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PubMed1998

[Learning curve for "tension-free" reparation of inguinal hernia].

A prospective randomized study of 106 patients with unilateral primary inguinal hernia who underwent "tension-free" mesh repair was carried out. Fifty-nine procedures (group A) were performed by a single experienced surgeon and 47 (group B) procedures were performed by a team of residents each with an experience level of less than ten cases. In group A the length of operation was statistically shorter; local anesthesia was more frequently used in group A, while intra-operative sedation and general anesthesia were more frequently used in group B. A subgroup of twenty patients (group C) operated on by residents with a personal experience of at least 5 tension free repairs was selected. No statistically significant difference in operation time and in anesthesia used were found between group A and group C. No significant difference was found between group A and group B in morbidity rate, mean postoperative stay, median time to return to work, and recurrence rate. Because easy, efficacy, and minimally invasive, the tension-free mesh repair remains the gold standard in the treatment of inguinal hernia.

Adult↗

PubMed2004

Analysis and design of behavioral experiments to characterize population learning.

In population learning studies, between-subject response differences are an important source of variance that must be characterized to identify accurately the features of the learning process common to the population. Although learning is a dynamic process, current population analyses do not use dynamic estimation methods, do not compute both population and individual learning curves, and use learning criteria that are less than optimal. We develop a state-space random effects (SSRE) model to estimate population and individual learning curves, ideal observer curves, and learning trials, and to make dynamic assessments of learning between two populations and within the same population that avoid multiple hypothesis tests. In an 80-trial study of an NMDA antagonist's effect on the ability of rats to execute a set-shift task, our dynamic assessments of learning demonstrated that both the treatment and control groups learned, yet, by trial 35, the treatment group learning was significantly impaired relative to control. We used our SSRE model in a theoretical study to evaluate the design efficiency of learning experiments in terms of the number of animals per group and number of trials per animal required to characterize learning differences between two populations. Our results demonstrated that a maximum difference in the probability of a correct response between the treatment and control group learning curves of 0.07 (0.20) would require 15 to 20 (5 to 7) animals per group in an 80 (60)-trial experiment. The SSRE model offers a practical approach to dynamic analysis of population learning and a theoretical framework for optimal design of learning experiments.

Algorithms↗

PubMed2005

Comparison of training modalities for performing laparoscopic radical prostatectomy: experience with 1,000 patients.

PURPOSE: We report a detailed analysis of different training modalities on the transferability of laparoscopic radical prostatectomy to generations of surgeons. MATERIAL AND METHODS: The first generation surgeon with experience with 600 cases and the second generation surgeon with 150 were trained in open retropubic radical prostatectomy and laparoscopy, whereas the third generation surgeon with 150 cases was trained only laparoscopically. The fourth generation of surgeons with a total of 50 cases was trained in our fellowship program. We analyzed groups of 50 operations. The groups were comparable with respect to patient age, prostate weight and pathological tumor stage. RESULTS: We observed a continual decrease in operative time between (322 to 247 minutes.) and within (332 to 196 minutes.) the analyzed groups. This result was also expressed in a decrease in the time required for anastomosis. A significant decrease was observed for the initial transfusion rate (4% to 10%). No difference was found in the complication rate (ie conversion in 8% to 0% of cases). Pathological outcomes (ie positive margins for pT2/pT3) were comparable in the first 3 surgeon groups (14.9%, 14.2% and 22%, respectively) and available functional results (followup greater than 2 years) did not reveal any influence of the learning curve. A learning curve was observed only for overall operative time and the time required for anastomosis but it was shown to be significantly shorter for the following generations. CONCLUSIONS: Based on a specific training program the personal level of education has a minor impact on the results and reproducibility of the laparoscopic radical prostatectomy technique.

Clinical Competence↗

PubMed2003

Early results of a new liver transplant program in Szczecin, Poland.

