Many studies evaluated the efficiency of different simulation-training programs in terms of acquisition of surgical skills and self-confidence improvement of medical students [2, 3, 14, 18, 19]. However, and to our knowledge, few of these studies assessed both the integration of high-fidelity simulation and trainees’ self-assessment in laparoscopic training program, and none examined trainees’ vigilance development. Imaizumi et al. conducted a similar study, confirming the effectiveness of a simulation-based laparoscopic training program, depending on objective and subjective parameters [20]. The objective evaluation consisted of examining the task-achievement time and the accuracy in performing FLS tasks, the subjective evaluation depended on a questionnaire assessing the satisfaction and the self-perceived improvement of trainees at the end of the program [20]. However, only five trainees were implicated in this study and only satisfaction and improvement were assessed [20]. Our study consists of eleven trained participants and ten novices. Moreover, the questionnaire used in our study is more comprehensive by assessing perceived difficulty and frustration in addition to satisfaction. Moreover, our study is unique in comparing the performance self-assessment of trained participants with that of novices to estimate the trained participants’ acquired vigilance regarding their performance.
Our results affirm the fact that simulation-based training proves to be an efficient method to learn laparoscopic surgery skills [3]. Starting with the basic psychomotor skills, both groups were able to complete the tasks successfully, but experienced participants, are faster in transferring objects and in cutting circles compared to the novices. These results match those mentioned in the literature that laparoscopy simulation-based training improve performance time as much as fifty percent [3, 21]. However, novices were able to manage these tasks completely this may be due to the fact that sixty percent of novices play video games; which is known to enhance the laparoscopic surgical skills education [22].
Regarding the complex psychomotor skills, specifically suturing with intracorporeal knot, experienced participants were significantly better performing and faster than the novices. These results are comparable with many studies confirming that this method of surgical training is effective and superior in developing complex surgical skills including suturing laparoscopically [23, 24]. Important is to highlight the value of rapidity when it comes to laparoscopic surgery. In fact, it has been demonstrated that increased operative time is linked to increased risk of post-operative complications and morbidity [25, 26]. Additionally, approximately third of experienced participants have finished their simulation-based training six months before the tasks with no training in the meantime, consequently proficiency-based simulator training leads to long-lasting enhancements in the surgical skills, even when practice is absent for few months [27].
Recognizing that executing laparoscopic intracorporeal anastomosis is a sophisticated complex skill, which could be developed through repetitive simulation-based training [28], a cutoff of eight training sessions seemed to be necessary to acquire this skill [28]. Despite that experienced participants in our research have either completed twenty-four hours of training on suturing only or completed the laparoscopic training program six months before the tasks, most of them and none of novices have completed the intestinal anastomosis with acceptable score. This finding affirms the efficacy of simulation-based laparoscopic training in developing advanced and retainable surgical skills [28, 29].
Four months after the training session, at the end of the laparoscopic training program, residents performed intestinal end-to-end anastomosis on porcine live tissue in approximately twenty minutes versus thirty minutes of time consumed by participants, who have finished their training program six months before (unpublished data). Although these results could not be compared statistically, it supports the fact that simulation-based training contributes to laparoscopic skill retention, but continuous training is necessary to minimize skill loss [29].
Being unaware of self-ignorance is critical in the medical field [16]. For this reason, participants’ own vigilance and awareness towards their own ignorance and level of performance were evaluated. In fact, experience is associated with more vigilance [30]. In addition, more knowledge is linked to increased perception of ignorance and limitations [30]. In other words, the more you know, the more you know you don’t know [30]. Accordingly, experts in a domain should feel themselves less satisfied and rate themselves lesser in comparison to novices [31]. Our study shows that both experienced and novice participants have comparable levels of satisfaction with no differences in performance self-rating. Consequently, experienced participants are not different to novices in term of vigilance, as they rate their own performance, and they feel satisfied the same way the novices did, even though they performed better. Additionally, when the subjective aspects are compared to the objective scores, no reliable correlation was found between participants ‘level of satisfaction, confidence, and performance self-assessment in one hand and their corresponding scores in precision cutting and end-to-end anastomosis in other hand. These findings may be either due to the small effective or to the fact that experienced participants were wrongfully judging or rating themselves, independently from their objective evaluation, which reflects their low level of vigilance towards their ignorance and limitations. Our findings are comparable to those demonstrated by Hansson et al., where experts rated their knowledge higher and their ignorance lesser in comparison to novices in different disciplines: history, medicine, physics, and psychology [31]. It is conceivable that humans lean towards considering what they already possess rather than focusing on what they do not [31, 32].
To the best of our knowledge, our study is the first to assess vigilance development among trainees during surgical laparoscopic training. It is well known that confidence is an essential quality for a surgeon, however confidence without competence is arrogance and harmful to the patients [17]. Based on that, it is very important for the surgical trainees to develop vigilance during residency. Because of previous repetitive simulation training, experienced trainees demonstrated better levels of confidence and difficulty perception compared to novices during tasks execution [18, 19]. Finally, being tested in a familiar environment, as evidenced by low effect from local stress, could be attributed to the relatively high level of satisfaction and contentment marked by novices, as evidenced that job’s satisfaction is linked to good and cohesive personal relationships [33–35].
This study has several limitations. The low number of participants did not permit us to conclude in a statistically relevant method. Additionally, the lack of expert surgeons, as a control group, which could represent a reference goal to compare with, especially on the level of self-ignorance perception. Finally, the subjective evaluation depends on a created non-validated questionnaire.
In conclusion, the present study confirms the efficacy of the simulation-based laparoscopic training as a superior surgical training method that leads to basic and complex surgical skills development and retention. A continuous long-term training remains necessary in order to retain the learned advanced surgical skills. This kind of training appears to contribute to better stress handling and higher self-confidence. However, it still insufficient for residents to develop high level of vigilance and self-awareness. Maybe these necessary characteristics could be acquired through live hands-on operative experience.