‘Working Against the Camera’ During Minimally Invasive Surgery: Extending the Use of the Fundamentals of Laparoscopic Surgery Platform During Surgical Simulation

Enrico Danzer, MD, Kristoffel Dumon, MD, Mayank Mittal, MD, Amy Cha, MD, Kenric Murayama, MD, Jon B Morris, MD, Noel N Williams, MD, Andrew Resnick, MD. Department of General Surgery, University of Pennsylvania

Background
The SAGES Fundamentals of Laparoscopic surgery (FLS) is a validated program for the teaching and evaluation of the basic knowledge and skills required to perform laparoscopic surgery. We hypothesize that the utility of FLS can be expanded further to incorporate training junior surgical residents on “working against the camera”; a skill which has not yet been measured objectively, but is sometimes critical and unavoidable during minimally invasive surgery.
Methods and Procedures
Nineteen junior residents (PGY-1=16, PGY-2=3) were invited to voluntarily participate in this observational study during their simulation rotation at the Penn Medicine Clinical Simulation Center and were randomly assigned to study (SG, n=13) or control (CG, n=6) groups. First, each resident completed the five standard FLS tasks (peg transfer, pattern cut, endoloop placement, and extracorporeal and intracorporeal knot tying) in an attending supervised session. Subsequently, they were asked to place 5 titanium helical tacks (ProTack; Covidien, USA) within 1cm of the edge of a previously fixated 1-mm-thick polytetrafluoroethylene mesh (Parietex- Composite, Tyco Healthcare Group LP, France), using a low-fidelity ventral hernia box model while “working against the camera”. Under attending guidance, the SG then practiced performing several tasks while working against the camera, (one-handed [FLS-1H] and two-handed [FLS-2H] peg transfer, and endoloop placement), while the CG continued with “standard” FLS-training. Outcome measures were task completion times in seconds (s) and accuracy of tack placement pre- and post training. Pre- and post training performances were compared using Student’s t-test. Data are presented as mean ± standard deviation. Statistical significance was defined as p<0.05.
Results
“Standard” FLS task performance was similar between groups. Mean pre-training tack placement time while “working against the camera” tended to be lower in the SG, although this did not reach statistical significance (SG 147±50s vs. CG 260±121s, P=0.07). Pretraining accuracy of tack placement was not different between groups (SG 3±1 vs. CG 3±1, P=0.58). During the attending supervised training session (providing feedback and instruction) of peg transfer and endoloop placement while “working against the camera,” the SG residents significantly improved their overall task completion times for FLS-1H, FLS-2H, and endoloop placement by 247±204s, 137±106s, 36±46s, respectively (P<0.001). Post-training analysis demonstrated that the SG residents significantly improved in task completion times (SG 66±33 vs. CG 19±10s, P<0.001) and accuracy (SG 5±0 vs. CG 3±1, P=0.01) of tack placement while “working against the camera”.
Conclusions
This study demonstrates that the FLS platform can be used to teach surgical residents the basic principles of “working against the camera” and may help to improve laparoscopic skills that might be needed under unavoidable circumstances during common minimally invasive procedures. “Working against the camera” FLS will become part of our surgical simulation curriculum.

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