New liver transplant programs have usually been associated with a significant learning curve. This learning curve, however, can be minimized or avoided if certain conditions are met. In this paper we describe the establishment of a new liver transplant program in Szczecin, Poland and present its early results. Four members of the team underwent training in clinical liver transplantation in major centers in Europe. Transplant protocols were then adopted, all the necessary facilities set up, and multidisciplinary team created. Between February 2002 and August 2003, 22 adult orthotopic liver transplantations (OLT) were performed in 21 patients (13 male; mean age 46.3 years; range 33-62), including I retransplant for early hepatic artery thrombosis. Eighteen (86%) patients are alive between 4 and 22 (median 11) months after OLT. Seventeen patients have normal liver function and 14 of them have resumed full life activity. Three patients died: one of bacterial peritonitis (day 6), one of chronic rejection with allograft failure (month 4) and one following massive stroke (month 10). Surgical complications occurred in 7 patients (33%). We believe that proper training of vital team members at established transplant centers with good results, availability of adequate equipment and all the facilities required with strict adherence to transplant protocols are all paramount for a successful start of a liver transplant program.

Adult↗

PubMed2004

Dynamic analysis of learning in behavioral experiments.

Understanding how an animal's ability to learn relates to neural activity or is altered by lesions, different attentional states, pharmacological interventions, or genetic manipulations are central questions in neuroscience. Although learning is a dynamic process, current analyses do not use dynamic estimation methods, require many trials across many animals to establish the occurrence of learning, and provide no consensus as how best to identify when learning has occurred. We develop a state-space model paradigm to characterize learning as the probability of a correct response as a function of trial number (learning curve). We compute the learning curve and its confidence intervals using a state-space smoothing algorithm and define the learning trial as the first trial on which there is reasonable certainty (>0.95) that a subject performs better than chance for the balance of the experiment. For a range of simulated learning experiments, the smoothing algorithm estimated learning curves with smaller mean integrated squared error and identified the learning trials with greater reliability than commonly used methods. The smoothing algorithm tracked easily the rapid learning of a monkey during a single session of an association learning experiment and identified learning 2 to 4 d earlier than accepted criteria for a rat in a 47 d procedural learning experiment. Our state-space paradigm estimates learning curves for single animals, gives a precise definition of learning, and suggests a coherent statistical framework for the design and analysis of learning experiments that could reduce the number of animals and trials per animal that these studies require.

Algorithms↗

PubMed2006

Elevated T-maze evaluation of anxiety and memory effects of NMDA/glycine-B site ligands injected into the dorsal periaqueductal gray matter and the superior colliculus of rats.

Rat behaviors in the elevated T-maze (ETM) were evaluated following tectum microinjections of either glycine (GLY, 1, 10, 80 and 120 nmol) or d-serine (D-SER, 160 and 320 nmol), the putative endogenous agonists of GLY-B site at NMDA receptor, or the respective antagonist 7-chloro-kynurenic acid (7CK, 8 nmol). ETM performance was appraised by two validated scores of anxiety, i.e., the inhibitory avoidance duration (AD) and risk assessment behavior, and two scores derived from a newly developed approach to inhibitory avoidance learning curves, i.e., the learning median number of trials (T50) and avoidance variability (standard deviation of learning curve). Effects on aversive memory consolidation were assessed through changes in the AD measured 48 h after the full-acquisition of inhibitory avoidance. Drug effects were compared to those of vehicle. In most cases, microinjection of GLY-B site agonists into the dorsal periaqueductal gray (dPAG) produced increases in AD, which were compatible with an increase in anxiety. However, neither the intra-periaqueductal injection of 80 nmol GLY, nor that of 160 nmol D-SER, increased the AD. On the other hand, these microinjections invariably produced a parallel left shift in avoidance learning curves, thereby reducing the T50 but not the variability. Effects of 120 nmol GLY on AD and T50 were both antagonized by a previous microinjection of 7CK into the dPAG. The inverse relationship of AD and T50 suggests that increases in the anxiety level reduce the number of trials required for the acquisition of inhibitory avoidance. The above data also suggest the higher consistency and drug sensitivity of T50 as compared to the AD. In turn, whereas the microinjection of 120 nmol GLY into the superior colliculus (SC) did not affect the T50, it increased the AD. On the other hand, there was an increase in avoidance variability following the microinjection of either 120 nmol GLY into the SC or 8 nmol 7CK into the dPAG. Therefore, the GLY-B receptors within these structures seem to play opposite roles on avoidance variability. In contrast, neither of these treatments changed T50. Finally, whereas the risk assessment was solely decreased by the microinjection of GLY into the SC, the aversive memory was only impaired by the microinjection of 7CK into the dPAG. Overall, these data suggest that NMDA/GLY-B receptors of dPAG mediate both anxiety and aversive memory, while those in the SC are most likely involved with attention and visuomotor components of risk assessment behavior.

