Remote and asynchronous training network: from a SAGES grant to an eight-country remote laparoscopic simulation training program

Abstract

Background
Limitations in surgical simulation training include lack of access to validated training programs with continuous year-round training and lack of experts’ ongoing availability for feedback. A model of simulation training was developed to address these limitations. It incorporated basic and advanced laparoscopic skills curricula from a previously validated program and provided instruction through a digital platform. The platform allowed for remote and asynchronous feedback from a few trained instructors. The instructors were continuously available and provided personalized feedback using a variety of different media. We describe the upscaling of this model to teach trainees at fourteen centers in eight countries.

Methods
Institutions with surgical programs lacking robust simulation curricula and needing instructors for ongoing education were identified. The simulation centers (“skills labs”) at these sites were equipped with necessary simulation training hardware. A remote training-the-administrators (TTA) program was developed where personnel were trained in how to manage the skills lab, schedule trainees, set up training stations, and use the platform. A train-the-trainers (TTT) program was created to establish a network of trained instructors, who provided objective feedback through the platform remotely and asynchronously.

Results
Between 2019 and 2022, seven institutions in Chile and one in each of the USA, Bolivia, Brazil, Ecuador, El Salvador, México, and Perú implemented a digital platform-based remote simulation curriculum. Most administrators were not physicians (19/33). Eight Instructors were trained with the TTT program and became active proctors. The platform has been used by 369 learners, of whom 57% were general surgeons and general surgery residents. A total of 6729 videos, 28,711 feedback inputs, and 233.7 and 510.2 training hours in the basic and advanced programs, respectively, were registered.

Conclusion
A remote and asynchronous method of giving instruction and feedback through a digital platform has been effectively employed in the creation of a robust network of continuous year-round simulation-based training in laparoscopy. Training centers were successfully run only with trained administrators to assist in logistics and setup, and no on-site instructors were necessary.

Full text

Vol.:(0123456789)
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Surgical Endoscopy
https://doi.org/10.1007/s00464-022-09386-5
2022 SAGES ORAL
Remote andasynchronous training network: fromaSAGES grant
toaneight‑country remote laparoscopic simulation training program
MaríaInésGaete1· FranciscaBelmar1· MatíasCortés1· AdnanAlseidi2· DomenechAsbun3· ValentinaDurán1·
GabrielEscalona1· PabloAchurra1· IgnacioVillagrán1· FernandoCrovari1· FernandoPimentel1· JuliánVaras1
Received: 21 March 2022 / Accepted: 6 June 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022
Abstract
Background Limitations in surgical simulation training include lack of access to validated training programs with continuous
year-round training and lack of experts’ ongoing availability for feedback. A model of simulation training was developed
to address these limitations. It incorporated basic and advanced laparoscopic skills curricula from a previously validated
program and provided instruction through a digital platform. The platform allowed for remote and asynchronous feedback
from a few trained instructors. The instructors were continuously available and provided personalized feedback using a
variety of different media. We describe the upscaling of this model to teach trainees at fourteen centers in eight countries.
Methods Institutions with surgical programs lacking robust simulation curricula and needing instructors for ongoing educa-
tion were identified. The simulation centers (“skills labs”) at these sites were equipped with necessary simulation training
hardware. A remote training-the-administrators (TTA) program was developed where personnel were trained in how to
manage the skills lab, schedule trainees, set up training stations, and use the platform. A train-the-trainers (TTT) program
was created to establish a network of trained instructors, who provided objective feedback through the platform remotely
and asynchronously.
Results Between 2019 and 2022, seven institutions in Chile and one in each of the USA, Bolivia, Brazil, Ecuador, El Salva-
dor, México, and Perú implemented a digital platform-based remote simulation curriculum. Most administrators were not
physicians (19/33). Eight Instructors were trained with the TTT program and became active proctors. The platform has been
used by 369 learners, of whom 57% were general surgeons and general surgery residents. A total of 6729 videos, 28,711
feedback inputs, and 233.7 and 510.2 training hours in the basic and advanced programs, respectively, were registered.
Conclusion A remote and asynchronous method of giving instruction and feedback through a digital platform has been
effectively employed in the creation of a robust network of continuous year-round simulation-based training in laparoscopy.
Training centers were successfully run only with trained administrators to assist in logistics and setup, and no on-site instruc-
tors were necessary.
Keywords Laparoscopic simulation· Simulation training· Remote feedback· Asynchronous feedback· Training network
Laparoscopic surgical skills are a critical part of many sur-
geons’ armamentarium [1–6]. However, the acquisition of
laparoscopic skills presents a specific and protracted learn-
ing curve compared to open surgery [7–12]. Residents’
ability to master laparoscopic skills during their training is
limited by many factors, including the reduction of working
hours, low incidence of certain diseases in some centers,
patient safety policies that limit resident autonomy, among
others. These constraints require exploring other learn-
ing methods. In this context, surgical simulation training
emerges as a complementary tool for the attainment of surgi-
cal skills. Simulation training reduces learning curves in a
and Other Interventional Te
chniques
* Julián Varas
jevaras@uc.cl
1 Experimental Surgery andSimulation Center, Department
ofDigestive Surgery, Catholic University ofChile,
Marcoleta 377, 2nd floor, ZipCode:8330024Santiago,
Chile
2 Department ofSurgery, University ofCalifornia,
SanFrancisco, USA
3 Hepatobiliary & Pancreatic Surgery, Miami Cancer Institute,
Miami, USA

