OBJECTIVE:The aim of this study was to evaluate the effect of three training methodologies on the acquisition of psychomotor skills for laparoendoscopic single-site surgery (LESS), using straight and articulating instruments.METHODS:A prospective study was conducted with subjects randomly divided into three groups, who performed a specific training for 12 days using three laparoscopic tasks in a laparoscopic simulator. Group-A trained in conventional laparoscopy setting using straight instruments and in LESS setting using both straight and articulating instruments. Group-B trained in LESS setting using straight and articulating instruments, whereas Group-C trained in LESS setting using articulating instruments. Participants' performance was recorded with a video-tracking system and evaluated with 12 motion analysis parameters (MAPs).RESULTS:All groups obtained significant differences in their performance in most of the MAPs. Group-C showed an improvement in nine MAPs, with a high level of technical competence. Group-A presented a marked improvement in bimanual dexterity skills.CONCLUSIONS:Training in LESS surgery using articulating laparoscopic instruments improves the quality of skills and allows smoother learning curves.

Background heart rate variability (HRV) is an important part of cardiovascular response to stress. Literature about the utility of HRV to predict intubation and invasive mechanical ventilation (IMV) need in Covid-19 patients is scarce. We analysed if HRV metrics could be used to identify, in the first 24 hours from admission in the intensive care unit (ICU), those patients who were going to need IMV during their stay. Methods we conducted a prospective single-centre observational study. Adult patients admitted in the ICU with respiratory failure due to RT-PCR-confirmed SARS-CoV-2 but not under IMV were included. Electrocardiogram (EKG) was recorded at least for 15 minutes at 500 Hz during a stable sitting condition, in the morning time. Power spectrum was obtained using wavelets. We also analysed non-linear HRV dynamics. Results 27 patients were included. We found no differences in HRV metrics between groups. However, in the linear regression model for ICU length-of-stay (ICU LOS), we found that DFA⍺2 (OR -64.16; 95% CI: -3.497–0.832, P = 0.013), Fi02 (OR 0.37; 95% CI: 0.032–0.71, P = 0.033) and temperature (OR 16.02; 95% CI: 3.537–28.5, P = 0.014) were associated with longer ICU LOS. When performing bivariate correlation in patients lately intubated (Spearman`s test, n = 15), only DFA⍺2 was correlated (r -5.11, p = 0.05) with ICU LOS. Conclusion We found that HRV on ICU admission did not discriminate patients that might require IMV. DFA⍺2 was the HRV variable with the strongest association with ICU LOS along with other easy-to-collect clinical variables. These results could be helpful for newer prognostication tools.

Objetivo: Evaluar el efecto de tres métodos de entrenamiento en la adquisición de habilidades psicomotrices para la cirugía laparoendoscópica por puerto único (LESS, laparoendoscopic single-site surgery) utilizando instrumental recto y articulado. Método: Se realizó un estudio prospectivo con sujetos divididos aleatoriamente en tres grupos, quienes realizaron un entrenamiento específico durante 12 días utilizando tres tareas laparoscópicas en un simulador laparoscópico. El grupo A entrenó en el entorno laparoscópico convencional con instrumentos rectos, y en el entorno LESS con instrumentos rectos y articulados. El grupo B entrenó en el entorno LESS con instrumentos rectos y articulados. El Grupo C entrenó en el entorno LESS con instrumentos articulados. El desempeño de los participantes se registró con un sistema de seguimiento en video y fue evaluado con 12 parámetros de análisis de movimiento (MAP, motion analysis parameters). Resultados: Todos los grupos obtuvieron diferencias significativas en su desempeño para la mayoría de los MAP. El grupo C mostró una mejora en nueve MAP, con un alto nivel de competencia técnica. El grupo A mostró una marcada mejora en la habilidad de destreza bimanual. Conclusiones: El entrenamiento en cirugía LESS con instrumentos articulados mejora la calidad de las habilidades adquiridas y permite curvas de aprendizaje más suaves.

