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Procedure specific preoperative warm-up results in improved operative outcomes.
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Surgical performance of primary operators was shown to improve post simulation-based surgical priming.
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Use of preoperative warm-up should be considered to improve patient outcomes.
Abstract
Background
Preoperative warm-up in preparation for surgery is a technique used in recognition of similarities between surgeons and performance based professionals. The aim of this review was to evaluate the use of simulation-based preoperative warm-up on surgical performance in the operating room and its impact on both clinical and patient outcomes.
Materials and methods
A systematic review of the literature was carried out in accordance with PRISMA guidelines between August–September 2021. In total 15 studies were retrieved.
Results
Seven studies across general surgery, urology, and vascular surgery used a procedure specific warm-up, with significant improvement in operative performance, rate of errors, radiological and patient-based outcomes. Variables including level of experience and specialty appeared to have no impact on the merits of preoperative warm-up demonstrated.
Conclusions
While heterogeneity in the benefit of generic warm-up procedures was noted, procedure specific warm-up methods consistently resulted in significantly better operative outcomes.
noted the use of warm-up techniques is common in performance driven careers to promote both physical, psychological dexterity, instil confidence and suitably “prime” performers for the task ahead, however this has yet be widely adapted in everyday surgical practice. The introduction of surgical simulation on a virtually based platform has led to a recent surge in the use of simulation-based learning in surgical training to promote surgical skill acquisition,
A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
Several studies have highlighted the use of simulation based training to evaluate the efficacy of the virtual platform in the preoperative period to promote surgical performance.
While its use has been demonstrated to improve measured outcomes, significant limitations to the use of simulation derived metrics without in vivo assessment exist. Learning bias is a recognised limitation to assessment tools using machine automated scores,
with participants demonstrating improved performances and outcomes due to familiarity with the equipment.
It is incumbent on clinicians to ensure adequate validation of novel educational or simulation based equipment is completed prior to implementation into clinical practice.
The step from the virtual platform to the operating room is the most significant to ensure that time and training given to simulation based tools is reflected in improved operative performance.
The aim of this review was to evaluate the use of simulation-based preoperative priming defined as simulation in the preoperative period on technical surgical performance carried out in the operating room and its impact on clinical and patient outcomes.
2. Materials and methods
2.1 Search strategy
A comprehensive search strategy was performed of electronic databases including PubMed, Ovid Medline, EMBASE, Google Scholar, with study selection identification from August 2021–September 2021. Broad search terms to ensure adequate capture were used; with a combination of “warm*”, “prim*”, “performance”, “surg*”, “outcomes”, using Boolean characters “AND” and “OR”. The search was carried out in accordance with PRISMA guidelines. Two independent reviewers performed a literature search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines
and reviewed the search results, with a senior author arbitrating in the event of a disagreement, based on a protocol agreed on by all authors. Use of Assessing the Methodological Quality of Systematic Reviews (AMSTAR) was applied to retrieved studies to evaluate quality of articles retrieved. This review was registered with PROSPERO under registration number CRD42021285522.
2.2 Eligibility criteria
The inclusion criteria consisted of (i) in-vivo studies (ii) use of simulation as a warm-up method pre-operatively (iii) English or full translation freely available. The exclusion criteria included (i) case reports (ii) use of simulation-based assessment to analysis effect of pre-operative warm-up (iii) warm-up techniques not involving simulation-based practice.
2.3 Outcomes analysed and statistical analysis
Ad-hoc tables were designed to summarize data from the included studies. Study design, surgical specialty and level of participant experience were collected. Comparison groups if used were also noted, in addition to the warm-up regimen employed by each study. Evidence of any change in surgical performance by participants following priming were recorded in addition to subjective or objective tools used. and any differences in study outcomes recorded. Risk of bias was assessed using the ROB (Risk of Bias) and ROBINS-I (Risk of Bias in Non randomised Studies) tools. No deviations from protocol were noted during data collection and collation.
2.4 Objectives and aims
The objective is to review and collectively compare the impact of virtual reality simulation in the preoperative period on technical surgical performance in the operating room.
3. Results
In total 15 study fulfilling outlined criteria were included for analysis (Fig. 1).
