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ORIGINAL ARTICLE
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To Compare the effectiveness of traditional textbook-based learning with video-based teaching for basic laparoscopic suturing skills training - A randomized controlled trial


 Department of Surgery, AFMC Pune, Pune, Maharashtra, India

Date of Submission20-Aug-2021
Date of Decision15-Sep-2021
Date of Acceptance01-Nov-2021

Correspondence Address:
KK Arunjeet,
Department of Surgery, AFMC Pune, Wanoworie, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_691_21

  Abstract 


Background: It is often seen that surgeons face with a situation where he is asked to perform procedure which he has never done independently before. During such times traditionally surgeons refer to standard textbooks before he goes to perform the surgery. However, with increased awareness and use of social media, surgeons are increasingly taking resort of easily available YouTube videos. Aim: This study aims to compare the effectiveness of traditional textbook-based learning (TBL) with video-based teaching (VBT) for basic laparoscopic suturing skills training by comparing pre- and post-test cognitive and psychomotor skills. Materials and Methods: Randomized control trial. Results: A total of 50 residents were divided randomly into TBL and VBT groups. The mean post test scores for both the skills in each group showed a significant improvement compared to the pretest results (P < 0.001). While comparing the post test scores among both the groups it was seen that VBT is as effective as TBL. Conclusion: Based on this study we can safely conclude that video-based learning is an effective mode of learning as compared to TBL for teaching laparoscopic suturing skill.

Keywords: Cognitive skill, psychomotor skill, textbook-based learning, video-based teaching



How to cite this URL:
Routh D, Rao PP, Sharma A, Arunjeet K K. To Compare the effectiveness of traditional textbook-based learning with video-based teaching for basic laparoscopic suturing skills training - A randomized controlled trial. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337806




  Introduction Top


Surgeons very often face the situation of performing procedure never having done independently before. In the Armed Forces, a surgeon with relatively less experience encounters this when posted in remote locations. During such times traditionally surgeons refer to standard textbooks and other written material. Now, there are increased number who watch videos performed by master surgeons. The perception is that more and more surgeons are relying on watching only videos before doing the procedure. It possibly gives them more confidence to carry out the task.

The advantage of referring to standard book is that it is evidence-based, gives various perspectives, the variations in anatomy, many ways of performing the procedure and enlisting the complications. Additional diagrams, sketches, and pictures further reenforce the written material. The disadvantage is that the surgeon based on his previous experience makes his own mental representation of what he reads, and this may not be the actual what he may encounter.

The video learning on the other hand has the advantage of watching the operation performed which may be easy to reproduce. However, he may miss out difficult and tricky steps, and other ways of doing the procedures. Seeing procedure being performed by an experienced operator effortlessly may also instill a false sense of confidence that he may be able to replicate it.

Aims and objectives

In this study, we aim to compare the effectiveness of traditional textbook-based learning (TBL) with video-based learning (VBL) for basic laparoscopic suturing skills training.

Our primary objective was to compare TBL versus VBL for basic laparoscopic suturing skills training on:

  • cognitive performance (pre and post knowledge test)
  • surgical skills performance (pre and post Objective Structured Assessment of Technical Skills [OSATS] score).


Our secondary objective was to evaluate the impact of individual learning preferences on performance (VARK© learning styles questionnaire).


  Materials and Methods Top


Study setting

It was a 1:1 randomized control trial conducted in October 2020. This study was performed in a General Surgery department of a medical college. All general surgery residents irrespective of their year of training were asked to enroll in the study. A demographic survey was developed based on prior studies on skills teaching.[1] Variables included age, sex, handedness, English literacy, and exposure to basic surgical skills prior to the study. Demographic data of all participants were collected at the start of the study. The residents were randomized into two groups using computer-generated randomization and allocation concealment with on-site computer system. A pretest for the cognitive skill was taken based on 25 MCQ and the psychomotor skill was assessed on the OSATS–basic laparoscopic suturing (Pretest OSATS score) on box trainers.[2] The learning preferences among residents were assessed by the VARK© learning styles questionnaire.[3] The study arms were then given an hour for learning a laparoscopic suturing skill by either textbook-based or VBL material. Participants randomized to the TBL group were provided instruction through written study materials prepared by the faculties based on literature.[4],[5] They were freely allowed to ask instructors any questions and clear doubts if any. There were 4 instructors with an average student-to-instructor ratio of 7:1. Participants randomized to the VBL group were provided with basic laparoscopic suturing skills instructional videos of 9 min duration which were also prepared by the faculties for this purpose. Students were freely allowed to watch, play, pause the video any number of times during the allotted time. However, they were not allowed to ask the instructors any questions.

