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“iTrainers” – Novel and Inexpensive Alternatives to Traditional Laparoscopic Box Trainers

Published:November 18, 2013DOI:https://doi.org/10.1016/j.urology.2013.09.030

      Objective

      To evaluate the use of 2 inexpensive laparoscopic trainers (iTrainers) constructed of easily attainable materials and portable tablets (iPads).

      Methods

      Two different laparoscopic trainers were constructed using a cardboard box, thumbtacks, and Velcro tape (box trainer). A separate box was constructed using the same supplies with a 3-ring binder (binder trainer). An iPad was used as the camera and monitor for both trainers. A total of 10 participants, including 4 junior surgical residents, 4 senior surgical residents, and 2 surgical staff, completed 3 Fundamentals of Laparoscopic Surgery (FLS) tasks using the 2 “iTrainers.” Participants then completed the same tasks on a traditional FLS box trainer. All 10 participants were asked to complete a 13-question survey after the exercises.

      Results

      All the participants (100%) had access to an “iPad” for the visualization component. The 10 participants completed all 3 tasks on all 3 trainers. Senior residents outperformed junior residents on 6 of the 9 total tasks. Attending surgeons outperformed all residents on all tasks and trainers. Survey results revealed the cardboard box “iTrainer” to be the most practical and easiest to construct.

      Conclusion

      “iTrainers” are an inexpensive and easy-to-construct alternative to traditional box trainers that might have construct validity as demonstrated in this trial. The box trainer might be easier to construct and have more similarities to the FLS trainer than the binder iTrainer.
      Laparoscopic surgery has become a mainstay in the training and practice of many surgical disciplines, including general surgery and urology. A number of trainers exist to help surgical trainees practice their laparoscopic skills, including the validated McGill Inanimate System for Training and Evaluation of Laparoscopic Skills trainer.
      • Fried G.M.
      • Feldman L.S.
      • Vassiliou M.C.
      • et al.
      Proving the value of simulation in laparoscopy.
      Although this system represents the gold-standard box-style laparoscopic trainer, it is neither portable nor inexpensive. Cheaper alternatives have been described, but still require the use of a laparoscopic tower. In addition, the portable box trainers commonly used among surgical trainees require a Web camera, special software, and a laptop computer.
      Medical educators and students alike believe that the iPad can improve medical training efficiency and quality.
      • Luo N.
      • Chapman C.G.
      • Patel B.K.
      • et al.
      Expectations of iPad use in an internal medicine residency program: is it worth the “hype?”.
      As such, numerous medical schools and residency programs have incorporated the iPad into their curricula.

      George P, Dumenco L, Dollase R, et al. Introducing technology into medical education: two pilot studies [e-pub ahead of print]. Patient Educ Couns. doi: 10.1016/j.pec.2013.04.018, accessed May 16, 2013.

      • Wodajo F.M.
      Column: The iPad in the hospital and operating room.
      We report the use of 2 novel laparoscopic trainers that are inexpensive, easy to construct, and can be used in conjunction with an iPad device to improve laparoscopic surgical training. The primary aim of this study was to construct a low-cost laparoscopic training alternative to standard boxes while using the popular and readily available iPad and assess its validity for laparoscopic surgical training. As such, we hypothesized that a valid training box would be perceived by surgical trainees and staff as comparable with the standard training box and that higher level surgeons would perform consistently better on tasks than surgical trainees on that box.