OBJECTIVE:Deep brain stimulation (DBS) is a surgical technique that alleviates motor symptoms in Parkinson's disease. Surgically implanted microelectrodes stimulate the basal ganglia to improve patients' symptoms. One of the training challenges for neurophysiologists is to identify during surgery the target area of the brain in which the electrodes must be implanted. Identification is based both on visual and auditory inspection of the microelectrode recordings (MERs) as they are lowered through the basal ganglia. We present the preliminary evaluation of DBSTrainer, a novel desktop application to train neurophysiologists in the identification of signals corresponding to different basal structures. METHODS:A pilot study was conducted with neurologists and neurophysiologists at the Hospital Universitario La Paz (Madrid, Spain). After completing a series of tasks with the application, they were asked to complete an evaluation questionnaire. Usability was assessed using the System Usability Scale (SUS). Functionality, contents, and perceived usefulness were assessed using an ad-hoc Likert questionnaire following the e-MIS framework for surgical learning platforms. RESULTS:15 volunteers participated in the study. Obtained SUS score was 86.7 ± 0.47. Most positive aspects on functionality were platform design and interactivity. Contents were found realistic and aligned with learning outcomes. Minor problems were identified with signal loading times. CONCLUSIONS:This study provides preliminary evidence on the usefulness of DBSTrainer. It is, to our knowledge, the first Technology Enhanced Learning application to train neurophysiologists outside the operating room, and thus its introduction can have a real impact on patient safety and surgical outcomes.

INTRODUCTION:Technology Enhanced Learning (TEL) can provide the tools to safely master minimally invasive surgery (MIS) skills in patient-free environments and receive immediate objective feedback without the constant presence of an instructor. However, TEL-based systems tend to work isolated from one another, focus on different skills, and fail to provide contents without a sound pedagogical background. OBJECTIVE:The objective of this descriptive study is to present in detail EASIER, an innovative TEL platform for surgical and interventional training, as well as the results of its validation. METHODS:EASIER provides a Learning Management System (LMS) for institutions and content creators that can connect and integrate TEL "external assets" (virtual reality simulators, augmented box trainers, augmented videos, etc.) addressing different skills. The platform integrates all skills under an Assessment Module that measures skills' progress in different courses. Finally, it provides content creators with a pedagogical model to scaffold contents while retaining flexibility to approach course design with different training philosophies in mind. Three courses were developed and hosted in the platform to validate it with end-users in terms of usability, performance, learning results in the courses and student self-perception on learning. RESULTS:In total 111 volunteers completed the validation. The study was limited due to the COVID-19 pandemic, which limited access to external assets (virtual reality simulators). Nevertheless, usability was rated with 73.1 in the System Usability Scale. Most positive aspects on performance were easiness to access the platform, easiness to change the configuration and not requiring additional plug-ins to use the platform. The platform was rated above average in the six scales of the User Experience Questionnaire. Overall, student results improved significantly across the three courses (p < 0.05). CONCLUSIONS:This study provides, within its limitations, evidence on the usefulness of the EASIER platform for distance learning of MIS skills. Results show the potential impact of the platform and are an encouraging boost for the future, especially in the aftermath of the COVID-19 pandemic.

Abstract PURPOSE: cardiovascular response to stress (such as hypoxemia) is mediated by the autonomic nervous system (ANS) and heart rate variability is an important part of it. Neurotropism is an important feature of SARS-CoV-2 infection and clinical dissociation between hypoxemia and the cardiovascular response has been reported. We proposed that HRV could be used to identify, at admission in the intensive care unit (ICU), those patients who were going to need invasive mechanical ventilation (IMV) during their stay. METHODS: We performed a prospective single-centre observational study analyzing adult patients admitted to ICU at Hospital Clínico San Carlos with respiratory failure due SARS-CoV-2 pneumonia but not under IMV. We recorded continuous EKG waveforms and obtained time and frequency domains and non-linear dynamics HRV metrics. RESULTS: 47 patients were screened and 27 were finally analyzed. 15 (55.5%) of them required intubation and IMV. Heart rate was 80 beats/min in each group. HRV metrics were similar between groups in the time domain, frequency domain and after using nonlinear analysis. However, when comparing against literature control, Covid-19 patients admitted in the ICU had a diminished HRV but higher heart rates. CONCLUSION: We found that HRV on ICU admission didn't discriminate patients requiring IMV. We found that Covid-19 patients had a diminished HRV although having higher heart rates than healthy literature controls.

