Cir Cir 2013;81:386-392.

New technologies in minimally invasive surgery training: what do surgeons demand? Luisa Fernanda Sánchez-Peralta,1 Javier Sánchez-Fernández,2 José Blas Pagador,1 Francisco Miguel Sánchez-Margallo3

Abstract Background: Minimally invasive surgery may greatly benefit from the information and communications technologies. The objective of this work is to determine the best approach to include those technologies, in particular an e-Learning platform, into an in-person training course. Methods: An online survey was sent to all participants in any of the laparoscopic training courses at Jesús Usón Minimally Invasive Surgery Centre. This survey included questions regarding new technologies used for training. Once all data were gathered, a descriptive analysis was performed. Results: There were 382 questionnaires sent of which 102 were correctly returned. This indicates a response rate equal to 30%. Current theoretical training means are watching surgical videos (85 – 83.3%) and assisting at in-person training courses (77 – 75.5%). Participants rated as useful the use of new technologies for training (4.1 ± 0.9) and would mainly use it both before and after assisting at an in-person training course (80 – 78.4%). Conclusions: A methodology is proposed that provides participants with didactic resources based on surgical videos, both before and after assisting at an in-person training course. Through the application of this methodology, an improvement and reduction of the time that surgeons expend in training is the goal. Key words: Surgical procedures, minimally invasive, laparoscopy education, education, distance, multimedia.

Introduction Because of the large adoption of minimally invasive surgery as a routine surgical practice, training of surgeons in this area has currently become a need.1,2 This is evident by the recently approved changes included in the Specialty Training Programme in General Surgery and Gastroenterology3 and analyzed by the Postgraduate Training Section of the Spanish Association of Surgeons.4 In

1 2

Unidad de Bioingeniería y Tecnologías Sanitarias, Coordinación de Formación, 3Dirección Científica, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain

Correspondence: Luisa F. Sánchez Peralta Unidad de Bioingeniería y Tecnologías Sanitarias Centro de Cirugía de Mínima Invasión Jesús Usón Ctra. N-521, km 41.8 10071 Cáceres, Spain Tel: +34 927 18 10 32 Fax: +34 927 18 10 33 E-mail: [email protected] Received: 2-20-13 Accepted: 8-13-13

addition to residents training, it is necessary to consider the lifelong learning of professionals.5 Because minimally invasive surgery has witnessed rapid developments, it is essential for surgeons to maintain updated knowledge. So far there is no standardized training model for minimally invasive surgery because of complications that the surgeon must face compared with the widely accepted Halsted model2,6 and the fact that European regulations require personnel to work 48 h a week and society has increased awareness about patient security. Apparently, there is not a unique training model, but it is possible to have models that include a combination of training surgeries, specialization courses, tutoring and application of new technologies.7 In any case, all training should aim to train more surgeons in less time, to carry out interventions in the best possible way, providing the best outcome for patients.6 E-learning is one of the new technologies available that uses the Internet to distribute educational materials from a central location to users who are in different locations. This minimizes time-related barriers because users are not limited by schedule or specific location (access to content is ubiquitous) or costs (absence of travel expenses to training centers).8 Therefore, the inclusion of an e-Learning platform on a traditional training program, which requires in-person attendan-

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ce, could be a combination that improves surgical training. This study aims to determine how new e-Learning technologies can be included in in-person training programs so that acceptance by end users is as high as possible. We designed an easy survey for laparoscopic surgery trainees at the Jesús Usón Center for Minimally Invasive Surgery (JUMISC). Using the results from the survey, the study includes the design of a proposed model that combines e-Learning with an in-person training program.

