Another use of the mobile device: warm-up for laparoscopic surgery. Simulated Procedure Rehearsal Is More Effective Than a Preoperative Generic Warm-Up for Endovascular Procedures Warm-up in a Virtual Reality Environment Improves Performance in the Operating Room Standards of Outcome Reporting in Surgical Oncology: A Case Study in Esophageal Cancer Feedback and motor skill acquisition using a haptic dental simulator The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery. The Effect of Video Game “Warm-up” on Performance of Laparoscopic Surgery Tasks Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect. Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study. Preoperative warm-up the key to improved resident technique: a randomized study Warm-up on a simulator improves residents’ performance in laparoscopic surgery: a randomized trial Laparoscopic hepatic lobectomy: advantages of a minimally invasive approach. Does Surgical “Warming up” Improve Laparoscopic Simulator Performance? Mental Practice Enhances Surgical Technical Skills: A Randomized Controlled Study
BACKGROUND An important facet of laparoscopic surgery is its psychomotor component . As this aspect of surgery gains attention , lessons from other psychomotor-intense fields such as athletics have led to an investigation of the benefits of " warming up " prior to entering the operating room . Practical implementation of established methods of warm-up is hampered by a reliance on special equipment and instrumentations that are not readily available . In light of emerging evidence of translatability between video-game play and operative performance , we sought to find if laparoscopic task performance improved after warming up on a mobile device balance game . MATERIAL S AND METHODS Laparoscopic novices were r and omized into either the intervention group ( n = 20 ) or the control group ( n = 20 ) . The intervention group played a mobile device balance game for 10 min while the control group did no warm-up whatsoever . Assessment was performed using two tasks on the ProMIS laparoscopic simulation system : " object positioning " ( where small beads are transferred between four cups ) and " tissue manipulation " ( where pieces of plastic are stretched over pegs ) . Metrics measured were time to task completion , path length , smoothness , h and dominance , and errors . RESULTS The intervention group made fewer errors : object positioning task 0.20 versus 0.70 , P = 0.01 , tissue manipulation task 0.15 versus 0.55 , P = 0.05 , total errors 0.35 versus 1.25 , P = 0.002 . The two groups performed similarly on the other metrics . CONCLUSIONS Warm-up using a mobile device balance game decreases errors on basic tasks performed on a laparoscopic surgery simulator , suggesting a practical way to warm-up prior to cases in the operating room Introduction : Patient-specific simulated rehearsal ( PsR ) of a carotid artery stenting procedure ( CAS ) enables the interventionalist to rehearse the case before performing the procedure on the actual patient by incorporating patient-specific computed tomographic data into the simulation software . This study aim ed to evaluate whether PsR of a CAS procedure can enhance the operative performance versus a virtual reality ( VR ) generic CAS warm-up procedure or no preparation at all . Methods : During a 10-session cognitive/technical VR course , medical residents were trained in CAS . Thereafter , in a r and omized crossover study , each participant performed a patient-specific CAS case 3 times on the simulator , preceded by 3 different tasks : a PsR , a generic case , or no preparation .  Technical performances were assessed using simulator-based metrics and expert-based ratings . Results : Twenty medical residents ( surgery , cardiology , radiology ) were recruited . Training plateaus were observed after 10 sessions for all participants . Performances were significantly better after PsR than after a generic warm-up or no warm-up for total procedure time ( 16.3 ± 0.6 vs 19.7 ± 1.0 vs 20.9 ± 1.1 minutes , P = 0.001 ) and fluoroscopy time ( 9.3 ± 0.1 vs 11.2 ± 0.6 vs 11.2 ± 0.5 minutes , P = 0.022 ) but did not influence contrast volume or number of roadmaps used during the “ real ” case . PsR significantly improved the quality of performance as measured by the expert-based ratings ( scores 28 vs 25 vs 25 , P = 0.020 ) . Conclusions : Patient-specific simulated rehearsal of a CAS procedure significantly improves operative performance , compared to a generic VR warm-up or no warm-up . This technology requires further investigation with respect to improved outcomes on patients in the clinical setting Objective : To assess the impact of warm-up on laparoscopic performance in the operating room ( OR ) . Background : Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR . The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP . Methods : Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR . Participants were r and omized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group . After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up . All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale ( from 7 to 35 ) . Results : There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up , median 28.5 ( range = 18.5–32.0 ) versus median 19.25 ( range = 15–31.5 ) , P = 0.042 . The results demonstrated excellent reliability of the assessment tool used ( Cronbach 's & agr ; = 0.92 ) . Conclusion : This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP . The suggested program is short , easy to perform , and therefore realistic to implement in the daily life in a busy surgical department . This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR re sources Background Multimodal strategies before surgery are often used to improve outcomes , but disease progression ( precluding surgical resection ) and inoperability at planned surgery still occur following neoadjuvant treatment . The st and ards of reporting of these outcomes have not previously been considered . This study examined reporting of rates of progression to surgical resection and inoperability at planned surgery following neoadjuvant treatment in surgical oncology , using esophageal cancer as a case study . Methods A systematic review identified r and omized trials and prospect i ve nonr and omized studies reporting short-term outcomes of neoadjuvant treatment and surgery for esophageal cancer . Results Of 4,763 abstract s , 224 papers were retrieved and 76 studies included ( 8 r and omized trials and 68 cohort studies of 19,441 esophagectomies ) . Articles reported outcomes of  preoperative chemotherapy  ( n = 33 , 43.4 % ) , chemoradiotherapy ( n = 13 , 17.1 % ) , or both within one paper ( n = 18 , 23.7 % ) and 12 ( 15.8 % ) did not specify the type of neoadjuvant treatment . Also , 20 papers ( 26.3 % ) reported numbers of patients not progressing to surgery after  neoadjuvant treatment  ( with rates of nonprogression ranging between 2.0 and 35.3 % ) . In addition , 24 papers ( 31.6 % ) reported rates of inoperability at planned surgery ( with inoperability rates ranging between 0 and 26.2 % ) . More r and omized controlled trials ( RCTs ) than observational studies reported nonprogression ( 4 r and omized and 16 nonr and omized studies , 95 % CI −9.6 to 62.6 % , p = 0.108 ) and inoperability ( 6 r and omized trials and 18 observational studies , 95 % CI 16.8–80.3 % , p = 0.005 ) . Some 17 and 10 articles provided reasons for the observed rates of nonprogression and inoperability , respectively . Conclusions Reporting rates of progression to surgery after neoadjuvant treatment and inoperability at planned surgery for esophageal cancer were poor , limiting data synthesis and comparisons . It is suggested that core outcome sets for trials in surgical oncology are developed with inclusion of these important endpoints . Collaboration between medical and surgical oncologists is necessary to achieve this AIM To investigate the effect of qualitatively different types of pedagogical feedback ( FB ) on the training , transfer and retention of basic manual dexterity dental skills using a virtual reality ( VR ) haptic dental simulator . METHODS Sixty-three participants ( M = 22.7 years ; SD = 3.4 years ) , with no previous dental training , were r and omly allocated to one of three groups ( n = 21 each ) . Group 1 received device-only feedback during the training phase , that is the visual display of the simulator ( DFB ) ; Group 2 received verbal feedback from a qualified dental instructor ( IFB ) ; and Group 3 received a combination of instructor and device feedback ( IDFB ) . Participants completed four tasks during which feedback was given according to group allocation as well as two skills transfer tests . Skill retention was examined immediately after training , at 1 week and at 1 month post-test . RESULTS Statistically significant differences were found between the groups in overall performance ( P < 0.001 ) and error ( P = 0.006 ) . Post hoc comparisons revealed the IDFB group produced substantially better performance and fewer errors in comparison with DFB and IFB training . This difference translated to improved performance in skill retention and generalisation of knowledge to novel tasks . CONCLUSION These data indicate that the acquisition and retention of basic dental motor skills in novice trainees is best optimised through a combination of instructor and visual display (VR)-driven feedback . The results have implication s for the utility and implementation of VR haptic technology in dental education Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more BACKGROUND AND PURPOSE Surgery is a high-stakes " performance . " Yet , unlike athletes or musicians , surgeons do not engage in routine " warm-up " exercises before " performing " in the operating room . We study the impact of a preoperative warm-up exercise routine ( POWER ) on surgeon performance during laparoscopic surgery .  