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controlled and safe environment without putting the patient
at risk and transferring successfully the skills to the operat-
ing room [7, 13, 14].
In spite of this, surgical simulation training often has
significant limitations. These include restricted access to
validated training programs that provide deliberate practice
on an ongoing, year-round basis, as well as a lack of continu-
ous expert feedback. Availability of expert feedback is often
constrained by the expert’s busy schedule, lack of formal
training in teaching/evaluation or inability to be physically
present during training sessions. These impediments are
common and often result in a limited number of in-person
sessions given with a maximum of students per instructor,
who are restricted to their geographical locations [15–17].
In 2019, thanks to the support of a SAGES research grant,
a web-based and mobile iOS and Android digital platform
(“LAPP”) was developed with the goal of overcoming these
limitations. The platform was designed to train general sur-
gery residents and surgeons remotely and asynchronously
in basic and/or advanced laparoscopic skills using simula-
tion training. It uses a network of trained instructors, who
remotely review practice by enrolled trainees, providing
objective multimedia feedback (texts, audios, drawings, and/
or videos) within 72h [7]. The use of this digital method-
ology was successfully validated as a tool at least as good
as in-person training, showing that surgeons can be trained
remotely and asynchronously [7].
Remote training through the digital platform was initially
established at two training centers. Given successful proof-
of-concept (as above), the program was further expanded to
include multiple training centers across different countries.
We describe our experience of scaling the use of remote
and asynchronous feedback through the platform to fourteen
training centers across eight countries.
Methods
How Institutions were selected
Institutions whose surgical training programs lacked a robust
simulation curriculum and did not have ongoing availabil-
ity of instructors for continuous coaching were identified.
Particular attention was given to locations that performed
a low number of advanced laparoscopic procedures, which
increases the potential for a training program to have a sub-
stantial impact on surgical education and the clinical use of
laparoscopy.
Development ofnew laparoscopic skills labs:
thethree‑pillar framework
Once the institutions were selected, the necessary adjust-
ments were made for the setup of a laparoscopic skills lab
in each location, using and modifying the infrastructures
that already existed in the institutions. A three-pillar frame-
work developed at our institution for the implementation
of any surgical simulation program was applied to success-
fully implement the remote training programs. They are as
follows: (1) Infrastructure (Hardware, training facilities,
administrative human resources, etc.), (2) validated surgi-
cal simulation training program (instructional design and
content, learning objectives, objective feedback, etc.). (3)
Trainers (an expert instructor network for instruction and
feedback) [7, 18–20].
Infrastructure: whereandwhat supplies are required
totrain
Each institution was equipped with the same infrastructure
needed for the implementation of the laparoscopic simula-
tion training programs. This included ample training space
and supplies, such as laparoscopic training boxes, energy
devices, high-definition video recorders, accessory supplies,
among others. Figure1 shows the hardware accessories
needed for the basic training program. Then, a training-the-
administrators (TTA) remote program was developed to train
each administrator and/or faculty involved in the simula-
tion curriculum. These administrators are not involved in
teaching the surgical trainees, but instead assist with local
logistical issues. Four remote, live training sessions were
held during the TTA program, complemented with thirty
asynchronous instructional videos. These videos included
instructions on how to organize training at the skills lab,
manage trainees’ practice schedules, set up training stations,
record/upload videos, as well as general troubleshooting. A
technical and educational support structure was developed
to assist with any questions local administrators may have by
providing around-the-clock availability through the platform
or via email. Finally, an exam was given to each local admin-
istrator involved in the digital platform training site to ensure
that the necessary knowledge was acquired to successfully
run the curriculum at a local level.
Validated surgical simulation training programs: what
todowiththe hardware
The training program consisted of basic and advanced
laparoscopic skills courses, which had been previously
developed and validated [14, 19, 21–25]. The basic skills