Materials and Methods An on-line survey was provided to trainees attending the laparoscopic surgery course at JUMISC via the web platform SurveyMonkey (www.surveymonkey.com). The link to the survey was sent by e-mail explaining the study objectives and instructions in regard to completing the survey. The e-mail addresses were obtained from the JUMISC database, which adheres to the General Registry of the Spanish Data Protection Agency. All legal requirements were met. The survey contained two sets of questions: one related to demographics and the other related to new technologies used for training in addition to other blocks without interest for the present study. Surveyed trainees were prompted about current tools they use and were required to assess an e-Learning process and its usefulness. The questionnaire included direct response, multiple-choice questions and Likert 5-point scale (1 being the lowest score and 5 the highest). The survey ended with an open comment section. To validate the survey, check the comprehensibility, detect ambiguities and ensure adequate semantics, a pilot test was carried out beforehand with ten users. Results from the initial sampling were not included in this study. An invitation was sent initially to all participants who had provided an e-mail address during registration for classroom courses at JUMISC. A week later, a reminder was sent to all addresses that had not responded to the questionnaire. The responses were tabulated as quantitative and qualitative variables and were analyzed using the Survey Monkey platform. Due to sample size, design and purpose of the study, no variables relationship analysis was carried out.

Results The study considered 427 participants from any laparoscopic surgery courses at JUMISC. Of these participants, 270 (63.2%) were male and 157 (36.8%) were female; 414 provided an e-mail address in the registration form and 32 were involved in more than one training activity. Therefore, the population for the actual study was reduced to

382 students. Of 382 surveys sent, 42 (11.0%) were returned by e-mail servers and 104 were completed. Of surveys, 102 (26.7%) were regarded as valid, with a response rate of 30% defined as the number of valid responses received from the total questionnaires sent successfully. Demographic results are shown in Table 1. Surgical experience for participants was 11.71 ± 8.7 years (range 0.5-35 years) of previous experience as a surgeon in their specialty. The use of video as a training tool in minimally invasive surgery (Figure 1) was rated positively by 100% of students. The majority described them as either essential (42-41.2%) or recommended (48-47.1%). Students were asked about the tools they use to acquire theoretical knowledge; favored options were watching surgical videos and attending courses or seminars (Figure 2). As this was a multiple-choice question, users were able to select as many responses as they considered necessary, so percentages exceed 100%. The survey covered the assessment of four aspects related to the inclusion of new technologies such as the Internet or e-Learning, applied to theoretical training in minimally invasive surgery. The following results were obtained on a 5-point Likert scale (Figure 3): usefulness was rated with 4.14 ± 0.9 points; acceptance by the surgeon scored 3.89 ± 0.9 points, ease of access to content was scored with 4.18 ± 0.8 points and, finally, 3.9 ± 0.9 points for credibility. As for the utility and use of a custom web platform, results are shown in Figure 4, including the relationship between the assessment made by participants and the time they would use the platform using larger or smaller spheres depending on frequency. Overall results of each option were either to the right of the graph for assessing utility or at the top of the graph for platform usage time. We can observe the highest frequencies match when both maximum scores are combined (4-5) and the use before and after attending a training course.

Discussion First we should acknowledge a 30% response rate compared with similar study responses9,10 in spite of attempts to increase this response rate.11 This participation level may be motivated by the survey itself (writing complex, unattractive or excessively long surveys) or selected channel, which could lead to a selection bias because participants who are more interested or familiar with the use of new technologies may show further interest in responding to the survey.12 However, percentages of males and females attending courses and responses were very similar; therefore, we can draw trends of current perceptions of minimally invasive surgery trainees even though carrying out a statistical analysis is not feasible.

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Table 1. Demographics of the participants

Essential 50 45

No. of responses

%

40

Question

Response options

Gender

Male

68

66.7

Female

34

33.3

25

65

0

0.0

1st year resident

0

0.0

2nd year resident

1

1.0

3rd year resident

2

2.0

4th year resident

3

2.9

35

Age (years)