MATERIAL S AND METHODS Serving as their own controls , each subject performed two pairs of laparoscopic cases  , each pair consisting of one case with POWER ( + POWER ) and one without ( -POWER ) . Subjects were r and omly assigned to + POWER or -POWER for the initial case of each pairing , and all cases were performed ≥ 1 week apart . POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer . For each case , cognitive , psychomotor , and technical performance data were collected during two different tasks : mobilization of the colon ( MC ) and intracorporeal suturing and knot tying ( iSKT ) . Statistical analysis was performed using SYSTAT v11.0 . RESULTS A total of 28 study cases ( 14+POWER , 14-POWER ) were performed by seven different subjects . Cognitive and psychomotor performance ( attention , distraction , workload , spatial reasoning , movement smoothness , posture stability ) were found to be significantly better in the + POWER group ( P ≤ 0.05 ) and technical performance , as scored by two blinded laparoscopic experts , was found to be better in the + POWER group for MC ( P=0.04 ) but not iSKT ( P=0.92 ) . Technical scores demonstrated excellent reliability using our assessment tool ( Cronbach ∝=0.88 ) . Subject performance during POWER was also found to correlate with intraoperative performance scores . CONCLUSIONS Urologic trainees who perform a POWER  approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive , psychomotor , and technical performance This study suggests that those who “ warm-up ” with select video games may have improved laparoscopic clinical task performance compared to those not engaged in “ warm-up . BACKGROUND Surgery is a skill-driven discipline . While other high-stake professions with comparable cognitive and psychomotor skill requirements often use warm-up exercises for achieving better proficiency , the effects of such practice have not been investigated sufficiently in surgical tasks . DESIGN Subjects performed st and ardized exercises as a preoperative warm-up , after which the st and ardized exercises were repeated in a r and omized order . In a variation to investigate the generalizability of preoperative warm-up , the experimental group was allowed to warm-up with the st and ardized exercises , after which a different task ( electrocautery simulation ) was performed . To investigate the effect of warm-up on fatigue , participants were involved in eight sessions ( four before night call , four after night call ) , after which the tasks were repeated . Results were analyzed using ANOVA to plot differences between warm-up and followup condition . RESULTS All outcomes measures demonstrated statistically significant improvements after all of the post-warm-up exercises ( p < 0.01 ) , and were seen in all groups with differing experience levels . In addition , the simple warm-up exercises led to a significant increase in proficiency in followup electrocautery task for the experimental group when compared with the control group ( p < 0.0001 ) . There was also significant improvement in performance of the fatigued group to approximately baseline performance ( p < 0.05 ) , although they were not able to reach their optimal potential performance . CONCLUSION Preoperative warm-up for 15 to 20 minutes with simple surgical exercises leads to a substantial increase in surgical skills proficiency during followup tasks BACKGROUND Preoperative simulation warm-up has been shown to improve performance and reduce errors in novice and experienced surgeons , yet existing studies have only investigated conventional laparoscopy . We hypothesized that a brief virtual reality ( VR ) robotic warm-up would enhance robotic task performance and reduce errors . STUDY DESIGN In a 2-center r and omized trial , 51 residents and experienced minimally invasive surgery faculty in General Surgery , Urology , and Gynecology underwent a vali date d robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot ( Intuitive Surgical Inc ) .  Once they successfully achieved performance benchmarks , surgeons were r and omized to either receive a 3- to 5-minute VR simulator warm-up or read a leisure book for 10 minutes before performing similar and dissimilar ( intracorporeal suturing ) robotic surgery tasks . The primary outcomes compared were task time , tool path length , economy of motion , technical , and cognitive errors . RESULTS Task time ( -29.29 seconds , p = 0.001 ; 95 % CI , -47.03 to -11.56 ) , path length ( -79.87 mm ; p = 0.014 ; 95 % CI , -144.48 to -15.25 ) , and cognitive errors were reduced in the warm-up group compared with the control group for similar tasks . Global technical errors in intracorporeal suturing ( 0.32 ; p = 0.020 ; 95 % CI , 0.06 - 0.59 ) were reduced after the dissimilar VR task . When surgeons were stratified by earlier robotic and laparoscopic clinical experience , the more experienced surgeons ( n = 17 ) demonstrated significant improvements from warm-up in task time ( -53.5 seconds ; p = 0.001 ; 95 % CI , -83.9 to -23.0 ) and economy of motion ( 0.63 mm/s ; p = 0.007 ; 95 % CI , 0.18 - 1.09 ) , and improvement in these