      Methods

      Two laparoscopic box trainers were constructed using inexpensive, easily attainable materials. The first was constructed using a 3-inch, 3-ring binder (Fig. 1A). Plastic dividers that were included in the binder purchase were used to support the front surface (Fig. 1B). A power drill was used to create port sites for instruments, and a 1 × 1 inch segment of the binder was excised using a box cutter to allow for visualization with camera device (Fig. 1C). An iPad was used as the camera and viewing device. Thumbtacks were placed into the front surface to stabilize and support its weight. Once the iPad was installed on the front surface and stability was ensured, Velcro tape was added to the surface of the binder's base to use traditional Fundamentals of Laparoscopic Surgery (FLS) task components. Care was taken to ensure proper alignment of the Velcro with the camera's fixed viewing angle.
      Figure thumbnail gr1
      Figure 1The binder trainer. (A) The orientation of the 5-inch divider within the binder's 3 rings is shown. This divider is used to provide structural rigidity and to support the weight of the iPad when the device is fully assembled. Velcro was placed in the center of the iPad's field of view as needed to accommodate the placement of practice materials. (B) The orientation of the viewing hole, port sites, and support tacks is shown. The 1 × 1 inch viewing hole is cut out such that its center lies 5.75 inches from either side of the trainer and 3 inches from the upper border. The 10-mm port sites are drilled 7 inches apart from each other, 4 inches from the upper border, and 2.75 inches from the sides. Thumbtacks are placed horizontally, 3.5 inches from top of the trainer as needed to support the weight of the iPad. (C) The fully assembled binder trainer is shown. An additional tack has been placed 1 inch below the iPad to help distribute its weight more evenly along the supporting divider. (Color version available online.)
      The second trainer was constructed of a standard 8.5 × 11 inch copy paper box, measuring 11.5 × 17.5 × 8.75 inch (Fig. 2A). A box-cutter was used to excise wedges of cardboard from both sides of the box to allow for angling of the top surface and orienting the viewing device toward the user (Fig. 2B). Trapezoids were excised from both the sides and front of the box to allow for the entrance of ambient light. Holes were created on the top surface to accommodate the instruments and iPad. Thumbtacks were placed in the top surface to stabilize and support the weight of the iPad. Velcro tape was placed on the box cover's underside, which served as the floor of the trainer, allowing for placement of the task devices. The box was placed onto the lid so that the underside of the box represented the top surface on which the iPad was placed (Fig. 2C). Both trainers were placed at a user-appropriate height. During construction of both trainers, care was taken to recreate the FLS trainer camera, port site, and operative field orientation as closely as possible.
      Figure thumbnail gr2
      Figure 2The box trainer. (A) The type of box used and the 6 × 3.5 inch rectangular hole that has been excised to allow for entrance of ambient light are shown. (B) Shortening the nearside of the box to 5.5 inches serves to angle the port sites and viewing device toward the user and allows for more natural hand and wrist positioning. Slits are cut on the nearside of the lid to accommodate this configuration. Additional holes are cut from either side of the box to allow for entrance of ambient light. (C) As with the binder trainer, holes are created to accommodate the iPad camera and laparoscopic instruments. The 10-mm port sites are cut 7 inches apart from each other and 6.5 inches from the upper edge of the box. They should each lie 3.5 inches from the box's centerline. The 1 × 1 inch viewing hole is cut out such that its center lies 5.75 inches from either side of the trainer, and 4 inches from the top. Supporting thumbtacks are placed horizontally, 5 inches from top of the trainer as needed to support the weight of the iPad. (Color version available online.)
      The study was institutional review board exempt. A total of 10 participants completed 3 FLS tasks on the binder and cardboard box trainers in addition to a standard FLS trainer. The tasks were completed in 1 location (simulation center) and scored by 1 reviewer. FLS tasks included peg transfer, intracorporeal knot tying, and pattern-cut. An iPad was used as the camera and viewing device for this study. All performances were timed, videotaped, and scored using FLS grading criteria with “time to completion” as the primary endpoint. After completion of all tasks, participants were asked to complete a 13-question survey (Appendix), which addressed their opinions of each trainer (3 point Likert scales) and whether they owned a smart phone or iPad device. Questions 2, 6, and 10 queried the participants regarding how easily each device would be to construct from scratch. It was clarified to the group that the intent of this question was to assess how practical it would be to build this device with basic, currently available supplies with the assumption that the FLS box materials are not available.

      Results

      All 10 participants completed the tasks and survey. Participants included residents in general surgery (4 junior and 4 senior) and 2 minimally invasive, fellowship-trained attending surgeons. Two junior residents failed to stay within 2 mm of the line in the pattern-cut task. All the participants (100%) reported possession of an iPad. Figure 3 demonstrates that senior resident's completion times were lower than junior residents in 6 of the 9 tasks. Attending surgeons completion times were lower than all residents in all tasks on all trainers.
      Figure thumbnail gr3
      Figure 3Time to complete trainer tasks (in s) for junior residents, senior residents, and attending surgeons. (Color version available online.)
      Figure 4 demonstrates that the FLS trainer was believed to be the most comfortable and most effective when compared with the other 2 trainers. It was also believed to be the most difficult to construct from scratch and the least practical. The binder trainer was rated as least comfortable and least effective when compared with the cardboard box and FLS trainers. The cardboard box trainer was thought to be the easiest to construct and the most practical.
      Figure thumbnail gr4
      Figure 4Participant survey results pertaining to training boxes (higher score is more desirable). FLS, Fundamentals of Laparoscopic Surgery.