Workplace

Specialty

5th year resident

8

7.8

Area specialist

52

51.0

Adjunct

22

21.6

Head of Section

3

2.9

Head of Service

5

4.9

Other

6

5.9

General and GI surgery

32

31.4

Gynecology

16

15.7

Urology

37

36.3

Thoracic surgery

6

5.9

Pediatric surgery

8

7.8

Otorhinolaryngology

3

2.9

72

70.6

Private

11

10.8

Both

19

18.6

Work sector Public

Undoubtedly, information technology and communications provide added value to training processes in many different fields. There are emerging initiatives in medical training based on the former13,14 including e-Learning15-17 platforms and surgical videos.18 Because e-Learning has great potential for surgical training,19 it is interesting to determine how these new tools can be reconciled with short in-person training courses, which are currently the most common way of training in minimally invasive surgery7 resulting in improvements in clinical practice20 , in order to optimize the time surgeons devote to training. Therefore, our approach (Figure 5) is to combine e-MIS (eLearning and multimedia content for minimally invasive surgery21) with in-person training courses such as those in-

Unecessary

30

Recommended

10 5 0

Nonessential

Useful

Figure 1. Assessment of the use of surgical videos as tools in training in minimally invasive surgery.

cluded in the training methodology at JUMISC.22-24 Before participating in a training course, the trainee could use an e-Learning platform (adapted to surgical specialty and experience, previous training, etc.) where he/she could gather information on theoretical concepts related to the upcoming course: anatomy, surgical instruments involved, ergonomic recommendations, techniques description, intervention steps and others by watching multimedia content and surgical videos. A hands-on practice will be carried out during in-person courses and, afterwards, the trainee will be able to review learned concepts using an e-Learning platform, ask questions directed at the experts, foresee complications or query about news in the field. Thus, participants could perform the theoretical training remotely while they optimize the time outside their workplace for hands-on activities. The media currently used for theoretical training are mainly attending courses and visualization of surgical videos, followed by the literature search and CDs/DVDs. The established methodology will bring these together in a single training environment under the “umbrella” of recognized training institutions and integrating well-established training courses. In view of the assessment attendees make about surgical videos as a training tool, it appears they need to be included in any training tool, considering that these resources are easily created with the currently available computer programs.25 In our view, these surgical videos can be edited and supplemented with additional material to ge-

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90 80 70 60 50 40 30 20 10 Others

Consult with expert

Specialized Web pages

Attendance at courses and seminars

Visualization of surgical videos

Consult literature (journals, books, etc.)

CDs/DVDs

0

Figure 2. Current methods for theoretical training in minimally invasive surgery.

5.00 4.50

4.14

4.00

3.89

4.18

3.90

3.50 3.00 2.50 2.00 1.50 1.00 0.50 Credibility

Easy access to contents

Surgeon acceptance

Usefulness

0.00

Figure 3. Rating of different aspects associated with the inclusion of new technologies in theoretical training for minimally invasive surgery using a 5-point Likert scale (1 min, 5 max).

nerate appropriate teaching materials for e-Learning environments,26 thus increasing their educational value. Despite all the advantages provided by an e-Learning trai-

ning program, we need to keep in mind that it also requires an ongoing effort to maintain quality content that is updated and that encourages user participation. A critical component in any training process is feedback and these should be included in the platform because it is regarded as an appropriate method to encourage user participation.27 Also keep in mind that the acceptance and credibility of new technologies used for theoretical training in minimally invasive surgery is currently low. However, we believe future generations, including Gen Y,28 are increasingly used to new technologies in every aspect of their life as they have used mobile phones, computers and technology with immediate access to information 24/7 during their lifetime along with Web 2.0 technologies (such as instant messaging, videoconferencing, social networking, blogs etc.). Therefore, it seems likely that soon there will be new technologies such as e-Learning, which will be integrated into any training program, especially in surgery. In addition, it will be necessary to establish new channels such as social networks that enable communication in line with technological advances as reported by other authors29 without neglecting professionalism.30 Another new development that may have a major impact on training, especially for medical residents, are the so-called serious games, which include different aspects of computer-based training with a very creative component.31 Although some studies have been carried out in this regard, we believe that it is interesting to advance research in this field and to de-

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5( Much)

4

3

2

1(None)

Ns/Nc Would not use it

Ns/Nc

Before formation course

After formation course

Before and after formation course

Figure 4. Bubble graph between the assessment of a custom web platform (vertical axis) and when it would be used (horizontal axis).