metrics was not statistically significantly appreciated in the less-experienced cohort ( n = 34 ) . CONCLUSIONS We observed significant performance improvement and error reduction rates among surgeons of varying experience after VR warm-up for basic robotic surgery tasks . In addition , the VR warm-up reduced errors on a more complex task ( robotic suturing ) , suggesting the generalizability of the warm-up Background The ACGME has required that a skills lab be incorporated into the surgical residency curriculum . While the value of warm-up is generally accepted in other areas requiring complex motor skills , there is little evidence to support the benefits of warm-up prior to performing surgery . We are conducting this study in an attempt to identify whether a warm-up period prior to operating impacts operative technique . Methods All general surgery residents and MIS fellows were included in this IRB-approved r and omized study . Participants were r and omized to either warm-up or no warm-up groups . Participants r and omized to the warm-up group completed a 10 min practice session in the simulation lab within 1 h of starting the case , using an FLS training box . At the conclusion of the operation , the participant was evaluated by the attending surgeon using the vali date d global rating scales of Reznick and Vassiliou . The attending surgeons were blinded to the use of pre-procedure warm-up . The results of the question naire were analyzed using student ’s t test with p < 0.05 for significance . Results Pilot data were obtained after completing 40 cases that were r and omized to warm-up ( 19 ) or no warm-up ( 21 ) . There was a statistically significant improvement in depth perception ( p = 0.02 ) , bimanual dexterity ( p = 0.01 ) , and efficiency of movements ( p = 0.03 ) for those r and omized to warm-up . There was statistical improvement when we preformed a composite scoring of the attending evaluations for each of the Reznick ( p = 0.008 ) and the Vassiliou ( p = 0.01 ) global rating scales . Conclusions Preoperative warm-up significantly improves depth perception , bimanual dexterity , and efficiency of movements , as well as improvement in composite scores as judged by the attending surgeon . The lack of self-perceived improvement by the residents may be a reflection of the high st and ards and intense self-critique that is common among surgical trainees . We believe that our findings , while preliminary , reflect that surgical performance can be enhanced through structured warm-up activities Introduction and hypothesisOur aim was to assess the impact of immediate preoperative laparoscopic warm-up using a simulator on intraoperative laparoscopic performance by gynecologic residents . Methods Eligible laparoscopic cases performed for benign , gynecologic indications were r and omized to be performed with or without immediate preoperative warm-up . Residents r and omized to warm-up performed a brief set of st and ardized exercises on a laparoscopic trainer immediately before surgery . Intraoperative performance was scored using previously vali date d global rating scales . Assessment was made immediately after surgery by attending faculty who were blinded to the warm-up r and omization . Results We r and omized 237 residents to 47 minor laparoscopic cases ( adnexal/ tubal surgery ) and 44 to major laparoscopic cases ( hysterectomy ) . Overall , attendings rated upper-level resident performances ( postgraduate year [ PGY-3 , 4 ] ) significantly higher on global rating scales than lower-level resident performances ( PGY-1 , 2 ) . Residents who performed warm-up exercises prior to surgery were rated significantly higher on all subscales within each global rating scale , irrespective of the difficulty of the surgery . Most residents felt that performing warm-up exercises helped their intraoperative performances . Conclusion Performing a brief warm-up exercise before a major or minor laparoscopic procedure significantly improved the intraoperative performance of residents irrespective of the difficulty of the case BACKGROUND As compared with open hepatic lobectomy ( OHL ) , laparoscopic hepatic lobectomy ( LHL ) carries a substantial learning curve and potential for improved perioperative outcomes . The purpose of this analysis was to compare the outcomes of patients undergoing LHL  with those of patients undergoing OHL .  METHODS Analysis of a 1,545-patient prospect i ve hepato-pancreatico-biliary data base from January 2000 to June 2009 identified 450 hepatic lobectomy patients , in whom 90 were LHL .  