Learning video surgery techniques at the beginning of a surgeon’s career is challenging since such skills are not natural and must be acquired through consistent training(17). To assist in this process and provide an alternative learning tool, the course was designed in such a way that the practical training exercises were carried out with accessible materials, creating conditions that can be easily reproduced in any environment during medical residency and reduce the inherent costs of the learning curve(5, 12, 18). The basic training structure was a handcrafted wooden box, with a tutorial provided for its preparation being offered to interested students at the end of the course (Fig. 1). The camera used to view the exercises was the participants’ own cellular phone or tablet. The use of these inexpensive readily available materials may contribute to expand the application of these video-surgery courses, increasing the training opportunities of young surgeons and, hopefully, improving their surgical abilities.
Despite not providing the acquisition of all the skills necessary for the practice of video surgery, short-term training appears to be effective in increasing an individual’s basic skills, resulting in reduced surgical training costs during the learning curve, as well as encouraging independent practice of video surgery(13, 18–20).
Assisted training, with individual guidance by a supervising professor, proved to be superior to self-taught training(13, 16). The presence of a professor appears to be the factor with the greatest impact on improving skill acquisition in video surgery(21). In the present course, the students were supervised by one or more instructors, with individual comments on the participants’ performance during and after the course, explaining points of improvement by comparing pre- and post-training (knot quality, ergonomics, camera skill, movement smoothness).
The best way to evaluate the development of surgical skills among residents is still a matter of debate. Error rate reduction when performing exercises in a simulator box has been widely used for evaluating the effectiveness of laparoscopic training(13, 22). The time taken to perform a given laparoscopic exercise before and after training has also been used and it appears to be easier to control(9, 13, 22). In the present study, an improvement in the time taken to perform the exercises could be observed after participation in the short-term theoretical-practical course offered during the study. When comparing all participants’ results, it was observed that, after the short-term practical training, there was an increase in the number of individuals who were able to perform the exercise within the maximum time limit of 5 minutes, as well as a significant reduction in the time needed to execute a laparoscopic stitch, indicating the course’s effectiveness in improving participants’ skills.
Subjectively, after the training stage, it was observed that the residents were able to apply what was learned in the course to facilitate the completion of knots. They increased the use of their non-dominant hand to support the structure and assist in movements, employed smoother and more elegant movements, and improved the quality of the knots (fewer “false knots”); also, there was an improvement in the ability to handle the camera (understanding what their fellow surgeon needs to see).
On the other hand, that there was very little improvement in ergonomics, even with the frequent tips given on posture during practice. This aspect could be explained by the excessive concern and attention directed towards the exercise, associated with the difficulties in performing video surgery at this point in the learning curve. Nevertheless, we suggest that ergonomics be taught, corrected and practiced continuously, from the beginning of the surgeon's training, considering its importance in the long-term quality of life of professionals in the area.
Recent publications have attempted to correlate the playing of video games with greater skill in video surgery procedures(8, 23, 24). In the present study participants who had video game experience demonstrated a better performance in the pre-training exercise, with a reduction in the time taken to perform the stitch (p=0.0116). This may mean that participants with video game experience may have better eye-hand coordination and find it easier to handle laparoscopic instruments and to deal with two-dimensional vision. This data corroborates previous studies, which correlated surgeons’ previous video game experience with video surgery skills, highlighting the spatial awareness needed for both activities, provided by the complex interaction between the visual and cognitive systems(8, 23–25). However, this correlation still needs further investigation.
Other factors possibly associated with surgical skills – such as age, gender and area of interest – have also been investigated with varying results(6). Our results point to a better post-course performance amongst female residents. It is important to note that this is a secondary outcome and that the subdivision into genders also resulted in a sample size reduction of each subgroup, thus reducing the test’s power (approximately 50%). Therefore, in the present settings, these results should be taken carefully.
Nevertheless, investigating a possible gender difference regarding the development of surgical skills has been a frequent subject of study. Overall, published data suggest that male individuals perform better than females after graduation. Amongst surgical residents, this difference is not apparent anymore, possibly associated with the increased interest of all individuals who decide to pursue a surgical speciality. Female individuals, on the other hand, seem to have a better response to assisted individual training, which is corroborated by the apparent improved response amongst female participants to the training offered in the present study. Thus, different advantages seem to be associated with each gender, resulting in similar overall performance among surgeons of both genders(6, 25–27).
Participants’ satisfaction with the course was high, with all 36 participants stating that they would recommend the course “a lot” or “quite a lot” to a colleague also in General Surgery training. When the activities were completed, many showed interest in continuing practising in classes both during the curricular year and at home.
Finally, it is believed that the present course, because of its low cost of execution and its short duration, can easily be reproduced in any other institutions that have surgical residency programs.