Animals↗

PubMed1998

Laparoscopic visual field. Voice vs foot pedal interfaces for control of the AESOP robot.

BACKGROUND: In order for robotic devices to be introduced successfully into surgical practice, the development of transparent surgeon/machine interfaces is critical. METHODS: This study evaluated the standard foot pedal for the AESOP robot compared to a voice control interface. Speed, accuracy, learning curves, durability of learning at 2 weeks, and operator-interface failures were analyzed in an ex vivo model. RESULTS: Foot control was faster and had less operator-interface failures. Voice control was more accurate as measured by "pass points." The foot control learning curve reached a plateau at the third trial, while the voice control did not fully plateau. Durability of learning favored the foot control but was not significantly different. CONCLUSIONS: Currently, the voice control is more accurate and has the advantage of not requiring the surgeon to look away from the operative field. However, it is slower and may require more attention as an interface. As voice recognition software continues to advance, speed and transparency are anticipated to improve.

Equipment Design↗

PubMed2003

How many cases are enough for accreditation in sentinel lymph node biopsy in breast cancer?

BACKGROUND: There is considerable argument concerning the number of sentinel node biopsy cases with axillary dissection that surgeons should perform before they are eligible on abandoning axillary dissection in negative sentinel node patients. DATA SOURCES: Papers that (1) address directly or indirectly the subject of credentialing or of learning curve, (2) report on a surgeon's performance, (3) are reported as feasibility or learning curve studies, or both, (4) discuss the learning curve issue, and (5) express an expert's opinion on the learning curve. CONCLUSIONS: The number of procedures of the learning curve can not be fixed for all surgeons. Only surgeons in specialized breast cancer centers can succeed in meeting current recommendations with 20 to 30 cases. Surgeons from affiliated community hospitals will need more than 30 cases, whereas broad-based surgeons might need as many as 60 cases with their current caseload. Not all surgeons will be able to offer the procedure to their patients by the current recommendations.

Accreditation↗

PubMed2003

[Surgeons learn how to learn. Study of 76,499 herniorrhaphies performed between 1993 and 1997 registered by the chamber of physicians in Westfalia-Lippe].

INTRODUCTION: New techniques require "new" surgeons who are able to apply them safely. The bushfire-like employment of laparoscopic cholecystectomy confronted a community of surgeons totally inexperienced in that technique. Thus, the collective learning curve was paralleled by a temporary increase of postoperative complications. The aim of the following study was to analyze the learning curve for laparoscopic herniorrhaphy with regard to the complication rates during that period. METHODS: A total of 76,499 questionnaires from the external quality assurance of the Westfalia-Lippe physicians board registered between 1993 and 1997 were analyzed retrospectively. The parameters (duration of the operation and hospitalization, ASA classification, rate of obese patients, intra- and postoperative complications) were analyzed and plotted as a synchronized learning curve of the whole group of surgeons. RESULTS: As for laparoscopic cholecystectomy, a learning curve was found for laparoscopic herniorrhaphy, which could be attributed to a decreasing duration of the procedures and increasing ASA classification and rate of morbid obese patients while complication rates were kept constantly low. After 9 months of application laparoscopic hernia repair seemed to have been introduced to a new collective of surgeons while learning parameters showed inverse trends for a short period of time. The complication rate of laparoscopic hernia repair was constantly lower than in routine open inguinal hernia repair. CONCLUSION: Since laparoscopic inguinal hernia repair is a demanding method, surgeons apparently did not forget the lessons learned from the introduction of laparoscopic cholecystectomy as they were able to avoid increasing intra- and postoperative complication rates during their learning curve. Surgeons are learning to learn.

Adolescent↗

PubMed2004

Evaluation of dose-volume histograms after prostate seed implantation. 4-year experience.