A 4:1 case-matched analysis comparing LHL with 360 OHL patients , controlling for age , American Society of Anesthesiologists class , tumor size , histology , and tumor location was performed . RESULTS A total of 450 patients underwent hepatic lobectomy for malignant or benign lesions , with LHL performed in 90 ( 20 % ) patients . There was a significant increase in the percentage of LHL performed during 3 intervals of time : 1995 to 1999 , 0 % ; 2000 to 2004 , 1 % ; 2005 to 2009 , 24 % ( p < 0.0001 ) . There were no significant differences in age ( 60 versus 62 years ) , American Society of Anesthesiologists class , body mass index ( 28.1 versus 26.4 ) , size of largest tumor ( 4.0 cm versus 6.4 cm ) , location of tumor(s ) , or number of tumors ( 1 versus 1 ) comparing LHL versus OHL , respectively . There were substantial differences in estimated blood loss , Pringle maneuver , transfusion requirements , complications , and length of stay . Proportional hazards model for all 450 patients demonstrated that  OHL  ( odds ratio = 2.5 ; 95 % CI , 1.2 - 8.7 ) , blood transfusion , and blood loss were all independently associated with increased complications . CONCLUSIONS In this prospect i ve evaluation , LHL was associated with substantial improvements in operative time , Pringle maneuver time , blood loss , transfusion requirements , length of stay , and morbidity without compromising resection margins . These results suggest that LHL is appropriate in selected patients with hepatic tumors Introduction The objective of this study was to determine if preoperative warming up by obstetrics and gynecology trainees , using a vali date d bench model for intracorporeal suturing , improves efficiency , precision , and quality of laparoscopic suturing . Methods A r and omized crossover design was used . Fourteen obstetrics and gynecology residents were r and omized [ 3 junior ( year 2 ) and 11 senior ( years 3–5 ) residents ] . Participants were r and omized to warm-up or no warm-up and then acted as their own controls at least 2 weeks later . Warm-up consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes . All participants performed a prevali date d intracorporeal suturing task ( after either warm-up or no warm-up ) , which was scored based on time , precision , and knot strength . Each participant also completed a question naire anonymously to determine if they believed that warming up improved their performance , regardless of the score they received . Results Thirteen participants completed the study . There was no difference in score when warm-up was compared with no warm-up for the group as a whole . When the junior residents were excluded from the analysis , however , analysis of variance showed a significant improvement in score only when a warm-up was completed in the second session ( P = 0.022 ) . The question naire revealed that 81.8 % of participants felt that warming up subjectively improved their ability , independent of their actual score . Conclusions This study demonstrates that a preoperative warm-up , combined with repetition , is beneficial in improving senior obstetrics and gynecology residents ’ laparoscopic suturing performance . This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills OBJECTIVE To assess the effects of mental practice on surgical performance . BACKGROUND Increasing concerns for patient safety have highlighted a need for alternative training strategies outside the operating room . Mental practice ( MP ) , " the cognitive rehearsal of a task before performance , " has been successful in sport and music to enhance skill . This study investigates whether MP enhances performance in laparoscopic surgery . METHODS After baseline skills testing , 20 novice surgeons underwent training on an evidence -based virtual reality curriculum .  After r and omization using the closed envelope technique , all participants performed  5 Virtual Reality ( VR ) laparoscopic cholecystectomies ( LC ) . Mental practice participants performed 30 minutes of MP before each LC ; control participants viewed an online lecture .  Technical performance was assessed using video Objective Structured Assessment of Technical Skills-based global ratings scale ( scored from 7 to 35 ) . Mental imagery was assessed using a previously vali date d Mental Imagery Question naire . RESULTS Eighteen participants completed the study . There were no intergroup differences in baseline technical ability . Learning curves were demonstrated for both MP and control groups . Mental practice was superior to control ( global ratings ) for the first LC ( median 20 vs 15 , P = 0.005 ) , second LC ( 20.5 vs 13.5 , P = 0.001 ) , third LC ( 24 vs 15.5 , P < 0.001 ) , fourth LC ( 25.5 vs 15.5 , P < 0.001 ) and the fifth LC ( 27.5 vs 19.5 , P = 0.00 ) . The imagery for the MP group was also significantly superior to the control group across all sessions ( P < 0.05 ) . Improved imagery significantly correlated with better quality of performance ( ρ 0.51–0.62 , Ps < 0.05 ) . CONCLUSIONS This is the first r and omized controlled study to show that MP enhances the quality of performance based on VR laparoscopic cholecystectomy . This may be a time- and cost-effective strategy to augment traditional training in the OR thus potentially improving patient care
Background Recent evidence indicates that a preoperative warm-up is a potentially useful tool in facilitating performance .
But what factors drive such improvements and how should a warm-up be implemented ?