Risk of Bias using ROB2 and ROBINs-I tools was calculated. Risk of bias arising due to randomisation where applicable, deviation from intended intervention, missing data, outcome measurements, and selection of reported results was assessed for each study. No studies were identified as containing a high risk of bias. A moderate risk of bias was identified due to bias in measurement of outcomes,
included used a randomised crossover design, with intraparticipant scores recorded for comparison (Table 1.). Two studies randomised patients to warm-up and control groups, with surgical teams undergoing warm-up according to the grouping status of the patient.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Subjects completed two laparoscopic renal surgery cases having completed electrocautery simulation task on LapMentor and laparoscopic suturing on a box trainer on one occasion
Renal surgical cases including nephrectomy (radical and partial), pyeloplasty, renal cyst decortication
Procedures were randomised to be carried out by a participant who had warmed-up on a simulator using “bead transfer”, “rubber band placement”, “run the rope” or one who had not completed a warm-up.
Major: Supercervical and total hysterectomies Minor: adnexal and tubal surgery
Global Rating Scale- OSATs (Objective Structured Assessment of Technical Skills)
Procedures were randomised to warm-up or no warm-up
Improved resident performance intraoperatively following warm-up compared to control group (p
Participants were randomised to undergo warm up on simulator using one of 4 tasks: peg transfer, pattern cutting, endoloop, intracorporal suturing before 1st case of the day over 5 days or perform the operation without simulated warm up. Participants than crossed over to the other arm.
Participants recruited to undergo 2 laparoscopic cholecystectomies, one of which carried out with standard preoperative preparation, and one with a simulated warm-up on a simulator consisting of 5 tasks: Transference, cuts, endoloop, Extracorporeal and intracorporal knots.
Laparoscopic Cholecystectomy
Operative time, blood loss, perforation, drainage, postoperative pain, haematoma formation
No VR warm-up
Less bleeding (p = 0.01), reduced operative time (p = 0.019)
Participants underwent virtual laparoscopic tasks consisting of fine dissection, Cholecystectomy II, Peg transfer before and after each operation. Scores from each attempt were compared to evaluate comparative improvement in surgical skills after laparoscopic surgery
Participants were randomised to warm-up consisting of a virtual laparoscopic sigmoid resection or no warm up prior to undertaking a laparoscopic sigmoid colectomy on pigs. Performance assessed by colorectal surgeons blinded to the grouping status of participants.
Laparoscopic sigmoid colectomy
Generic laparoscopic technical skills scores, and specific skills related to sigmoid colectomy
No VR warm-up
Warm-up group significantly outperformed control in generic (p = 0.002) and specific skills (p = 0.001)
A surgical team carried out laparoscopic cholecystectomies having undergone warm-up on a VR or not. Warm-up consisted of camera navigation, coordination, clip application, clipping and grasping, electrocautery, cystic pedicle dissection, clipping and cutting. Blinded reviewers assessed performance using GRS tool
Laparoscopic Cholecystectomy
Modified Global Rating Score
No VR warm-up
Respect for tissues significantly improved in the warm-up group (p = 0.021; p = 0.04)
Participants were randomised to complete a laparoscopic cholecystectomy having completed a generic laparoscopic warm-up VR training program consisting of “lifting and grasping”, “clip applying”, “dissection” or without warm-up.
Laparoscopic Cholecystectomy
Generic OSATS Global Rating Scale
Trainees acted as own control
Surgical performance was significantly improved following a VR warm-up (p = 0.04)
A combination of modules “Ring and Rail 2”, “Match Board 3”, “Endowrist manipulation 2”, “Suture Sponge 3”, and “Running Suture 2” were used across 5 groups
Not specified
Global Evaluative Assessment of Robotic Skills (GEARS) tool
Subjects acted as own control
No significant difference in performance between scores following warm-up and no warm-up in any measured metric
Review of outcomes following laparoscopic partial nephrectomies (LPN) and radical nephrectomies (LRN) carried out by a single surgeon were analysed for difference in collected outcomes. Warm-up consisted of pelvic trainer suturing exercises.
Laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN)
Total operative time, surgical time, estimated blood loss, warm ischemia time, complications, positive margins, length of stay, Hb fall, creatinine, analgesic requirements
Subject acted as own control
Surgical time post warm-up was significantly faster (p = 0.03)
Participants carried out live porcine laparoscopic cholecystectomy after watching a video explaining the procedure, with half having also undergone a simulated laparoscopic cholecystectomy.
Laparoscopic cholecystectomy
Global Operative Assessment of Laparoscopic Skills (GOALS)
Participants performed USO having either undergone warm-up exercises including peg transfer, pattern cutting and fine dissection or performing USO without VR warm-up.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Participants were randomised to carry out a game console exercise, perform intracorporal suturing, or no warm-up prior to surgery. Videos of LC and LA were taken and assessed.