      Comment

      The explosion of minimally invasive surgical techniques in all surgical specialties, including general surgery and urology, has led to resident training issues in numerous disciplines. Concerns over surgeon efficiency, ethics, and resident duty-hour restrictions limit the number of operative “repetitions” on live patients for surgical trainees. Laparoscopic surgical simulation has been shown to improve surgeon performance in the animal laboratory and the human operating room.
      • Diesen D.L.
      • Erhunmwunsee L.
      • Bennett K.M.
      • et al.
      Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices.
      • Seymour N.E.
      • Gallagher A.G.
      • Roman S.A.
      • et al.
      Virtual reality training improves operating room performance: results of a randomized double-blinded study.
      It has been demonstrated that box trainers and virtual reality simulators are equally effective means of training in laparoscopic skills.
      • Diesen D.L.
      • Erhunmwunsee L.
      • Bennett K.M.
      • et al.
      Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices.
      Senior-level general surgery residents are currently required to pass the FLS curriculum and have FLS certification to be eligible for board certification in General Surgery.
      • Sweet R.M.
      • Beach R.
      • Sainfort F.
      • et al.
      Introduction and validation of the American Urologic Association basic laparoscopic urologic surgery skills curriculum.
      The FLS curriculum teaches and assesses laparoscopic skills while examining eye-hand coordination by the use of laparoscopic box trainers.
      • Wong J.
      • Bhattacharya G.
      • Vance S.J.
      • et al.
      Construction and validation of a low-cost laparoscopic simulator for surgical education.
      The FLS curriculum is being evaluated for maintenance of certification as well.
      • Sweet R.M.
      • Beach R.
      • Sainfort F.
      • et al.
      Introduction and validation of the American Urologic Association basic laparoscopic urologic surgery skills curriculum.
      • Wong J.
      • Bhattacharya G.
      • Vance S.J.
      • et al.
      Construction and validation of a low-cost laparoscopic simulator for surgical education.
      The American Urologic Association is currently evaluating a modification of FLS called Basic Laparoscopic Urologic Skills Curriculum (BLUS) for similar usage.
      • Sweet R.M.
      • Beach R.
      • Sainfort F.
      • et al.
      Introduction and validation of the American Urologic Association basic laparoscopic urologic surgery skills curriculum.
      The trademark FLS training box costs approximately $1500 plus the cost of instrumentation and supplies. It is estimated that the 5-year costs of training 5 surgical residents with FLS boxes is approximately $36,000.
      • Orzech N.
      • Palter V.N.
      • Reznick R.K.
      • et al.
      A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trail.
      The same training program using a virtual reality simulator is anticipated to reach a cost of $80,000.
      • Orzech N.
      • Palter V.N.
      • Reznick R.K.
      • et al.
      A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trail.
      Such devices are limited with regards to their practicality, as they are costly and require a full-size computer monitor or laparoscopic tower. Hence, to use such devices, trainees need to be on the premises of their hospital or training facility. Cheaper alternatives for laparoscopic training are a necessity for full diffusion of the curriculum throughout all surgical disciplines to all trainees around the world.
      Numerous low cost alternatives to the previously mentioned training systems have been proposed and include the use of cardboard boxes,
      • Blacker A.J.
      How to build your own laparoscopic trainer.
      plastic crates,
      • Smith M.D.
      • Norris J.M.
      • Kishikova L.
      • et al.
      Laparoscopic simulation for all: two affordable, upgradable, and easy-to-build laparoscopic trainers.
      and folding portable boxes to be used at home.
      • Nakamura L.Y.
      • Martin G.L.
      • Fox J.C.
      • et al.
      Comparing the portable laparoscopic trainer with a standardized trainer in surgically naïve subjects.
      One alternative, consisting of <$300 worth of materials, required a machinist to construct the device and, ultimately, a traditional laparoscope and monitor for use.
      • Ricchuiti D.
      • Ralat D.A.
      • Evancho-Chapman M.
      • et al.
      A Simple cost-effective design for construction of a laparoscopic trainer.
      Less expensive alternatives constructed of plastic storage boxes have been described; however, these options also require the use of a laparoscopic tower.
      • Mughal M.A.
      Cheap laparoscopic surgery trainer.
      Another storage box-style trainer instead requires only a “micro spy-cam” ($99-$400) rather than the traditional tower apparatus. Although laudable, this system involves finding an appropriately sized camera, affixing it to a 30-40–cm pipe, and plugging it into a television, thus limiting portability.
      • Pokorny M.R.
      • McLaren S.L.
      Inexpensive home-made laparoscopic trainer and camera.
      The commonly used TASKit (Ethicon Endo-surgery Inc.) portable Webcam trainer represents an effective, inexpensive, and portable option for trainees but still requires a laptop or desktop computer coupled with potentially incompatible Webcam software.
      • Nakamura L.Y.
      • Martin G.L.
      • Fox J.C.
      • et al.
      Comparing the portable laparoscopic trainer with a standardized trainer in surgically naïve subjects.
      One hundred percent of the participants in the study owned an iPad. The “iTrainers” used in this study can be constructed in minutes, require materials that cost <$5, and can be used with devices already possessed by the trainee. This allows for numerous trainers to exist among residents within a given training program. Few programs can afford to provide trainers to every resident or to have them available in multiple areas of the hospital setting (eg simulation center, break room, call room). These devices in conjunction with the prevalence of smartphone and iPad devices allow for multiple practice sessions per day, independent of location.
      Fellowship-trained attending surgeons outperformed resident surgeons in all the tasks on all the 3 boxes. Senior level residents performed better than junior level residents on most of the tasks regardless of the box used. This might give construct validity to the “iTrainer” boxes as an alternative training tool. All surgeons believed the box trainer was easier to assemble and more practical than the binder.
      Medical educators and learners alike believe that the iPad can improve medical training efficiency, whereas numerous medical schools and residency programs have incorporated the iPad into their curricula.
      • Luo N.
      • Chapman C.G.
      • Patel B.K.
      • et al.
      Expectations of iPad use in an internal medicine residency program: is it worth the “hype?”.

