Spaced Education Improves the Retention of Laparoscopic Suturing Skills: A Randomized Controlled Study

Abstract

Introduction Spaced learning has been shown to be superior in complex motor skill acquisition like laparoscopic suturing and knot tying. By using a pre–post follow-up design, the aim of the study was to evaluate the long-term impact of implementation of the spaced learning concept in laparoscopic training.

Materials and Methods To evaluate the effectiveness of spaced learning, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes—prior and after 3 hours of hands-on training. To examine the long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 12 months later as follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation.

Results Twenty students were included in the study; after simple randomization, 10 were trained using the “spaced learning” concept and 10 via traditional methods. Both groups had comparable baseline characteristics and improved after training significantly, regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of speed (p = 0.021), knot quality (p = 0.008), and suture strength (p = 0.003). Additionally, spaced learning significantly decreased anxiety (p = 0.029) and probability of success (p = 0.005).

Conclusion The spaced learning concept is very suitable for long-term complex motor skill acquisition, like laparoscopic suturing and knot tying. It is superior to conventional training regarding speed and, most importantly, knot quality and stability, resulting in improved confidence and motivation. Thus, we strongly recommend to incorporate the spaced learning concept into training courses and surgical programs.

Keywords

laparoscopy - training - spaced learning

Authors' Contributions

J.B. acquired the data, conceptualized the questionnaire, validated statistics, and approved the final manuscript as submitted. L.K. acquired the data, conceptualized the questionnaire, validated statistics, and approved the final manuscript as submitted. S.M. acquired the data, acted as course instructor, and approved the final manuscript as submitted. F.G. acquired the data, acted as course instructor, and approved the final manuscript as submitted. T.K. acquired the data, acted as course instructor, and approved the final manuscript as submitted. R.B. acquired the data, acted as course instructor, and approved the final manuscript as submitted. K.R. conceptualized and designed the study, and approved the final manuscript as submitted. M.B. conceptualized and designed the study, acquired the data, acted as course instructor, performed statistics, drafted the initial manuscript, and approved the final manuscript as submitted. All authors approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

^∗ Johannes Boettcher and Lea Klippgen contributed equally to the study.