Participants were randomised to undergo warmup on simulator comprising of a bimanual task, peeling, and retinal detachment surgery 20 min prior or proceed directly to surgery. Operative performance was videoed and assessed by 2 blinded reviewers.
Pars plana vitrectomy
Global rating assessment of skill in intraocular surgery (GRASIS)
No warm-up
Final operative outcome improved post warm-up (p = 0.03)
Vascular Patients with AAA + Complete operative team
Vascular surgeons carried out operation on patients having carried out a virtual team-based operation using patient-based metrics within 24 h of the procedure, or proceeding without a virtual run-through
Endovascular Aneurysm Repair
Intraoperative errors, 30-day mortality, Imperial College Error Capture (ICECAP), operative time, number of angiograms
Patients randomised to have no virtual run through preoperatively
Intervention group lower error rate (p = 0.004; p = 0.03), number of angiograms lower in the intervention group (p = 0.005; p = 0.004)
ANGIO Mentor Express Dual Access Simulation System (Simbionix)
Legend.
a Obstetrics + Gynaecology Abdominal Aortic Aneurysm.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
also including a group exposed to video gaming devices in the preoperative period.
Studies used either a generic or specific warm-up approach. Within studies using a procedure specific warm-up, two main methods were used; the complete procedure was utilised in the virtual environment in four studies,
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Both objective and subjective methods of assessment were used within studies. A variety of subjective laparoscopic global rating scales were used to measure the impact of preoperative warm-up including Objective Structured Assessment of technical skills (OSAT),
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
also used number of intraoperative images taken to evaluate efficacy of patient-specific preoperative virtual run-throughs.
3.7 Time dedicated to warm-up
Two main methods were used during the required warm-up time given to participants. Studies included in this review used a predominantly task-based approach to the warm-up procedure, with nine studies allotting time dedicated to the warm-up period based on completion of a required task.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
allocated a time of 2 h to complete the set task, although noted all participants completed it within this time frame.
3.8 Time warm-up implemented prior to surgery
A degree of heterogeneity was demonstrated in the use of preoperative priming prior to the operative assessment. While four studies noted the warm-up was completed immediately preoperatively,
reported the longest degradation time with completion of the simulated operation done within 24 h. Six studies did not specify the use of warm-up in relation to the operative list to be completed.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Studies evaluating objective metrics demonstrated a significant improvement in radiological, patient, and participant-based endpoints with the exception of one study.
found no difference in operative time from procedures carried out by specialists having completed a generic preoperative warm-up was found (p = 0.2)21. This is in contrast with two studies who demonstrated a significantly faster time to completion by trainees (p = 0.01)
found intraoperative steps were completed in a shorter duration by novices who had practiced procedure specific manoeuvres as a preoperative warm-up (p = 0.01).
Both studies evaluating patient-based outcomes demonstrated a significant improvement in estimated blood loss in those who had completed a preoperative warm-up, with both generic (p = 0.01)
reported a significant difference in outcomes using simulator based metrics following completion of simulator modules, demonstrated using a simulator following completion of an intraoperative procedure (p = 0.03).
3.9.2 Kinemetric-based outcomes
Two studies noted a significant improvement in unexperienced participants' operative performances following completion of a procedure specific warm-up.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
found medical students having completed a virtual cholecystectomy performed better than their unprimed counterparts across several metrics including depth perception (p = 0.004), bimanual dexterity (p = 0.004), tissue handling (p = 0.01), and autonomy (p = 0.02).
In studies using an operative component specific to the procedure in their warm-up, a significant improvement was noted kinemetric assessments made intraoperatively. Calatayud et al.
noted a significant improvement in overall performance using validated assessment tools within the surgically primed groups (p = 0.04). Similarly, Moldovanu et al.
found a similar outcome with the preoperatively prepared demonstrating a greater degree of respect for tissue (p = 0.04) than those who had not undergone a surgical warm-up using procedure specific components.
Generic warm-ups using basic laparoscopic or other skills resulted in heterogenous outcomes. Three studies found an improvement in kinemetric outcomes in participants having completed a generic warm up.
found no significant difference across any kinemetric assessment was noted. Similarly, no significant difference was noted in the group carrying out video games in the preoperative period.
used patient specific anatomy in the preoperative simulated simulation, which may account for the stark contrast in the findings between these studies.