Abstract Introduction Training tools should follow a thorough validation process that assure their value before their wider use. In this regard, three online modules for laparoscopic cholecystectomy, lumbar punction and knee arthroscopy have been created for an integrative Learning Management System (LMS) that connects external assets, therefore allowing training of technical and nontechnical skills. This work focuses on the content validation of the modules to determine the appropriateness of the material for learning purposes. Methods The contents for the three modules have been developed following a 3D pedagogical model designed for e-learning in minimally invasive surgery. Experts were requested to rate 10 items about the contents and the activities included within the modules. Rating was done on a 5-point Likert scale (5-Strongly agree, 1-Strongly disagree). Results Six experts took part in the study. Contents were well rated as unique (4.17), sufficient to cover the learning objectives (4.50), up to date (4.33), realistic and relevant (4.83), professional (4.67), with adequate assessment (4), useful forum (4.33), good quality multimedia contents (4) but not so innovative (3.83). Lastly, external assets provided added value to the courses (4.5). Conclusions In general, experts were satisfied with the structure and the quality of the education material and found them to be well prepared according to the best practice of each profession. Therefore, the modules will be incorporated in the LMS for training, which will be further validated to prove its utility as a training tool.

The Objective Structured Clinical Exam (OSCE) is an assessment tool used as a reliable method for clinical competence evaluation of students. This paper presents an investigation focused on the chain of survival, its related exploration, management, and technical skills, and how Virtual Reality (VR) can be used for the creation of immersive environments capable of evaluating students' performance while applying the correct protocols. In particular, the Cardiopulmonary Resuscitation (CPR) procedure is studied as an essential step in the development of the chain of survival. The paper also aims to highlight the limitations of traditional methods using mechanical mannequins and the benefits of the new approaches that involve the students in virtual, immersive, and dynamic environments. Furthermore, an immersive VR station is presented as a new technique for assessing CPR performance through objective data collection and posterior evaluation. A usability test was carried out with 33 clinicians and OSCE evaluators to test the viability of the presented scenario, reproducing conditions of a real examination. Results suggest that the environment is intuitive, quick, and easy to learn and could be used in clinical practice to improve CPR performance and OSCE evaluation.

Automatic surgical workflow analysis (SWA) plays an important role in the modelling of surgical processes. Current automatic approaches for SWA use videos (with accuracies varying from 0.8 and 0.9), but they do not incorporate speech (inherently linked to the ongoing cognitive process). The approach followed in this study uses both video and speech to classify the phases of laparoscopic cholecystectomy, based on neural networks and machine learning. The automatic application implemented in this study uses this information to calculate the total time spent in surgery, the time spent in each phase, the number of occurrences, the minimal, maximal and average time whenever there is more than one occurrence, the timeline of the surgery and the transition probability between phases. This information can be used as an assessment method for surgical procedural skills.

Background The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance. Methods A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682). Results Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance. Conclusions The impact of stress responses presents an important factor in surgical environments, affecting residents’ training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons’ stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Modern surgical education is focused on making use of the available technologies in order to train and assess surgical skill acquisition. Innovative technologies for the automatic, objective assessment of nontechnical skills are currently under research. The main aim of this study is to determine whether personal resourcefulness can be assessed by monitoring parameters that are related to stress and visual attention and whether there is a relation between these and psychomotor skills in surgical education. For this purpose, we implemented an application in order to monitor the electrocardiogram (ECG), galvanic skin response (GSR), gaze and performance of surgeons-in-training while performing a laparoscopic box-trainer task so as to obtain technical and personal resourcefulness’ metrics. Eight surgeons (6 nonexperts and 2 experts) completed the experiment. A total of 22 metrics were calculated (7 technical and 15 related to personal resourcefulness) per subject. The average values of these metrics in the presence of stressors were compared with those in their absence and depending on the participants’ expertise. The results show that both the mean normalized GSR signal and average surgical instrument’s acceleration change significantly when stressors are present. Additionally, the GSR and acceleration were found to be correlated, which indicates that there is a relation between psychomotor skills and personal resourcefulness.

Surgeons' procedural skills and intraoperative decision making are key elements of clinical practice. However, the objective assessment of these skills remains a challenge to this day. Surgical workflow analysis (SWA) is emerging as a powerful tool to solve this issue in surgical educational environments in real time. Typically, SWA makes use of video signals to automatically identify the surgical phase. We hypothesize that the analysis of surgeons' speech using natural language processing (NLP) can provide deeper insight into the surgical decision-making processes. As a preliminary step, this study proposes to use audio signals registered in the educational operating room (OR) to classify the phases of a laparoscopic cholecystectomy (LC). To do this, we firstly created a database with the transcriptions of audio recorded in surgical educational environments and their corresponding phase. Secondly, we compared the performance of four feature extraction techniques and four machine learning models to find the most appropriate model for phase recognition. The best resulting model was a support vector machine (SVM) coupled to a hidden-Markov model (HMM), trained with features obtained with Word2Vec (82.95% average accuracy). The analysis of this model's confusion matrix shows that some phrases are misplaced due to the similarity in the words used. The study of the model's temporal component suggests that further attention should be paid to accurately detect surgeons' normal conversation. This study proves that speech-based classification of LC phases can be effectively achieved. This lays the foundation for the use of audio signals for SWA, to create a framework of LC to be used in surgical training, especially for the training and assessment of procedural and decision-making skills (e.g., to assess residents' procedural knowledge and their ability to react to adverse situations).