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course was composed of eleven exercises divided into two
groups whose complexity increases with each exercise and
group. Examples of these exercises include beans drop,
blocks movement, cannulation of a catheter into a train-
ing model, and interrupted intracorporeal sutures. The
advanced course consisted of performing a laparoscopic
hand-sewn jejunojejunostomy using an exvivo simulation
model with bovine intestine. Each of these courses is made
up of individual training modules that is successively build
on acquired skills. Assessments were established for each
module, being standardized with an objective grading scale
(objective structured assessment of technical skill, OSATS,
and specific rating scale, SRS), and focused on technical
details and time goals for each session. Further details of
the advanced laparoscopic training program are described
elsewhere [7, 14, 25].
Trainers: creation ofanexpert instructor network
A train-the-trainers (TTT) program was created with the
purpose of establishing a network of trained instructors who
could evaluate trainees remotely. Their purpose is to provide
objective multimedia feedback to trainees through the plat-
form remotely and asynchronously using personal digital
inputs [19]. Each instructor in training had to complete both
basic and advanced laparoscopic simulation courses. Then,
they completed four online courses on medical education.
They also received over fifteen tutorial videos on how to use
and navigate the platform, common errors made by trainees,
and sample videos showing an expert evaluating a student
through the platform. Then, each instructor in the TTT pro-
gram had to evaluate twenty videos of trainees undertaking
the laparoscopic simulation courses. The evaluations sought
to identify and categorize different types of errors, meas-
ure time to complete each exercise, and calculate an overall
score based on objective grading scales (OSATS & SRS).
Scores from these evaluations were compared to the average
scores of two expert evaluators in the same exercise. Once
the instructors started evaluating real trainees, they were ran-
domly supervised by experts throughout the year to maintain
a high level of inter-rater reliability.
The learning cycle: using adigital platform
duringsimulation training sessions
Once the above three pillars were established, surgical train-
ees were enrolled in the laparoscopic simulation training
programs. Trainees were general surgery, obstetrics and
gynecology, and urology professionals and residents with
interest in acquiring or improving their laparoscopic skills.
Trainees underwent basic and/or advanced laparoscopic
simulation training sessions through the platform in four
sequential steps (Fig.2):
(1) Trainees watch instructional videos on the digital plat-
form. These videos provide basic information on how
to perform each skill within the exercises that comprise
the simulation courses.
(2) They then perform unsupervised practice and upload
the videos of their corresponding training session to
Fig. 1 Hardware accessories needed for the basic training program

