***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The ideal objective assessment method for laparoscopic technical skills is difficult to achieve in the operating room . Recent " VR2OR " studies have used a blinded , 2- review er error-based video tape analysis for intraoperative performance assessment . This study examines the validity of this methodology applied to laparoscopic intracorporeal suturing and knot tying . METHODS Four groups of subjects -- experts ( EX ) , surgery residents trained to expert criterion levels using simulation ( TR ) , surgery residents receiving no supplemental training ( NR ) , and medical students receiving simulation-based training (MS)--performed the fundal suturing portion of a laparoscopic Nissen fundoplication  and were video-recorded for analysis . Two separate groups of surgeon review ers ( K.V.S. + M.B. ; I.-P.H. + A.G. ) were trained to evaluate laparoscopic suturing and knot tying performance using specific metrics . Subjects ' operative performance was assessed by review ers blinded to their training status and scored using an error-based , step specific scoring system to an inter-rater agreement of 80 % or greater . Three primary performance measures were assessed : time , errors , and needle manipulations and comparisons between groups were made using a 1-way analysis of variance ( ANOVA ) with post-test . RESULTS A total of 40 fundal sutures ( 10 in each group ) were scored by 2 separate rater groups with inter-rater agreement consistently greater than 80 % . Inter-rater agreement was highest with the EX group ( 91 % , range 76%-100 % ) and lowest with the NR group ( 85 % , range 81%-98 % ) . On average , the EX group significantly outperformed the other groups with regards to time ( P < .0001 ) , errors ( P < .002 ) , and needle manipulations ( P < .01 ) . Performance of the TR group was comparable to the EX group with regards to errors and manipulations ( P = not significant [ NS ] ) , and outperformed the NR and MS groups with regards to time ( P < .05 and P < .001 ) . Performance between the NR and MS groups were similar for all 3 measures . CONCLUSIONS This assessment method demonstrates discriminative validity . Time appears to be the most sensitive indicator of skill level , as significant differences between EX , TR , and NR/MS groups were seen . The methodology is transferable across different review ers and is acceptable for high-stakes assessment Background  Surgical skills training outside the operating room is beneficial . The best methods have yet to be identified . The authors aim ed to document the predictive validity of simulation training in three different studies . Methods Study 1 was a prospect i ve , r and omized , multicenter trial comparing performance in the operating room after training on a laparoscopic simulator and after no training . The Global Operative Assessment of Laparoscopic Skills ( GOALS ) was used to evaluate operative performance . Study 2 retrospectively review ed the operative performance of junior residents before and after implementation of a laparoscopic skills training curriculum .  Operative time was the variable used to determine resident improvement . Study 3 was a prospect i ve , r and omized trial evaluating intern operative performance of laparoscopic cholecystectomy in a porcine model before and after training on a simulator .  Operative performance was assessed using GOALS . Results All three studies failed to demonstrate predictive validity . With GOALS used as the assessment tool , no difference was found between trained and untrained residents in studies 1 and 3 . In study 2 , the trained group took significantly longer to complete a laparoscopic cholecystectomy than the untrained group . Conclusions No correlation was found between the three types of training outside the operating room , and no improved operative performance was observed . Possible explanations include too few subjects , training introduced too late in the learning curve , and training criteria that were too easy . Additionally , simulator training focuses on precision , which may actually increase task time . Awareness of these issues can improve the design of future studies BACKGROUND AND STUDY AIM As for any manual procedure , the learning curves for medical interventions can have undesirable phases , occurring mostly in the early experience of applying a technique . There have been impressive advances in endoscopic procedures during recent years , and there is an emerging trend that the number of procedures is increasing in parallel with these . In addition , the introduction of screening programs for colorectal cancer will also increase the numbers of procedures needed . Recent developments in medical simulation seem promising with regard to the possibility of " training out " undesirable parts of the learning curve outside the operating room . The aim of this study was to investigate whether the use of the AccuTouch flexible endoscopy simulator improves the early part of the learning curve in colonoscopy training . METHOD 12 endoscopy trainees , 10 surgeons and two medical gastroenterologists , all with experience in gastroscopy but with no specific colonoscopy experience , were r and omly assigned to either simulator training or to a control group . They all received the same theoretical study package and the training group practice d with the AccuTouch colonoscopy simulator until a predefined expert level of performance was reached . All trainees performed their first ten individual colonoscopies described in detail in a separate protocol . RESULTS Trainees in the simulator-trained group performed significantly better ( P=0.0011 ) and managed to reach the cecum in 52 % of their cases ( vs. 19 % in the control group ) , and were 4.53 times more likely to succeed compared with the controls . Additionally , there was a significantly shorter procedure time and less patient discomfort in the h and s of the simulator-trained group . CONCLUSION Skills acquired using the AccuTouch simulator transfer well into the clinical colonoscopy environment . The results of this trial clearly support the plan to integrate simulator training into endoscopic education curricula BACKGROUND The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience . OBJECTIVE To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy . DESIGN R and omized , controlled , blinded , multicenter trial . SETTING Academic medical centers with accredited gastroenterology training programs . PATIENTS First-year GI fellows . INTERVENTIONS Subjects were r and omized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship .  After this period , both groups began performing real colonoscopies . The first 200 colonoscopies performed by each fellow were grade d by proctors to measure technical and cognitive success , and patient comfort level during the procedure . MAIN OUTCOME MEASUREMENTS A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time . RESULTS Forty-five fellows were r and omized from 16 hospitals over 2 years . Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases . A mixed-effects model demonstrated a higher objective competence overall in the simulator group ( P < .0001 ) , with the difference between groups being significantly greater during the first 80 cases performed . The median number of cases needed to reach 90 % competency was 160 in both groups . The patient comfort level was similar . CONCLUSIONS Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training BACKGROUND The efficacy of laparoscopy simulators remains controversial . METHODS This was a comparative prospect i ve study that evaluated the impact of  simulator training  on technical competence during a real surgical procedure . Residents were divided into 3 groups : the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills ( MISTELS ) group , training on a simple simulator ; LAP Mentor group , training on a virtual simulator ; and control group . An initial evaluation was made by a vali date d score during a laparoscopic cholecystectomy . Each resident was then trained for 1 month . A second evaluation was then performed . RESULTS Before/after scores were significantly improved in the MISTELS ( P = .042 ) and LAP Mentor ( P = .026 ) groups . It was not the case in the control group . There was a better progression in the MISTELS ( P = .026 ) and LAP Mentor ( P = .007 ) groups than in the control group . There was no significant difference between the MISTELS and LAP Mentor groups . CONCLUSIONS Simulator training provides a more rapid acquisition of competence in surgical technique BACKGROUND Developing technical skill is essential to surgical training , but using the operating room for basic skill acquisition may be inefficient and expensive , especially for laparoscopic operations . This study determines if laparoscopic skills training using simulated tasks on a video-trainer improves the operative performance of surgery residents . STUDY DESIGN Second- and third-year residents ( n= 27 ) were prospect ively r and omized to receive  formal laparoscopic skills training  or to a control group . At baseline , residents had a vali date d global assessment of their ability to perform a laparoscopic cholecystectomy based on direct observation by three evaluators who were blinded to the residents ' r and omization status . Residents were also tested on five st and ardized video-trainer tasks . The training group practice d the video-trainer tasks as a group for 30 minutes daily for 10 days . The control group received no formal training . All residents repeated the video-trainer test and underwent a second global assessment by the same three blinded evaluators at the end of the 1-month rotation . Within-person improvement was determined ; improvement was adjusted for differences in baseline performance . RESULTS Five residents were unable to participate because of scheduling problems ; 9 residents in the training group and 13 residents in the control group completed the study . Baseline laparoscopic experience , video-trainer scores , and global assessment s were not significantly different between the two groups . The training group on average practice d the video-trainer tasks 138 times ( range 94 to 171 times ) ; the control group did not practice any task . The trained group achieved significantly greater adjusted improvement in video-trainer scores ( five of five tasks ) and global assessment s ( four of eight criteria ) over the course of the four-week curriculum , compared with controls . CONCLUSIONS Intense training improves video-eye-h and skills and translates into improved operative performance for junior surgery residents . Surgical curricula should contain laparoscopic skills training This study examined the impact of virtual reality ( VR ) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy Background : This study was undertaken to investigate operating room performance of surgical residents , after participating in the Eindhoven virtual reality laparoscopic cholecystectomy training course . This course is the first formal surgical resident trainings course , using a variety of complementary virtual reality ( VR ) skills training simulation in order to prepare surgical residents for their first laparoscopic cholecystectomy . The course was granted EAES certification . Methods : The four-day course is based on multimedia and multimodality approach . A variety of increasingly difficult simulation training sessions , next to intimate focus-group “ knowledge sessions ” are included . Both basic and procedural VR simulation is featured , using MIST-VR and the Xitacts ' LapChol simulation software . The operating room performance of twelve surgical residents who participated in the course and twelve case-control counterparts were compared . The case-control grup was matched for clinical number laparoscopic cholecystectomy performance ( maximum of 4 procedures ) . Two observers analyzed a r and omly mixed videotape , featuring the part of the “ clip- and -cut ” procedure of the laparoscopic cholecystectomy , and were blinded for participants ' group status . Structured question naires including multiple observation scales were used to assess performance . Results : Residents of both the experimental and control group did not differ in demographic parameters , except for number of laparoscopic cholecystectomies in favor of the control group ( p-value 0.008 ) . Both observers judge the experimental group to perform significantly better ( p-value 0.004 and 0.013 ) . Experimental group residents valued their course highly in terms of their laparoscopic surgical skills improvement and the use of VR simulators in the surgical curiculum . Conclusions : The Eindhoven Virtual Reality laparoscopic cholecyctectomy training course improves surgical skill in the operating room above the level of residents trained by a variety of other training methods BACKGROUND New Residency Review Committee requirements in general surgery require 50 colonoscopies . Simulators have been widely suggested to help prepare residents for live clinical experience . We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients . METHODS A r and omized controlled trial included general surgery and internal medicine residents with limited endoscopic experience . Following a pretest , the treatment group ( n = 12 ) practice d on the simulator , while controls ( n = 12 ) received no additional training . Both groups then performed a colonoscopy on a live patient . Technical ability was evaluated by expert endoscopists using previously vali date d assessment instruments . RESULTS In the live patient setting , the treatment group scored significantly higher global ratings than controls ( t(22 ) = 1.84 , P = .04 ) . Only 2 of the 8 computer-based performance metrics correlated significantly with previously vali date d global ratings of performance . CONCLUSIONS Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls , demonstrating skill transfer to live patients . The simulator 's performance metrics showed limited concurrent validity , suggesting the need for further refinement Virtual reality surgical simulators have proven value in the acquisition and assessment of laparoscopic skills . In this study , we investigated skill transfer from a virtual reality laparoscopic simulator into the operating room , using a blinded , r and omised , controlled trial design . Surgical trainees using the LapSim System  performed significantly better at their first real-world attempt at a laparoscopic task than their colle 
    Output:
    
For laparoscopic cholecystectomy ( n = 10 studies ) and endoscopy ( n = 10 studies ) , participants who reached simulation-based skills proficiency before undergoing patient-based assessment performed with higher global assessment scores and fewer errors in the operating room than their counterparts who did not receive simulation training .
Not all parameters measured were improved .
Two of the endoscopic studies compared simulation-based training in isolation with patient-based training with different results : for sigmoidoscopy , patient-based training was more effective , whereas for colonoscopy , simulation-based training was equally effective .
Skills acquired by simulation-based training seem to be transferable to the operative setting for laparoscopic cholecystectomy and endoscopy .