BACKGROUND AND PURPOSE: Permanent interstitial brachytherapy by seed implantation is a treatment alternative for low-volume low-risk prostate cancer and a complex interdisciplinary treatment with a learning curve. Dose-volume histograms are used to assess postimplant quality. The authors evaluated their learning curve based on dose-volume histograms and analyzed factors influencing implantation quality. PATIENTS AND METHODS: Since 1999, 38 patients with a minimum follow-up of 6 months were treated at the authors' institution with seed implantation using palladium-103 or iodine-125, initially using the preplan method and later real-time planning. Postimplant CT was performed after 4 weeks. The dose-volume indices D90, V100, V150, the Dmax of pre- and postplans, and the size and position of the volume receiving the prescribed dose (high-dose volume) of the postplans were evaluated. In six patients, postplan imaging both by CT and MRI was used and prostate volumes were compared with preimplant transrectal ultrasound volumes. The first five patients were treated under external supervision. RESULTS: Patients were divided into three consecutive groups for analysis of the learning curve (group 1: n = 5 patients treated under external supervision; group 2: n = 13 patients; group 3: n = 20 patients). D90post for the three groups were 79.3%, 74.2%, and 99.9%, the V100post were 78.6%, 73.5%, and 88.2%, respectively. The relationship between high-dose volume and prostate volume showed a similar increase as the D90, while the relationship between high-dose volume lying outside the prostate and prostate volume remained constant. The ratio between prostate volumes from transrectal ultrasound and CT imaging decreased with increasing D90post, while the preplanning D90 and V100 remained constant. The different isotopes used, the method of planning, and the implanted activity per prostate volume did not influence results. CONCLUSION: A learning curve characterized by an increase in the D90post can be observed and results in a stable technique after 18 patients. An important factor influencing the learning curve in addition to the precision of seed positioning is organ volume definition on postimplant imaging.

Body Burden↗

PubMed1999

Implementation of new surgical technology: outcome measures for lymphatic mapping of breast carcinoma.

BACKGROUND: Recent advances in technology and the subsequent development of minimally invasive surgical techniques have heralded a new era in the surgical treatment of breast cancer. The dilemma of how to train surgeons in new technologies requires teaching, certification, and outcomes reporting in a non-threatening and non-economically damaging manner. This study examines 700 cases of lymphatic mapping and sentinel lymph node (SLN) biopsy for breast cancer and documents surgeon-specific and institution-specific learning curves. METHODS: Seven hundred cases of lymphatic mapping and SLN biopsy were examined. All procedures were performed using a combination of vital blue dye and radiolabeled sulfur colloid. Learning curves were generated for each surgeon as a plot of failure rate versus number of cases. RESULTS: Examination of the learning curves in this study demonstrates similar characteristics. Following a high initial failure rate, there is a rapid decrease after the first twenty cases. The learning curve, representing the mean of the five surgeons' experience, indicates that 23 cases and 53 cases are required to achieve success rates of 90% and 95%, respectively. CONCLUSIONS: The initial reports regarding lymphatic mapping combined with this experience of 700 cases confirm the presence of a significant learning curve. Although this procedure may have an inherent failure rate, it is important to identify those factors that are under the control of the surgeon and, therefore, subject to improvement. We believe that these data provide surgeons performing lymphatic mapping and SLN biopsy with a new paradigm for assessing their skill and adequacy of training.

Axilla↗

PubMed1993

Conversion to small-incision phacoemulsification: experience with the first 50 eyes.

Conversion from extracapsular cataract surgery to small-incision phacoemulsification is inevitably associated with a learning curve. Retrospective analysis of one surgeon's learning curve was carried out on the first 50 consecutive operations using small-incision phacoemulsification. Parameters were evaluated, including postoperative acuity and astigmatism at eight days, three weeks, three months, and six months. A comparison of the results of the first 25 operations and the subsequent 25 showed statistically significant differences only in acuity at eight days and cylinder at three months. The most frequent complication was corneal edema lasting at least one week. With careful preparation, proper patient selection, and meticulous technique, the learning curve for converting from extracapsular surgery to small-incision phacoemulsification does not necessarily increase the complication rate.

Aged↗

PubMed2004

Acquiring laparoscopic skill proficiency: does orientation matter?

OBJECTIVE: This study was undertaken to determine whether side-on laparoscopic operating orientation alters time-to-skill mastery compared with head-on orientation. STUDY DESIGN: One hundred thirty-one medical students were randomly assigned by operating axis (camera position to operating field) and completed 10 attempts at each of 5 previously validated laparoscopic skills stations. Time-to-completion was recorded for each attempt, generating an orientation and skill station learning curve. Statistical analysis was performed by using repeated measures analysis of variance and linear, polynomial, and logarithmic models with 95% CIs. RESULTS: Sixty-eight students were randomly assigned to head-on orientation and 63 to side-on orientation. Comparing median time-to-completion by station, head-on attempts were faster than side-on attempts for every station. Comparing learning curves by orientation, side-on learning curves were steeper than head-on learning curves for every station, except one. Asymptotes were reached in both strata by the tenth attempt. CONCLUSION: Greater initial disorientation is seen with side-on orientation compared with head-on orientation. This can be overcome with practice.