At the conclusion of 2-h session, participants again underwent the posttest MCQ and posttest OSATS score on box trainers. Participants were video recorded performing the OSATS pretests and posttests, and the videos were then scored later. To maintain anonymity, participants wore nonsterile white gloves and white coats while being recorded. Evaluators were also blinded to both study arm assignment and study stage – pretest versus posttest.

Sample size calculation

Sample size has been determined based on the hypothesis that VBL is effective for teaching basic laparoscopic suturing. The null hypothesis was that VBL has a worse outcome than TBL group. Our aim was to reject this null hypothesis with a one-sided significance level of α = 0.05 and conclude that VBL does not result in worse technical skills acquisition compared with TBL. The null hypothesis would have been rejected if students in VBL group have, on average, better technical skills, or worse technical skills within the noninferiority margin. If the difference between VBL and TBL groups is greater than the preselected margin, we would fail to reject the null hypothesis and conclude that VBL is inferior to TBL. The sample size per arm was calculated to detect noninferiority between the 2 groups at posttest with a noninferiority margin of 0.8 standard deviation (SD) with one-sided α = 0.05 (or two-sided α = 0.1) and 80% statistical power. The noninferiority margin was based on a previous study.[6] The target sample size was calculated to be 25 students per arm.[7]

Statistical analysis

A paired t-test was applied to compare the change in pre- and post-test scores in both the groups. To compare the effect of learning preferences among residents (by VARK© learning styles questionnaire) on performance scores a linear regression analysis was done. A P < 0.05 was considered to be statistically significant.

The study was approved by the Institutional Ethical Committee by letter number IEC/2020/322 dated 15 October 2020 and was registered with a Clinical Trial Registry India (CTRI/2020/11/029020).


  Results Top


A total of 50 residents participated and completed the study [Figure 1]. The results of the demographic survey of both the arms are shown in [Table 1]. In comparing baseline characteristics in both the groups, there were no significant differences between the groups. The medium for training for this study was conducted in English, and 100% of the residents reported 4/5 in Likert scale for English language proficiency with regards to reading, writing, listening, and speaking. With regards to previous experience in basic laparoscopic suturing skills, more than 50% of residents had no experience in both the groups.
Figure 1: Consort Diagram showing the study design and intervention

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Table 1: Comparison of demographic profile of both groups

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The mean pretest MCQ scores between the groups were comparable: 17.9 ± 0.9 for the TBL group and 18.4 ± 0.7 for the VBL group. The TBL group had a mean posttest MCQ score of 24.3 ± 0.6 (P < 0.002) which showed a significant improvement in their performance. Similarly, the mean posttest MCQ score for VBL group also showed significant improvement in comparison to their pretest values [Table 2].
Table 2: Comparison of cognitive skill scores following intervention in both groups

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[Table 3] shows the comparison of pre-and post-test of psychomotor skill by OSATS score. There has been a statistically significant improvement of post test score in both the groups. When we tried to compare the difference in mean posttest OSATS scores between the two groups it was found to be 0.94 with a 90% CI of ‒4.4–6.1. The noninferiority margin based on the SD of OSATS score combined across both the groups was 7.68. As a result, the VBL group satisfied the predetermined statistical criteria for noninferiority [Figure 2].
Table 3: Comparison of psychomotor skill scores following intervention in both groups

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Figure 2: Difference in posttest psychomotor skill score among both the groups

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As a part of our secondary objective, we tried to compare the learning preferences of residents on the performance outcome of both cognitive and psychomotor skills based on VARK© learning styles questionnaire. [Figure 3] shows the learning preferences of all 50 residents in both the groups who participated in this study. Majority of the residents had a multimodal learning preference. [Table 4] shows the influence of these learning preferences on the performance of various skills. While most of the learning preferences had no significant influences on cognitive and psychomotor skills, the residents who had visual preferences showed significant improvement in psychomotor skill performance.
Figure 3: Distribution of learning preferences among all the residents

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Table 4: Effect of learning preferences on change in cognitive and psychomotor skill scores

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  Discussion Top


VBL denotes the knowledge or skills acquired through teaching through video. One of the key features of video is the use of both auditory and visual cues. Visual aspects provide the primary source of information and audio is used to elaborate on the information. VBL possesses unique features that make it an effective learning method which can enhance and partially replace TBL. It is a powerful model used to improve learning outcomes and student satisfaction.

