With the advent of laparoscopic technology, the number of open operations such as open appendicectomy has gradually declined in recent decades , , , . The inclusion of modern technology in surgical training has increased and represents an important component of modern surgical education , . The use of software to assist in surgical teaching is widely documented in the literature. A large systematic review by Maertens et al. concluded that e-learning is as effective as other platforms for learning in surgery . Some of these modern teaching methods include digital simulations, which have been shown to be effective at improving surgical performance .
Simulation training is one method of developing proficiency in a safe and risk-free environment, and is used in formal surgical training , , . Touch Surgery™ is a free surgery simulator on iOS and Android developed primarily in the United Kingdom with contributors from surgeons around the world, and contains a simulation on open appendicectomy.
There is 1 study validating Touch Surgery™ as a surgical decision-making tool . There is 1 study protocol on intercostal catheter insertion involving Touch Surgery™ , 1 study evaluating its use in training for hand surgical procedures , 2 studies on the application of Touch Surgery™ in training for laparoscopic cholecystectomy , , 1 study assessing its use in intramedullary femoral nailing , and 1 review article discussing the use of the software in breast surgery . A relatively recent randomized trial also demonstrated the underlying potential of Touch Surgery™ to be incorporated into the surgical curriculum to improve technical skills among surgical trainees in low- and middle-income countries . Touch Surgery™ has been proposed as an innovative simulation-based platform covering numerous simulations from many different specialties, which helps meet the demands of modern professional surgical training .
However, a thorough literature search in PubMed and EMBASE has not yielded any studies evaluating the efficacy of digital simulations in the cognitive performance of surgeons, surgical trainees or medical students in open appendicectomy. In the broader realm of open surgery, very few studies have focused on the use of simulation in the training of open surgical skills . Within these few studies, Davies et al. highlighted the need for higher quality research . This research project will investigate the use of Touch Surgery™ in less commonly performed procedures (i.e. open appendicectomy) and quantify knowledge decay, thereby assessing the need for repeated rehearsal. In addition, this project would be a key article that further validates or refutes against Touch Surgery™ as a valid educational tool.
Simulation training has been shown to decrease the time to proficiency for novices and offer the chance to develop surgical skills in a risk-free environment , . Virtual surgical application tools such as Touch Surgery™ create a platform that enables users to simulate and become exposed to different surgical procedures, with the potential to be used in the education of novices in these procedures. In addition, the evidence for the impact of simulation training on patient care is suggested to be positive, although unequivocal data is lacking and benefits may be confined to novices , , . In fact, research from Belgium suggests that simulation training even during preclinical years has a significant positive effect on surgical performance during the first postgraduate surgical year .
Many simulators are costly and not readily accessible to novices. A cheap alternative is the plethora of medical apps to iOS, Android, and other platforms. Thus, if Touch Surgery™ can be used as a valid tool for educational purposes, the medical community would benefit from a free and widely accessible mobile device application to aid in surgical rehearsal.
The efficacy of digital simulations in improving the cognitive performance of surgeons, surgical trainees or medical students in open appendicectomy has not been previously studied. The primary aim is to determine if Touch Surgery™ is a valid educational training tool for open appendicectomy by assessing its face, content and construct validity. Furthermore, this project has an added component of knowledge decay, which has also not been previously studied. The secondary objectives include assessing the effectiveness of Touch Surgery™ as a training tool; whether repeated exposure to the simulation has an effect on knowledge decay after one week.
This study is based on Sugand's studies on Intramedullary Femoral Nail . Medical students, fellows, and consultant surgeons will be recruited to determine construct validity of Touch Surgery™. This determines whether the Touch Surgery™ Open Appendicectomy Test Module can differentiate between an inexperienced novice vs an experienced surgeon.
This study can be adapted for either multicentre or single institution recruitment.
The hypothesis is that Touch Surgery™ would be a valid education tool as demonstrated on face, content, and construct validity, as well as effective through assessment of training effect for Open Appendicectomy. This is based on previous studies by Sugand et al. on the Touch Surgery™ Intramedullary Femoral Nail modules . Based on recent systematic reviews on simulations and surgical outcomes for common procedures , , , it is reasonable to assume that if powered correctly, novices may demonstrate improved cognitive performance in open appendicectomy after brief interaction with the surgical simulation software.