Figure 5. Methodology for the inclusion of an e-Learning platform.

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termine the effectiveness of these new training systems. From the proposed training scheme, future work will focus on the development of appropriate teaching materials for a particular course and then conduct a pilot study that reveals possible improvements. Because there is a history of the benefits of combining multimedia content with basic skills training32 and the use of e-Learning,19 we are confident that these results can be reproduced in advanced training of minimally invasive surgery. To carry out this pilot study, TELMA16 environment will be used, which provides an online training environment based on the edition of laparoscopy videos, knowledge management and collaborative work with e-MIS contents,26 considering design33 and validation from e-Learning platforms.34 Finally, we review the major training centers.35 In Spain, the Iavante Foundation has courses among its surgical programs that include an e-Learning module before and after the course; however, none of these considers future editions.36,37 The Virtual Hospital Valdecilla38 does not mention e-Learning tools included in the programs of their courses. In Europe, the European School of Laparoscopic Surgery39 provides multimedia contents but not remote learning. IRCAD, in any of its centers,40 offers courses and WebSurg,18 which are not integrated in the same training process. The Skills Cushieri Centre41 offers the option of on-line classes, questions with multiple choices or DVDs for some courses. Finally, in the international scenario, the International College of Robotic Surgery (ICRS)42 offers a similar structure to that discussed in this paper, but primarily focused on robotic surgery. The International School of Robotic Surgery43 offers video broadcasts with commentary, and both the National Centre for Minimally Invasive Surgery44 and the VCU Minimally Invasive Surgery Center45 do not mention the use of e-Learning tools in its programs. In conclusion, there is a need to determine and validate a structured training program for minimally invasive surgery that reconciles in-person courses and e-Learning so that through its implementation and optimization it improves training in these techniques for resident surgeons and experts in lifelong learning programs. References 1. Carrasco-Rojas JA, Chouleb-Kalach A, Shuchleib-Chaba S. Los cambios generados por la cirugía de mínima invasión en la educación quirúrgica. Cir Cir 2011;79:11-15. 2. Fingerhut A, Veyrie N, Millat B, Leandros E. Educación y enseñanza en cirugía laparoscópica en Europa: limitaciones y papel de la Asociación Europea para la Cirugía Endoscópica. Cir Cir 2011;79:5057. 3. Programa formativo de la especialidad de Cirugía General y del Aparato Digestivo. BOE-A-2007-9409. 2007;110:19864-19873.