      George P, Dumenco L, Dollase R, et al. Introducing technology into medical education: two pilot studies [e-pub ahead of print]. Patient Educ Couns. doi: 10.1016/j.pec.2013.04.018, accessed May 16, 2013.

      • Wodajo F.M.
      Column: The iPad in the hospital and operating room.
      Although many surgical residents might use the iPad for home access to patient medical records and imaging and mobile access during work hours on the wards, this study might offer yet another application to further strengthen the usability of the iPad in surgical resident training.
      The primary aim of this study was to construct a low-cost laparoscopic training alternative to standard boxes while using the popular and readily available iPad. The validation of these training tools is limited by its small sample size. The other limitation of this training alternative is that it requires access to an iPad, which might not be readily available to some trainees in different locations around the world or in lower socioeconomic settings. As with all portable laparoscopic trainers, access to laparoscopic instrumentation and the proper supplies are a necessity, and it should not be assumed that trainees have access to or possess this instrumentation. Portable trainers also have limited value if they are not used by the trainee. We did not assess whether these trainers were used by our resident trainees after the trial. It would be interesting to note if the easy-to-construct nature of these tools combined with the high ownership of the iPad would lead trainees to increase usage of laparoscopic trainers on their own time. A limitation of the data analysis in this study is that there was no statistical analysis done before the trial to evaluate for the proper sample size or to determine the Likert scale. We must also note that formal statistical analysis was not completed and the comparisons between groups are descriptive in nature.

      Conclusion

      The “iTrainers” are an inexpensive and easy-to-construct alternative to traditional laparoscopic box trainers that might have construct validity, as demonstrated in this trial. The box trainer might be easier to construct and more practical than the binder iTrainer.

      Acknowledgments

      The authors thank Victoria L. Jackson, MLIS (Academic and Research Support, Mayo Clinic, Jacksonville, FL) for her editorial assistance in the preparation of this article.

      Appendix. Supplementary Data

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