It is also hypothesised that students will exhibit a knowledge decay effect after not using the app for one week, but those who underwent the high intensity intervention will have a higher baseline score than those who underwent the low intensity intervention.
Three different groups of participants are required, these are:
(1) Control group (Novices):
• Novices include medical students and non-board certified doctors.
• Will be administered test module once, and given the Likert 5-point scale questionnaire immediately after the test. The test will be repeated 1 week later.
• Participants will not have access to Touch Surgery™ in the interim.
(2) Intervention group (Novices):
• Novices including medical students and non-board certified doctors.
• Will be administered test module 6 times repeatedly, and given the Likert 5-point scale questionnaire immediately after the test. The test will be repeated 1 week later with administration of 6 repeated tests, to determine training effect and knowledge decay 1 week apart. 1 week was chosen for ease of follow-up and minimization of loss to follow-up. Participants are asked to repeat the test 6 times at 1 week to determine any differences in training effect (i.e. test score (%), time to complete module (seconds), attempts required to reach plateau effect (n)) compared to 1 week prior.
• Participants will not have access to Touch Surgery™ in the interim.
(3) Gold Standard group (Expert):
• Will comprise of consultant surgeons.
• Will be administered test module once only.
Both cohorts will complete a pre-study questionnaire to ensure the inclusion criteria are met.
• Novice group: Have never observed or performed an open appendicectomy.
• Expert group: Are able to perform open appendicectomy independently.
• Previous exposure to Touch Surgery™.
Sugand et al. 2015 showed statistical significance using 10 experts and 39 novices (p = 0.001) for the Touch Surgery™ Intramedullary Femoral Nail module. This study replicates Sugand et al.’s research to test construct validity of Touch Surgery™ in the Open Appendicectomy Test Module. A sample size calculation is not necessary as per consultation with Graduate Research School HDR StatsHelp Advisor at James Cook University. However, we plan to enrol 10 experts and 60 novices to better power our study to look for a difference. To achieve this, the following cohorts will be recruited.
Medical students naïve to open appendicectomy represent the novice group. This group will be recruited by word of mouth and consented to the study. The time involved for novices could range from 15 minutes to 1 hour, for 2 appointments one week apart. They will complete the following tasks:
The expert group will consist of consultant general surgeons or fellows who act as the gold standard as they have been certified to be able to independently perform open appendicectomy on patients. They would be recruited by word of mouth or email. Their time involved will be 15 minutes. They will complete the following tasks:
Each participant will be blinded to the randomisation event and test score. They will be given 5 attempts to answer a question, before being guided to the next step by the exam administrator. Statistical analysis will be done using the student’s 2-tailed t-test for difference. Intervention includes:
All objective data will be recorded as median with Bonett-Price 95% confidence intervals. Data will be confirmed as nonparametric by reviewing distribution. Analysis will be performed using the Mann–Whitney U test for independent data, the Wilcoxon signed-rank test will be used for paired data. A result will be deemed significant when a two-tailed p-value is less than 0.05.
This study will support or refute Touch Surgery™ as a valid cognitive assessment tool in surgical decision making. Future medical students would be able to determine whether they should use this app as a surgical training tool.
Ethics Approval (HREC/17/QTHS/181) was given by the Townsville Hospital and Health Service Human Research Ethics Committee (HREC).
Identifiable data from the screening questionnaire will be de-identified. Identifiable data will only be used by the researchers to follow-up with participants (when assessing the knowledge decay element of the study) and will not be published in any way. It will be de-identified upon transfer to electronic format by assignment of a unique alphanumeric identifier. De-identified data will be used for statistical analysis to determine face, content, construct validity, and training effect. Confidentiality and anonymity are guaranteed for the participants.
Paper copy data with identifiable information will be destroyed upon publication of the project in a peer-reviewed journal.
De-identified information will be stored for 5 years from the date of publication of results as per the Joint NHMRC/AVCC Statement on Guidelines on Research Practice (1997) Section 2.3.
All papers with identifiable information will be destroyed upon completion of the project, which is upon publication in a peer-reviewed journal. The same process used to handle patient sensitive information as per Queensland Health policies (likely 2-axis shredding or pulping) will be used. De-identified electronic information will be retained for 5 years after which it will be permanently deleted from the researcher's computer(s) via purging or overwriting.