4. Miguelena Bobadilla JM, Landa García JI, Jover Navalón JM, Docobo Durantez F, Morales García D, Serra Aracil X, et al. Formación en cirugía general y del aparato digestivo: nuevo programa, mismos retos. Cir Esp 2008;84:67-70. 5. Sitges-Serra A. Formación continuada: un instrumento para la plenitud y el liderazgo profesionales. Cir Esp 2003;73:202-205. 6. Targarona EM, Salvador Sanchís JL, Morales-Conde S. Formación en cirugía laparoscópica avanzada. ¿Cuál es el mejor modelo? Cir Esp 2010;87:1-3. 7. Wallace T, Birch DW. A needs-assessment study for continuing professional development in advanced minimally invasive surgery. Am J Surg 2007;193:593-595. 8. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-Learning in medical education. Acad Med 2006;81:207-212. 9. Feliu X, Targarona EM, García A, Pey A, Carrillo A, Lacy AM, et al. La cirugía laparoscópica en España. Resultados de la encuesta nacional de la Sección de Cirugía Endoscópica de la Asociación Española de Cirujanos. Cir Esp 2003;74:164-170. 10. Miguelena Bobadilla JM, Landa García JI, Docobo Durantez F, García García J, Iturbe Belmonte I, Jover Navalón JM, et al. Formación quirúrgica en España: resultados de una encuesta nacional. Cir Esp 2010;88:110-117. 11. Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Wentz R, Kwan I, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev 2009;8:MR000008. 12. Eysenbach G, Wyatt J, McKenzie B. Using the Internet for Surveys and Health Research. J Med Internet Res 2002;4:e13. 13. Álvarez RS, Losada Rodríguez J, Colina Alonso A. Enseñanza de la Cirugía: nuevos tiempos, nuevos métodos. Cir Esp 2012;90:17-23. 14. Rodriguez-Recio FJ, Sendra-Portero F. Analysis of the Spanishspeaking mailing list RADIOLOGIA. Eur J Radiol 2007;63:136-143. 15. SurgyTec-Gain by sharing. Sharing surgical know-how. E-learning. e-courses (consulted February 13, 2013.) Available at: http://www. surgytec.com/courses/ 16. Sánchez-González P, Burgos D, Oropesa I, Romero V, Albacete A, Sánchez-Peralta LF, et al. TELMA: Technology-enhanced learning environment for minimally invasive surgery. J Surg Res 2013;182:2129. 17. García Ureña MÁ, Marín Gómez LM, Vega Ruiz V, Díaz Godoy A. Aplicación de las nuevas tecnologías en la enseñanza de la cirugía en la licenciatura de medicina. Cir Esp 2009;85:165-170. 18. Mutter D, Vix M, Dallemagne B, Perretta S, Leroy J, Marescaux J. WeBSurg: An innovative educational web site in minimally invasive surgery—principles and results. Surg Innov 2011;18:8-14. 19. Bhatti I, Jones K, Richardson L, Foreman D, Lund J, Tierney G. E-learning vs lecture: which is the best approach to surgical teaching? Colorectal Dis 2011;13:459-462. 20. Targarona EM, Balagué C, Martínez C, Hernández MP, Segade M, Franco L, et al. Resultados a medio plazo en la implementación de la cirugía laparoscópica colorrectal en la práctica clínica tras la realización de un curso intensivo. Cir Esp 2011;89:282-289. 21. Sánchez-Peralta LF, Sánchez-Margallo FM, Pagador Carrasco JB, Moyano García Cuevas JL, Noguera JF, Sánchez-González P, et al. e-MIS: E-Learning and multimedia contents for minimally invasive surgery. Minim Invasive Ther Allied Technol 2010;19:29. 22. Usón J, Sánchez-Margallo FM, Pascual S, Climent S. Formación en cirugía laparoscópica paso a paso. 4ª ed. Cáceres: Centro de Cirugía De Mínima Invasión Jesús Usón, ed., 2010;23-335. 23. Pérez-Duarte FJ, Sánchez-Margallo FM, Díaz-Güemes I, SánchezHurtado MÁ, Lucas-Hernández M, Usón-Gargallo J. Ergonomía en cirugía laparoscópica y su importancia en la formación quirúrgica. Cir Esp 2012;90:284-291.