4. Discussion
The use of virtual reality-based simulation has been discussed in its potential uses to accelerate surgical skill acquisition,
A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
This review highlights its potential use in helping promote patient safety through surgically priming primary operators prior to the first case of the day. In studies whereby the preoperative warm-up carried out was specific to the operative case to be completed, a significant improvement across both objective and subjective metrics was demonstrated consistently.
Subjective assessment in surgical performance remains the standard method of evaluation in surgical and simulated surgical performances.
Numerous subjective assessment tools exist, with several attempts in recent years to develop a standardised instrument to subjectively assess surgical performance, with functional components within each tool consistent across the studies in which they are applied.
Several subjective assessment tools were used in the studies included in this review, with an improved overall performance score noted in four studies.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
Three studies however found no significant difference overall performance or measures metrics following priming; this highlights the potential future benefit to be yielded from introduction of a standardised template of subjective assessment of surgical performance,
The use of objective assessment tools in surgical skill acquisition are increasing in recognition of an evolving Halstedian surgical training model to a structured training method.
A plethora of objective assessment methods were used across in studies included in this review, which consistently demonstrated an improved performance following priming compared to unprimed surgical performance. Simulation derived performance was found to improve globally following preoperative priming by Paschold et al.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
its use as a method to evaluate proficiency should be used with caution. In this review, three of the four studies looking at operative times saw preoperative warm-up resulted in shorter surgical times recorded. Mucksavage et al.
found a significant decrease in operative time following introduction of a warm-up, however as a retrospective review using a single surgeon with a sequential rather than parallel method used, the impact of a greater degree of surgical experience during the period with which warm-up procedures were used on subsequent clinical and patient outcomes should be considered.
and its use is not reflective of superior operative performance; reduction in radiation exposure for both patient and practitioner should be encouraged to reduce sequelae associated with prolonged or repeat exposure
To date no significant impact on rates of complications arising from operative list composition has been demonstrated, with rates of orthopaedic postoperative infections thought to be associated with case order, potentially secondary to inadequate cleaning interoperatively.
found that patient on second and subsequent cases on the operating list had shorter operative times, and hospital lengths of stay. This was reflected in findings from studies included in this review, with significantly lower recorded blood loss following preoperative priming found in two studies.
This has potential implications on long-term downstream effects on patient outcomes and hospital costs, with additional benefits of a preoperative warm-up to promote work flow in operating lists, with three studies finding preoperative priming yielded significantly shorter operative times.
Similarly, conventional box training provides ample opportunities to obtain adequate exposure to the laparoscopic operative setup to derive significant benefit from its use.
In this review the use of operative aids including high-fidelity simulation, box trainers, and simple suturing techniques appear to have an impact on subsequent operative performance. The use of simulation for surgical training in open procedures is sparse in the literature.
Only one study in this review used a non-laparoscopic or endovascular surgery to evaluate the impact of preoperative preparation, with positive results.
The merits of preoperative surgical priming appear not to be limited by surgical approach, highlighting the generalisability of this practice to all surgical specialities.
Use of virtual reality simulation has been reported to have variable impact on reported efficacy, and improvement in operative performance based on level of experience.
A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
this review highlights the potential use of simulation in experienced specialists, with improvement in outcomes demonstrated in both novices and qualified surgeons. While practical limitations of preoperative preparation using surgical simulators were not discussed at length in studies included for review; barriers to the introduction of preoperative priming should be considered, including additional constraints of time on surgical trainees, potential costs of equipment, and the potential limited availability of space near theatre to facilitate surgeon access to preoperative tools.
4.1 Limitations
Significant heterogeneity in study design was noted in this review. While a cross-over RCT method was used in three studies, most studies included used a parallel RCT design, and the impact of inter-surgeon performance variability
should be considered in the context of the findings.
5. Conclusion
Procedure specific warm-up methods consistently demonstrated significantly better outcomes in endpoints measured, including operative metrics and surgical performance, and in reported rates of intraoperative errors recorded. Heterogeneity in the benefit of generic warm-up procedures is apparent, however their use yielded mixed-positive results on both low and high-fidelity simulation-based equipment across all levels of experience. The use of procedure specific warm-ups should be considered to improve intraoperative performance and operative metrics including operative time and patient blood loss.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Financial disclosure
No grants or financial support was received for this work.
Conflict of interest
This is a letter pertaining to the submission of the manuscript “Use of procedure specific preoperative warm-up during surgical priming improves operative outcomes: a systematic review”.
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.
We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.
Acknowledgements
None.
References
Kroft J.
Ordon M.
Arthur R.
Pittini R.
Does surgical "warming up" improve laparoscopic simulator performance?.
A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.