C; Martin, Christopher J; Cartmill, John A. (2002). Virtual reality simulators: Current status in acquisition and assessment of surgical skills. Review Articles. ANZ Journal of Surgery. 72(1), 30-34.

8. Fried GM. Feldman LS. (2008). Objective assessment of technical performance. World J Surg. 32(2),156-160

9. Winfred Arthur Jr; Winston Bennett Jr; Pamela L. Stanush; Theresa L. McNelly (1998). Factors That Influence Skill Decay and Retention: A Quantitative Review and Analysis. Human Performance. 11(1) 57 -101.

10. Stefanidis D, Korndorffer JR Jr, Markley S, Sierra R, Scott DJ. (2006). Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg. 202(4), 599-603.

KEYWORDS: skill decay, surgical skills, expert , novices

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