All authors have made substantial contributions to design of the study, drafting of the article, revisions, and approval of the final version for submission.
This research will involve informed consent from participants. Participants will be briefed and consented for participation. Participation is voluntary and will have no effect on the clinical teaching or grade medical students receive as a consequence of consenting/declining/withdrawing from this study.
This research was not funded by any specific grant.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Tsui, C., Klein, R. and Garabrant, M. (2013). Minimally invasive surgery: national trends in adoption and future directions for hospital strategy. And Other Interventional Techniques Official. Journal of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and European Association for Endoscopic Surgery (EAES) 27(7): 2253–2257.
Evans, C.H. and Schenarts, K.D. (2016). Evolving Educational Techniques in Surgical Training. Surg. Clin. North Am. 96(1): 71–88. [PubMed]
Chauvin, S.W. (2015). Applying Educational Theory to Simulation-Based Training and Assessment in Surgery. Surg. Clin. North Am. 95(4): 695–715. [PubMed]
Cox, T., Seymour, N. and Stefanidis, D. (2015). Moving the Needle: Simulation’s Impact on Patient Outcomes: Simulation’s Impact on Patient Outcomes. Surg. Clin. North Am. 95(4): 827–883. [PubMed]
Dawe, R.S. (2014). A Systematic Review of Surgical Skills Transfer After Simulation-Based Training: Laparoscopic Cholecystectomy and Endoscopy. Ann. Surg. 259(2): 236–248. [PubMed]
Acton, R.D. (2015). The Evolving Role of Simulation in Teaching Surgery in Undergraduate Medical Education. Surg. Clin. North Am. 95(4): 739–750. [PubMed]
Sugand, K., Mawkin, M. and Gupte, C. (2015). Validating Touch Surgery™: A cognitive task simulation and rehearsal app for intramedullary femoral nailing. Injury 46(11): 2212–2216. [PubMed]
Friedrich, M. (2017). App-based serious gaming for training of chest tube insertion: study protocol for a randomized controlled trial. Trials 18(1): 56. [PubMed]
Tulipan, J. (2019). Touch Surgery: Analysis and Assessment of Validity of a Hand Surgery Simulation “App”. Hand (N Y) 14(3): 311–316. [PubMed]
Chidambaram, S. (2019). A Randomized Controlled Trial of Skills Transfer: From Touch Surgery to Laparoscopic Cholecystectomy. J. Surg. Res. 234: 217–223. [PubMed]
Kowalewski, K.F. (2017). Validation of the mobile serious game application Touch Surgery for cognitive training and assessment of laparoscopic cholecystectomy. Surg. Endosc. 31(10): 4058–4066. [PubMed]
Sugand, K. (2016). Training effect of using Touch Surgery for intramedullary femoral nailing. Injury 47(2): 448–452. [PubMed]
Patel, N.G. (2016). Modern use of smartphone applications in the perioperative management in microsurgical breast reconstruction. Gland Surg 5(2): 150–157. [PubMed]
Bunogerane, G.J. (2018). Using Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial. Journal of Surgical Education 75(1): 231–237. [PubMed]
Mandler, A.G. (2018). Touch Surgery: a Twenty-First Century Platform for Surgical Training. J. Digit. Imaging 31(5): 585–590. [PubMed]
De Win, G. (2013). Laparoscopy Training in Surgical Education: The Utility of Incorporating a Structured Preclinical Laparoscopy Course into the Traditional Apprenticeship Method. J. Surg. Ed. 70(5): 596–605.
Al-Kadi, A.S. and T. Donnon, Using simulation to improve the cognitive and psychomotor skills of novice students in advanced laparoscopic surgery: A meta-analysis. Medical Teacher, 2013, Vol.35(s1), p.S47-S55, 2013. 35(s1): p. S47-S55.
Andersen, S.A.W. (2016). The effect of self-directed virtual reality simulation on dissection training performance in mastoidectomy. Laryngoscope 126(8): 1883–1888. [PubMed]
Pedersen, P. (2014). Virtual-reality simulation to assess performance in hip fracture surgery. Acta Orthopaedica 85(4): 403–407. [PubMed]