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1.  Biological effects of bariatric surgery on obesity-related comorbidities 
Canadian Journal of Surgery  2013;56(1):47-57.
The prevalence of obesity has increased so rapidly over the last few decades that it is now considered a global epidemic. Obesity, defined as a body mass index (BMI) of 30 or more, is associated with several comorbid conditions that decrease life expectancy and increase health care costs. Diet therapies have been reported to be ineffective in the long-term treatment of obesity, and guidelines for the surgical therapy of morbid obesity (BMI ≥ 40 or BMI ≥ 35 in the presence of substantial comorbidities) have since been established. Considering the number of bariatric surgical procedures has dramatically increased since these guidelines were established, we review the types of bariatric surgical procedures and their impact on diabetes, sleep apnea, dyslipidemia and hypertension — 4 major obesity-related comorbidities.
PMCID: PMC3569476  PMID: 23351555
2.  Canadian Association of University Surgeons’ Annual Symposium. Surgical simulation: The solution to safe training or a promise unfulfilled? 
Canadian Journal of Surgery  2012;55(4 Suppl 2):S200-S206.
At its 2009 annual symposium, chaired by Dr. William (Bill) Pollett, the Canadian Association of University Surgeons brought together speakers with expertise in surgery and medical education to discuss the role of surgical simulation for improving surgical training and safety. Dr. Daniel Jones, of Harvard University and the 2009 Charles Tator Lecturer, highlighted how simulation has been used to teach advanced laparoscopic surgery. He also outlined how the American College of Surgeons is moving toward competency assessments as a requirement before surgeons are permitted to perform laparoscopic surgery on patients. Dr. Teodor Grantcharov, from the University of Toronto, highlighted the role of virtual reality simulators in laparoscopic surgery as well as box trainers. Dr. Peter Brindley from the University of Alberta, although a strong proponent of simulation, cautioned against an overzealous adoption without addressing its current limitations. He also emphasized simulation’s value in team training and crisis resource management training. Dr. Chris de Gara, also from the University of Alberta, questioned to what extent simulators should be used to determine competency. He raised concerns that if technical skills are learned in isolation, they may become “decontextualized,” and therefore simulation might become counterproductive. He outlined how oversimplification can have an “enchanting” effect, including a false sense of security. As a result, simulation must be used appropriately and along the entire education continuum. Furthermore, far more needs to be done to realize its role in surgical safety.
PMCID: PMC3432250  PMID: 22854147
3.  Research Priorities in Surgical Simulation for the 21st Century 
American Journal of Surgery  2012;203(1):49-53.
Despite a tremendous growth research in surgical simulation remains uncoordinated and unfocused. The objective of this study was to develop research priorities for surgical simulation.
Using a systematic methodology (Delphi), members of the Association for Surgical Education submitted 5 research questions on surgical simulation. An expert review panel categorized and collapsed the submitted questions and redistributed them to the membership to be ranked using a priority scale from 1(lowest) to 5(highest). The results were analyzed and categorized by consensus in distinct topics.
Sixty members submitted 226 research questions that were reduced to 74. Ratings ranged from 2.19–4.78. Topics included simulation effectiveness and outcomes, performance assessment and credentialing, curriculum development, team training and non-technical skills, simulation center resources and personnel, simulator validation, and other. The highest ranked question was “Does simulation training lead to improved quality of patient care, patient outcomes and safety?”
Research priorities for surgical simulation were developed using a systematic methodology and can be used to focus surgical simulation research in areas most likely to advance the field.
PMCID: PMC3322506  PMID: 22172482
surgical simulation; research priorities; research agenda; Delphi methodology
4.  Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized educational trial 
Several studies have found a positive effect on the learning curve as well as the improvement of basic psychomotor skills in the operating room after virtual reality training. Despite this, the majority of surgical and gynecological departments encounter hurdles when implementing this form of training. This is mainly due to lack of knowledge concerning the time and human resources needed to train novice surgeons to an adequate level. The purpose of this trial is to investigate the impact of instructor feedback regarding time, repetitions and self-perception when training complex operational tasks on a virtual reality simulator.