• References

• 1 Boettcher M, Boettcher J, Mietzsch S, Krebs T, Bergholz R, Reinshagen K. The spaced learning concept significantly improves training for laparoscopic suturing: a pilot randomized controlled study. Surg Endosc 2018; 32 (01) 154-159
• 2 Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R. Teaching surgical skills: what kind of practice makes perfect? A randomized, controlled trial. Ann Surg 2006; 244 (03) 400-409
• 3 Spruit EN, Band GP, Hamming JF. Increasing efficiency of surgical training: effects of spacing practice on skill acquisition and retention in laparoscopy training. Surg Endosc 2015; 29 (08) 2235-2243
• 4 Stickgold R. Sleep-dependent memory consolidation. Nature 2005; 437 (7063): 1272-1278
• 5 Fields RD. Making memories stick. Sci Am 2005; 292 (02) 75-81
• 6 Kelley P, Whatson T. Making long-term memories in minutes: a spaced learning pattern from memory research in education. Front Hum Neurosci 2013; 7: 589
• 7 Davis CR, Toll EC, Bates AS, Cole MD, Smith FC. Surgical and procedural skills training at medical school - a national review. Int J Surg 2014; 12 (08) 877-882
• 8 Romero P, Brands O, Nickel F, Müller B, Günther P, Holland-Cunz S. Intracorporal suturing--driving license necessary?. J Pediatr Surg 2014; 49 (07) 1138-1141
• 9 Mietzsch S, Boettcher J, Yang S. , et al. Training significantly improves fetoscopy performance: a pilot randomized controlled trial. Eur J Pediatr Surg. 2016; 26 (05) 436-442
• 10 Hibbeler B, Korzilius H. Arztberuf: Die Medizin wird weiblich, doch gilt dies nur bis zu einer bestimmten Hierarchiesrufe. Dtsch Arztebl 2008; 105: 609
• 11 Bitterman N, Shalev I. Profile of graduates of Israeli medical schools in 1981--2000: educational background, demography and evaluation of medical education programs. Isr Med Assoc J 2005; 7 (05) 292-297
• 12 Bastir M, García Martínez D, Recheis W. , et al. Differential growth and development of the upper and lower human thorax. PLoS One 2013; 8 (09) e75128
• 13 Muresan III C, Lee TH, Seagull J, Park AE. Transfer of training in the development of intracorporeal suturing skill in medical student novices: a prospective randomized trial. Am J Surg 2010; 200 (04) 537-541
• 14 Munz Y, Almoudaris AM, Moorthy K, Dosis A, Liddle AD, Darzi AW. Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: objective assessment of the transfer of skill from virtual reality to reality. Am J Surg 2007; 193 (06) 774-783
• 15 Dorsey JH, Sharp HT, Chovan JD, Holtz PM. Laparoscopic knot strength: a comparison with conventional knots. Obstet Gynecol 1995; 86 (4 Pt 1): 536-540
• 16 Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot-tying techniques. JSLS 2009; 13 (03) 416-419
• 17 Rheinberg F, Vollmeyer R, Burns BD. FAM: Ein Fragebogen zur Erfassung aktueller Motivation in Lern-und Leistungssituationen 12 (Langversion, 2001). Diagnostica 2001; 2: 57-66
• 18 Oostema JA, Abdel MP, Gould JC. Time-efficient laparoscopic skills assessment using an augmented-reality simulator. Surg Endosc 2008; 22 (12) 2621-2624
• 19 Palter VN, Orzech N, Reznick RK, Grantcharov TP. Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial. Ann Surg 2013; 257 (02) 224-230
• 20 Kahol K, Leyba MJ, Deka M. , et al. Effect of fatigue on psychomotor and cognitive skills. Am J Surg 2008; 195 (02) 195-204
• 21 Borragán G, Urbain C, Schmitz R, Mary A, Peigneux P. Sleep and memory consolidation: motor performance and proactive interference effects in sequence learning. Brain Cogn 2015; 95: 54-61
• 22 Sakamoto T, Kondo T. Visuomotor learning by passive motor experience. Front Hum Neurosci 2015; 9: 279
• 23 Johansson J, Skeff K, Stratos G. Clinical teaching improvement: the transportability of the Stanford Faculty Development Program. Med Teach 2009; 31 (08) e377-e382
• 24 Skeff KM, Stratos GA, Bergen MR, Regula Jr DP. A pilot study of faculty development for basic science teachers. Acad Med 1998; 73 (06) 701-704
• 25 Dawe SR, Pena GN, Windsor JA. , et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg 2014; 101 (09) 1063-1076
• 26 Hamaoui K, Saadeddin M, Sadideen H. Surgical skills training: time to start early. Clin Teach 2014; 11 (03) 179-183
• 27 Nomura T, Matsutani T, Hagiwara N. , et al. Characteristics predicting laparoscopic skill in medical students: nine years' experience in a single center. Surg Endosc 2018; 32 (01) 96-104
• 28 Shane MD, Pettitt BJ, Morgenthal CB, Smith CD. Should surgical novices trade their retractors for joysticks? Videogame experience decreases the time needed to acquire surgical skills. Surg Endosc 2008; 22 (05) 1294-1297
• 29 Boyd T, Jung I, Van Sickle K, Schwesinger W, Michalek J, Bingener J. Music experience influences laparoscopic skills performance. JSLS 2008; 12 (03) 292-294
• 30 Rosser Jr JC, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The impact of video games on training surgeons in the 21st century. Arch Surg 2007; 142 (02) 181-186
• 31 Verdaasdonk EG, Dankelman J, Lange JF, Stassen LP. Incorporation of proficiency criteria for basic laparoscopic skills training: how does it work?. Surg Endosc 2008; 22 (12) 2609-2615
• 32 Dawe SR, Windsor JA, Broeders JA, Cregan PC, Hewett PJ, Maddern GJ. A systematic review of surgical skills transfer after simulation-based training: laparoscopic cholecystectomy and endoscopy. Ann Surg 2014; 259 (02) 236-248
• 33 Larsen CR, Soerensen JL, Grantcharov TP. , et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009; 338: b1802
• 34 Strandbygaard J, Bjerrum F, Maagaard M. , et al. Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized trial. Ann Surg 2013; 257 (05) 839-844