Clinical Clerkship↗

PubMed2006

The radius surgical system - a new device for complex minimally invasive procedures in urology?

OBJECTIVE: Complex laparoscopic procedures in urology are technically demanding with an extended learning curve. Robotic systems add significant cost to laparoscopic procedures. We therefore evaluated the use of the Radius Surgical System (RSS), a mechanical manipulator, for complex laparoscopic cases in urology. MATERIAL AND METHODS: The RSS (Tuebingen Scientific) consists of two hand-guided surgical manipulators and provides a deflectable and rotatable tip allowing six degrees of freedom. We evaluated the system by using a series of standardized models in the pelvitrainer. We analyzed the effectiveness of the system and the learning curve. We then evaluated the system in the clinical setting during laparoscopic radical prostatectomy. RESULTS: Surgeons with experience on the RSS were compared to surgeons without previous experience on the system. We identified a learning curve in those participants without experience on the system only when performing complete anastomoses in the pelvitrainer. However, this learning curve included less than 10 anastomoses. The first clinical experiences during laparoscopic extraperitoneal radical prostatectomy (n=10) are promising. All anastomoses were patent on routine (X-ray) examination 8 days after surgery. CONCLUSIONS: The RSS system is easy to use and we identified a very short learning curve. We now optimize the system for use in urology. This device may facilitate complex laparoscopic procedures without the use of costly robotic systems and should be further evaluated in the experimental and clinical setting.

Equipment Design↗

PubMed2001

Trocar site recurrence in laparoscopic surgery for colorectal cancer. Myth or real concern?

Despite extensive research efforts, the incidence of wound recurrence and its causes are unknown. The data reviewed in this article suggest [table: see text] that the actual rate of port-site metastasis is much lower than initially reported. Thus port-site metastasis may not be an inherent detriment of laparoscopic colectomy, but rather an unfortunate sequelae of the learning curve of the application of laparoscopy for colorectal cancer. However, the learning curve may not be easily conquered for the average general surgeon in the United States who performs six to seven colorectal resections annually. The learning curve for laparoscopic colorectal surgery has been estimated to range from 20 to 70 cases. Thus, it is intuitive that the average general surgeon in the United States may never be able to conquer these technically challenging procedures. Even in a high volume practice, some patients will be operated on within the early experience thus being placed at higher risk of this complication. Clearly, a special informed consent is needed to alert patients to the existence of this complication, the individual surgeon's experience, and the preventative measures being employed to prevent it. In the interim, the safest approach is only to offer laparoscopic colorectal resections for attempted cure of carcinoma within prospectively randomized, externally monitored, peer-reviewed trials. The final results of the large randomized prospective studies which are currently underway, and information drawn from the continuous basic science efforts, will hopefully solve these questions in the near future.

Colonic Neoplasms↗

PubMed2005

Totally robotic Roux-en-Y gastric bypass.

HYPOTHESIS: We hypothesized that we could develop a safe and effective technique for performing a totally robotic laparoscopic Roux-en-Y gastric bypass procedure using the da Vinci surgical system. We anticipated that the learning curve for this totally robotic procedure could be shorter than the learning curve for standard laparoscopic bariatric surgery. DESIGN: Retrospective case comparison study. SETTING: Academic tertiary care center. PATIENTS: Consecutive samples of patients who met National Institutes of Health (NIH) criteria for morbid obesity and who completed the Stanford Bariatric Surgery Program evaluation process. INTERVENTION: A port placement and robot positioning scheme was developed so that the entire case could be performed robotically. The first 10 patients who underwent a totally robotic laparoscopic Roux-en-Y gastric bypass were compared with a retrospective sample of 10 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery. MAIN OUTCOME MEASURES: Patient age, gender, body mass index (BMI), numbers of NIH-defined comorbidities, operative time, length of stay, and complications. RESULTS: No significant differences existed between the 2 patient series with regard to age, gender, or BMI. The median surgical times were significantly lower for the robotic procedures (169 vs 208 minutes; P = .03), as was the ratio of procedure time to BMI (3.8 vs 5.0 minutes per BMI for the laparoscopic cases; P = .04). CONCLUSIONS: This study details the first report, to our knowledge, of a totally robotic laparoscopic Roux-en-Y gastric bypass and demonstrates the feasibility, safety, and potential superiority of such a procedure. In addition, the learning curve may be significantly shorter with the robotic procedure. Further experience is needed to understand the long-term advantages and disadvantages of the totally robotic approach.