The study population consists of medical students on their 4th to 6th year without prior laparoscopic experience. The study is conducted in a skills laboratory at a centralized university hospital. Based on a sample size estimation 98 participants will be randomized to an intervention group or a control group. Both groups have to achieve a predefined proficiency level when conducting a laparoscopic salpingectomy using a surgical virtual reality simulator. The intervention group receives standardized instructor feedback of 10 to 12 min a maximum of three times. The control group receives no instructor feedback. Both groups receive the automated feedback generated by the virtual reality simulator. The study follows the CONSORT Statement for randomized trials. Main outcome measures are time and repetitions to reach the predefined proficiency level on the simulator. We include focus on potential sex differences, computer gaming experience and self-perception.
The findings will contribute to a better understanding of optimal training methods in surgical education.
Trial Registration
PMCID: PMC3311079  PMID: 22373062
Virtual reality simulation; Laparoscopy; Training; Salpingectomy; Feedback
5.  Simulation in surgical education 
PMCID: PMC2917931  PMID: 20351120
6.  Teaching procedural skills 
BMJ : British Medical Journal  2008;336(7653):1129-1131.
“See one, do one” is not the best way to teach the complex technical procedures needed in many hospital based specialties
PMCID: PMC2386620  PMID: 18483056
7.  Objective Assessment of Gastrointestinal Endoscopy Skills Using a Virtual Reality Simulator 
This study was carried out to validate the role of virtual reality computer simulation as a method of assessment of psychomotor skills in gastrointestinal endoscopy. We aimed to investigate whether the GI Mentor II computer system (Simbionix Ltd.) was able to differentiate between subjects with different experience with GI endoscopy.
Twenty-eight subjects were included in the study. They were divided into 3 groups according to their experience with GI endoscopy: experienced [group 1, performed >200 endoscopic procedures, (n=8)] residents [group 2, performed <50 endoscopic procedures, (n=10)] and medical students [group 3, never performed GI endoscopy, (n=10)]. All participants received identical pretest instruction on the simulator. Assessment of endoscopic skills was performed during a simulated colonoscopy and was based on parameters measured by the computer system: time, percentage of mucosa surface examined, efficiency of screening, time with a clear view, excessive local pressure, pain, time with pain, loop formation, and total time with a loop.
Significant differences in performance existed between surgeons in the 3 groups. Experienced surgeons demonstrated best performance parameters, followed by the residents and the medical students. Significant differences in time (Kruskal-Wallis test, P<0.001), percentage of mucosa surface examined (P=0.001), efficiency of screening (P=0.001), time with a clear view (P=0.001), pain experienced (P=0.004), time with pain (P=0.012), loop formation (P<0.001), time with a loop (P<0.001), and excessive local pressure (P=0.001) were demonstrated. Significant differences existed between group 1 and 2 and 1 and 3 (Mann-Whitney test, P<0.05). Differences between groups 2 and 3 did not reach statistical significance (P>0.05).
The VR simulator was able to differentiate between subjects with different endoscopic experience. This indicates that the GI Mentor measures skills relevant for gastrointestinal endoscopy and can be used in training programs as an assessment tool.
PMCID: PMC3015591  PMID: 15984697
Virtual reality; Training; Assessment; Psychomotor skills; Endoscopy
9.  Effect of virtual reality training on laparoscopic surgery: randomised controlled trial 
Objective To assess the effect of virtual reality training on an actual laparoscopic operation.
Design Prospective randomised controlled and blinded trial.
Setting Seven gynaecological departments in the Zeeland region of Denmark.
Participants 24 first and second year registrars specialising in gynaecology and obstetrics.
Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls).
Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes.
Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79.
Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures.
Trial registration NCT00311792.
PMCID: PMC3273782  PMID: 19443914

Results 1-9 (9)