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24. Sánchez-Margallo FM, Asencio Pascual JM, Tejonero Álvarez MC, Sánchez Hurtado MÁ, Pérez Duarte FJ, Usón Gargallo J, et al. Diseño del entrenamiento y la adquisición de habilidades técnicas en la colecistectomía transvaginal (NOTES). Cir Esp 2009;85:307313. 25. Tolerton SK, Hugh TJ, Cosman PH. The production of audiovisual teaching tools in minimally invasive surgery. J Surg Educ 2012;69:404-406. 26. Sanchez LF, Pagador JB, Sánchez García P, Noguera Aguilar J, Sánchez Margallo FM, Pérez FJ. e-MIS Contents: multimedia contents for e-Learning environments in minimally invasive surgery. IJCA Proceedings on Design and Evaluation of Digital Content for Education (DEDCE) 2011;2:31-35. 27. Beddy P, Ridgway PF, Beddy D, Clarke E, Traynor O, Tierney S. Defining useful surrogates for user participation in online medical learning. Adv Health Sci Educ Theory Pract 2009;14:567-574. 28. Schlitzkus LL, Schenarts KD, Schenarts PJ. Is your residency program ready for generation Y? J Surg Educ 2010;67:108-111. 29. Belda Lozano R, Ferrer Márquez M, Reina Duarte A. Cirugía, internet y redes sociales: ¿está obsoleta nuestra forma de comunicarnos? Cir Esp 2012;90:73-74. 30. Landman MP, Shelton J, Kauffmann RM, Dattilo JB. Guidelines for maintaining a professional compass in the era of social networking. J Surg Educ 2010;67:381-386. 31. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg 2012;99:1322-1330. 32. Jakimowicz JJ, Jakimowicz CM. Simulación en cirugía, ¿dónde estamos y a dónde llegaremos? Cir Cir 2011;79:44-49. 33. Coughlan J, Brinkman WP. Design considerations for delivering e-Learning to surgical trainees. IJEHMC 2011;2:14-23. 34. Ortega-Morán JF, Pagador JB, Sánchez-Peralta LF, GómezAguilera EJ, Sánchez-Margallo FM. e-MIS Validity: methodology of user-level validation of e-Learning platforms in minimally invasive surgery. In: Prieto ME, Menéndez VH, Pech SJ, Brito JL, eds. SPDECE2011. Multidisciplinary symposium on the design and evaluation of digital content for education; June 15-17, 2011; Ciudad Real–Almagro, España: Escuela Superior de Informática. UCLM 2011;123-128.

35. Oshiro EO, Alonso CN, Martín PC. Centros de Formación en Cirugía Mínimamente Invasiva y Robótica. Seclaendosurgery.com. 2010;33:1–7 [consulted February 13, 2013.] Available at: http:// www.seclaendosurgery.com/index.php?option=com_content&view= article&id=97&Itemid=92 36. Entrenamiento en Cirugía Robótica Renal. Iavante Consejería de Salud. Consejería de Salud–Junta de Andalucía [consulted February 13, 2013.] Available at: http://www2.iavante.es/accionFormativa?id_ af=1727&privado=S 37. Entrenamiento robótico en cirugía laparoscópica prostática. Iavante Consejería de Salud. Consejería de Salud–Junta de Andalucía [consulted February 13, 2013.] Available at: http://www2.iavante.es/ accionFormativa?id_af=1721&privado=S 38. Cursos del Área Quiúrgica. Hospital Virtual Valdecilla [consulted February 13, 2013.] Available at://www.hvvaldecilla.es/formacion/ cursos/ 39. Didactic Material–DVDs. European School of Laparoscopic Surgery [consulted February 13, 2013.] Available at: http://www.lap-surgery. com/html/DVDs.html 40. IRCAD/EITS Laparoscopic Center. Training in minimally invasive surgery [consulted February 14, 2013.] Available at: http://www. ircad.fr/training/?lng=en 41. Cushieri Skills Centre. Courses [consulted February 14, 2013.] Available at: http://www.dundee.ac.uk/surgicalskills/courses/ 42. International College of Robotic Surgery (ICRS). Training Programs [consulted February 14, 2013.] Available at: http://www.icrstraining. org/training/ 43. International School of Robotic Surgery. Video of International School of Robotic Surgery. Live streaming with commentary [consulted February 14, 2013.] Available at: http://www. r o b o t i cs ch o o l . i t / i t / v i d eo / v i d eo - b y - sp eci al t y / g y n ecology/ viewcategory/68/?order=dateDESC 44. Centro Nacional de Cirugía de Mínimo Acceso. Centro de Educación de Postgrado del Instituto Superior de Ciencias Médicas. Educación [consulted February 14, 2013.] Available at: http://www.cce.sld.cu/ educacion/ 45. VCU Medical Center. Minimally Invasive Surgery Center. Laparoscopic Skills Laboratory [consulted February 14, 2013.] Available at: http://www.vcu.edu/lesspainsurgery/lapskills.htm/

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