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the platform (with help from the local administrator at
their center).
(3) A remote trained instructor is assigned to the trainee
and gets notified of the new video upload by the plat-
form. The instructor uses the platform to assess the
recording, providing objective multimedia feedback
including texts, audio recordings, drawings annotat-
ing the trainee’s video, and/or short videos from a
library of example errors and corrections—these last
ones characterized by a duration of fewer than 30s to
show the correct technique for a specific exercise. The
instructors also provide an objective assessment based
on the aforementioned grading scales [13, 25, 26].
(4) The above-personalized feedback is finalized and sent
back to the trainee within seventy-two hours, incorpo-
rating it into ongoing training.
Further details of the digital platform are described else-
where [7].
Data collection
The digital platform database was used to collect data
regarding the total number of students enrolled, the passing
rate for each course, the number of videos uploaded, the
total amount and format of provided multimedia feedback
inputs (video, audio recording, drawing, and short videos),
among others.
Results
Between April 2019 and March 2022, a total of 14 institu-
tions successfully implemented a remote simulation training
curriculum, with seven institutions in Chile and one in each
of the USA, Bolivia, Brazil, Ecuador, El Salvador, México,
and Perú. Most of the administrators trained by the TTA
program involved in laparoscopic simulation skills labs are
not physicians (19/33), but technicians who are familiar
with basic computing. A total of 8 instructors were trained
through the program. All of them had previously completed
the program as trainees. The instructors’ profession is listed
in Table1.
The platform was used by 369 trainees, 29% of them
completed the basic laparoscopic training program, and 13%
completed the advanced laparoscopic training program. The
remaining trainees were still undergoing the course at the
Fig. 2 Sequential steps to be followed for remote and asynchronous learning using a digital platform
Table 1 Instructors’ profession
Instructor profession No of
instruc-
tors
Veterinarian 3
Research fellow 2
General surgery resident 2
General surgeon 1

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time of this publication. So far, we have no dropouts, and
from the trainees that have completed the basic program, 2
trainees have not passed the course. Fifty-seven percent were
general surgeons/surgery residents, 14% were obstetrics and
gynecologist specialists/residents, 3% were urologists/urol-
ogy residents, and 26% were from other specialties. A total
of 6,729 videos were uploaded, receiving 28,711 feedback
inputs. Fifty-six percent of the feedback inputs were texts,
3% audio messages, 15% drawings, and 26% were videos
(Fig.3).
Discussion
The implementation of this unprecedented training network
distributed in fourteen training centers across eight coun-
tries was not without difficulties. The most pronounced
of these was formulating a system to standardize training
across all centers at an administrative and teaching level.
This standardization had to include equivalent quality of
equipment, training curriculum, local logistical support, and
remote feedback given by qualified trainers. Thus, the train-
ing centers were established in a stepwise fashion: first, the
required supplies and material had to be in place. Only after
this setup was confirmed were the TTA and TTT programs
implemented. The TTA program standardized the local sup-
port given to students, to avoid logistical issues interfering
with the quality of training and instruction. The TTT pro-
gram standardized the quality and objectivity of feedback
and training given by the instructors to the trainees. Several
cultural and language barriers (Spanish, English, and Por-
tuguese) had to be overcome, being necessary to translate
and iterate the system through real users to provide the best
learning experience to trainees.
The remote and asynchronous laparoscopic simulation
training programs and the platform training network allowed
to train 369 students of different countries and surgical spe-
cialties. This last fact demonstrates that, despite being a
program mainly aimed at general surgery residents and sur-
geons, professionals of other surgical specialties also sought
to acquire or improve their laparoscopic technical skills. To
date, the center with the highest number of trainees enrolled
was the one located in a rural area in the south of Chile,
Temuco. This is attributable to that center being one of the
first centers recruited, and also may reflect a lack of other
opportunities in the area to undergo targeted laparoscopic
skills training. On the other hand, the institution with the
lowest number of trainees enrolled was the one located in
Mexico City, Mexico. This is probably due to the fact that
this center is one of the last institutions added to the network.
Fig. 3 Results of using the digital platform training network during 2019–2022