Adult↗

PubMed2001

Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting.

BACKGROUND: Use of the sequential probability cumulative sum (CUSUM) technique may be more sensitive than standard statistical analyses in detecting a cluster of surgical failures. We applied CUSUM methods to evaluate the learning curve after a policy change by a single surgeon from routine on-pump (cardiopulmonary bypass [CPB]) to off-pump coronary artery bypass grafting (OPCAB). METHODS: Fifty-five consecutive first-time coronary artery bypass patients (CPB group) were compared with the next 55 patients undergoing an attempt at routine OPCAB using the same coronary stabilizer. The goal in OPCAB patients was to obtain complete revascularization, albeit with a low threshold for conversion to CPB to maximize patient safety during the learning curve. Preoperative patient risk was calculated using previously validated models of the Cardiac Care Network of Ontario. The occurrence of operative mortality and nine predefined major complications (myocardial infarction, bleeding, stroke, renal failure, balloon pump use, mediastinitis, respiratory failure, life-threatening arrhythmia, and sepsis) was compared between the CPB and OPCAB groups using Wilcoxon, Fisher exact, and two-tailed t tests, as well as CUSUM methodology. An intention to treat analysis was performed. RESULTS: The CPB and OPCAB groups had similar predicted mortality and length of stays (2.2% +/- 2.5%, 8.1 +/- 2.5 days versus 2.4% +/- 3.5%, 8.1 +/- 2.4 days, respectively). The mean number of grafts per patient was 3.1 +/- 0.7 in the CPB group versus 3.0 +/- 0.7 in the OPCAB group (p = 0.45). Two of 55 (3.6%) CPB patients died, as opposed to 1 of 55 (1.8%) OPCAB patients (p = 0.99). Eight of 55 CPB patients (14.5%) incurred major complications, as opposed to 4 of 55 (7.3%) OPCAB patients (p = 0.36). Median hospital length of stay was 6.0 days in the CPB group versus 5.0 days in the OPCAB group (p = 0.28). On CUSUM analysis, the failure curve in CPB patients approached the upper 80% alert line after eight cases, whereas the curve in OPCAB patients reached below the lower 80% (reassurance) boundary 28 cases after the policy change, indicating superior results in the OPCAB group despite the learning curve. CONCLUSIONS: A policy change from coronary artery bypass on CPB to routinely attempting OPCAB can be accomplished safely despite the learning curve. CUSUM analysis was more sensitive than standard statistical methods in detecting a cluster of surgical failures and successes.

Cardiopulmonary Bypass↗

PubMed2006

Objective assessment of gynecologic laparoscopic skills using the LapSimGyn virtual reality simulator.

BACKGROUND: Safe realistic training and unbiased quantitative assessment of technical skills are required for laparoscopy. Virtual reality (VR) simulators may be useful tools for training and assessing basic and advanced surgical skills and procedures. This study aimed to investigate the construct validity of the LapSimGyn VR simulator, and to determine the learning curves of gynecologists with different levels of experience. METHODS: For this study, 32 gynecologic trainees and consultants (juniors or seniors) were allocated into three groups: novices (0 advanced laparoscopic procedures), intermediate level (>20 and <60 procedures), and experts (>100 procedures). All performed 10 sets of simulations consisting of three basic skill tasks and an ectopic pregnancy program. The simulations were carried out on 3 days within a maximum period of 2 weeks. Assessment of skills was based on time, economy of movement, and error parameters measured by the simulator. RESULTS: The data showed that expert gynecologists performed significantly and consistently better than intermediate and novice gynecologists. The learning curves differed significantly between the groups, showing that experts start at a higher level and more rapidly reach the plateau of their learning curve than do intermediate and novice groups of surgeons. CONCLUSION: The LapSimGyn VR simulator package demonstrates construct validity on both the basic skills module and the procedural gynecologic module for ectopic pregnancy. Learning curves can be obtained, but to reach the maximum performance for the more complex tasks, 10 repetitions do not seem sufficient at the given task level and settings. LapSimGyn also seems to be flexible and widely accepted by the users.

Clinical Competence↗