Abstract Introduction Effectiveness of e-learning diminishes without the support of a pedagogical model to guide its use. In minimally invasive surgery (MIS), this has been reported as a limitation when technology is used to deliver contents without a sound pedagogical background. Material and methods We describe how a generic pedagogical model, the 3D pedagogy framework, can be used for setting learning outcomes and activities in e-learning platforms focused on MIS cognitive skills. A demonstrator course on Nissen fundoplication was developed following the model step-by-step in the MISTELA learning platform. Course design was informed by Kolb’s Experiential learning model. Content validation was performed by 13 MIS experts. Results Ten experts agreed on the suitability of content structuring done according to the pedagogical model. All experts agreed that the course provides means to assess the intended learning outcomes. Conclusions This work showcases how a general-purpose e-learning framework can be accommodated to the needs of MIS training without limiting the course designers’ pedagogical approach. Key advances for its success include: (1) proving the validity of the model in the wider scope of MIS skills and (2) raising awareness amongst stakeholders on the need of developing training plans with explicit, rather than assumed, pedagogical foundations. Abbreviations: MIS: minimally invasive surgery; TEL: technology enhanced learning

Currently surgical training is largely based on the improvement of Technology Enhanced Learning solutions. The progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. The main reasons to encourage these changes are increased efficiency of simulators and directly increased patient’s safety. The goal assumed by the EASIER Project is to develop multi-skill, online platforms for minimally invasive surgical (MIS) procedures—based on common pedagogical principles with reference value in a multinational space. The platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. This work presents the milestones of the project during its first year of life.

Brain health refers to the preservation of brain integrity and function optimized for an individual's biological age. Several studies have demonstrated that our lifestyles habits impact our brain health and our cognitive and mental wellbeing. Monitoring such lifestyles is thus critical and mobile technologies are essential to enable such a goal. Three databases were selected to carry out the search. Then, a PRISMA and PICOTS based criteria for a more detailed review on the basis of monitoring lifestyle aspects were used to filter the publications. We identified 133 publications after removing duplicates. Fifteen were finally selected from our criteria. Many studies still use questionnaires as the only tool for monitoring and do not apply advanced analytic or AI approaches to fine-tune results. We anticipate a transformative boom in the near future developing and implementing solutions that are able to integrate, in a flexible and adaptable way, data from technologies and devices that users might already use. This will enable continuous monitoring of objective data to guide the personalized definition of lifestyle goals and data-driven coaching to offer the necessary support to ensure adherence and satisfaction.

MIS-SIM is a virtual reality (VR) environment designed and developed for the creation of virtual scenarios that can be used to train and acquire basic and advance laparoscopic skills. The environment is composed by a task editor where a content creator design and develop tasks for the simulator to play. Once they are completed, objective metrics are automatically stored and examined in MIS-SIM’s server so they can be displayed by an online platform. The project was validated in Semmelweis University in Budapest, Hungary where an experienced professor designed tasks for 16 young surgeons (PGY 3-4-5) from different surgical fields (gynaecology, general-, plastic-, vascular-, thoracic-, neurosurgery, etc.) with different experiences in laparoscopy. Each participant fulfilled each task as if they were completing them on physical simulator.

En el presente trabajo se presenta un entorno de formacion para la tecnica de ecografia neonatal transcraneal. Es un entorno orientado a la adquisicion de habilidades tecnicas y no tecnicas requeridas durante el examen ecografico. Posibilita la incorporacion de un catalogo de casos y desempeno del analisis transcraneal a tiempo real. La introduccion del entorno de formacion en la practica clinica real puede conseguir desligar a los pacientes neonatos del proceso formativo y conseguir una mayor calidad de formacion de los medicos residentes en lo relativo a la tecnica de ecografia neonatal transcraneal