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Thanks to this digital platform methodology, it is feasi-
ble to have an average of 46 trainees per instructor a year,
obtaining promising results in-terms of scaling worldwide
and without the need to travel to remote places to learn or
teach laparoscopic skills.
To date, 29% of the trainees have completed the basic
skills course, whereas 13% completed the advanced course.
There have been no dropouts. This skew towards the basic
course may be because most centers have been active for less
than a year, making it hard for trainees to have completed
both courses. Additionally, the advanced program targeted
a smaller, more focused audience: practicing surgeons or
senior residents with baseline laparoscopic skills already.
It may likewise also reflect a greater population’s need for
basic skills to start.
Regarding feedback, an average of 4.3 inputs per video
was calculated. Text and common errors videos were the
feedback type preferred by instructors. The ease of writing
text and the ubiquity of text-centered commenting in social
media may explain this trend. At the same time, error vid-
eos were the second most common modality used, which
speaks of the utility of having specific examples available
to communicate a point. However, a more detailed analysis
is beyond the objectives of this project.
Multiple studies support the importance of all three pil-
lars used to expand this program [15, 27, 28]. However, the
authors see the cornerstone of success in this remote and
asynchronous training program to be the effective and per-
sonalized feedback given to students on an ongoing basis.
This pillar was feasible thanks to the TTT program, which
further expanded Quezada’s etal. “MITO” project [7], build-
ing a network of capable instructors to deliver the feedback.
These instructors were not necessarily practicing surgeons,
nor were they geographically near the trainees. The net-
work offers a realistic solution to the shortcomings of many
current simulation programs. It increases accessibility to
validated simulation training and provides a framework for
upscaling the program. This is of heightened importance
in places where laparoscopic surgical capacity is not fully
developed, nor are simulation training programs. Indeed, the
applications of this system may have positive implications
for any place with a constraint on expert time/availability,
which continues to be common in surgical communities
worldwide [2, 15, 27, 29].
To our knowledge, this is the first example of successful
remote simulation training using a combination of factors
not previously seen all together: instruction of a validated
program, remote and asynchronous multimedia feedback,
upscaling the program to multiple different countries, cul-
tures, and languages, and all instruction/feedback given
through a digital platform. There are multiple reports of
other tele-simulation projects, however, these have the limi-
tation of needing simultaneous availability of the trainee
and the instructor [2, 15, 29, 30]. It is also important to note
that both basic and advanced laparoscopic skills were taught
remotely, which is a novel achievement compared to most
other examples [2, 15, 29].
Only short-term outcomes are available, which neces-
sitates further studies to evaluate long-term outcomes of
the described methodology. In addition, an analysis of cost-
effectiveness related to implementation of this program
across multiple countries is warranted, which will aid in
overall assessment of sustainability.
Conclusion
A digital platform-based approach to simulation has been
successfully used in the creation of a robust multicultural
network of continuous, year-round laparoscopic training.
Training centers were successfully established with admin-
istrators to assist in setup, and no other on-site staff were
necessary. The approach may be used to further expand
simulation training without the constraints of traditional in-
person feedback from trainers by allowing distant unsuper-
vised practice with remote asynchronous feedback.
Acknowledgements This project would not have been possible with-
out the unwavering support of the Pontificia Universidad Católica de
Chiles’ Simulation team and the Department of Digestive Surgery:
Marcia Corvetto, Elga Zamorano, Valeria Alvarado, Eduardo Machuca,
Carlos Martinez, Francisco Serrano, Andres Campos, Raúl Nalvae,
Margarita Zapata, Fernando Crovari, Luis Ibañez, and Fernando
Pimentel. We also want to thank the programmer team led by Brian
del Alcazar, Marcelo Vargas, Ricardo Leiva, and Gabriel Ulloa.
Funding This study was funded and supported by SAGES Research
Grant 2017–2018, Chilean Research Grant FONDECYT No. 1100436
from CONICYT, and Chilean Research Grant code number 20CYE-
139772 from CORFO.
Declarations
Disclosures Julian Varas is the Founder of Training Competence, an
official spinoff startup from the Pontificia Universidad Católica de
Chile. Gabriel Escalona is the chief product manager of this startup.
María Inés Gaete, Francisca Belmar, and Ignacio Villagrán are consult-
ants of this startup. Training Competence and the Pontificia Univer-
sidad Católica de Chile are the owners of the rights and distribution
of the LAPP platform used for the assessment in this study. Pablo
Achurra, Fernando Crovari, Fernando Pimentel, Matías Cortés, Val-
entina Durán, Adnan Alseidi, and Domenech Asbun have no conflicts
of interest or financial ties to disclose.
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