The first use of VBL began during World War II when soldiers were rehearsed with a combination of audio and film tapes, which resulted in improvement of their skills. It continued with the use of educational television as an additional tool in classrooms, where teachers watched videos of their classes to further reflect on their teaching methods and improve their work. Later, the introduction of videotapes indicated a step forward in the field, as it became much easier to use the video in classrooms. The rise of digital video CDs in the mid-1990s provided teachers with multimedia assessment tools using the video on a computer. Following which, classrooms were provided with the Internet connection, while interactive digital video, as well as video conferencing, became available. Since then, new technologies such as smartphones and tablets combined with social media like YouTube have helped increase social interaction and facilitate the integration of video applications in education.[8]

It is often seen that surgeons face with situation where he is asked to perform procedure which he has never done independently before. It is more relevant in the Armed Forces where a surgeon with relatively less experience encounters this when posted in remote locations. During such times, traditionally surgeons refer to standard textbooks and other written material before he goes to perform the surgery. However, with increased awareness and use of social media, surgeons are increasingly taking resort of easily available YouTube videos showing procedures performed by experts worldwide. The perception among the surgeons is that more and more of them are relying on watching these videos before performing these procedures. It possibly gives them more confidence to carry out the task. However, often as seen the procedures do not seem to be so smooth sailing in reality. Video-based learning has the advantage of watching the operation performed which may be easy to reproduce. However, he may miss out on difficult and tricky steps, and other ways of doing the procedures. Seeing the procedure being performed by an experienced operator effortlessly may also instill a false sense of confidence that he may be able to replicate it.

The traditional experts, however, feel the other way. The advantages of referring to standard books and mentoring by experts are that they are evidence-based, give various perspectives, the variations in anatomy, many ways of performing the procedure, and enlisting the complications. Additional diagrams, sketches, and pictures further reenforces the written material.

With this premise, we wanted to evaluate these two methods of learning and objectively evaluate the degree of confidence among surgeons before starting the procedure and ability to perform the procedure.

  1. Questionnaire-based: pre and post intervention
  2. Testing knotting skills on box trainer.


In our study, residents in both groups showed significant improvement in both cognitive and psychomotor skills based on the improvement in MCQ and OSATS scores from pretest to posttest. VBL has been shown to be as effective as TBL, as the upper limit of the 90% CI of the difference in mean posttest OSATS scores did not encompass the a priori noninferiority margin.

The improvement in basic laparoscopic suturing surgical skills in the VBL group maybe attributed that these videos contain sufficient visual and auditory instructions for teaching these procedures. This explanation is supported by a similar study performed by Custers et al. where they demonstrated that a single observation of an excision of a skin lesion alone resulted in improved performance.[9]

The traditional TBL along with mentoring by experts has been the gold standard of surgical training. In this study we aimed to see whether VBL is as good as traditional teaching and surgeons can rely on it. We tried to compare the pre and post test results of both cognitive and psychomotor skills which were comparable in both the groups. A study by Truong et al. had shown that video-based learning is better statistically than the traditional method.[10] While another similar study done by Lwin et al. had shown that both the methods are equally effective.[6] The mean OSATS score in both the methods of teaching had improved to around 50%–60% of the maximum (total OSATS score is 49). In our study, the time duration for learning by both methods was limited to 1 h only. Hence, it may be assumed that the residents would likely reach a higher level of proficiency had they been given more time to practice.[11]

As a part of our secondary objective, we tried to see whether the learning preferences of an individual influence the performance of the learner. It was seen that visual preferences of residents have statistically significant improvement of psychomotor skill performance in those residents. Our findings are congruent with the findings of a similar study by Truong et al.[10]

Strengths of the study

This is one of the few randomized studies evaluating VBL with TBL for teaching laparoscopic suturing skills. This study has also used validated questionnaire for learning preference and evaluating psychomotor skills. Both the learners and examiners were blinded for the study to prevent biases. This study has also used the same pre-and post-test examination tool to see the difference which has been made by the learning tools.

Limitations of the study

It was a single-institution study with a small sample size of 50 participants. A larger sample size may have produced a narrower a priori noninferiority margin which may in turn prove to have a higher power to support the noninferiority. The teaching time was also limited to an hour which may have influenced the level of performance in both the arms. Although there was a significant increase in post test score in both the groups, it was only around 50%–60%, which is still below the expected level.


  Conclusion Top


Based on this study we can safely conclude that VBL is an effective mode of learning as compared to TBL for teaching laparoscopic suturing skill. Surgeons may safely take help of available videos in social media before performing any procedure. It has also been shown in our study that learners with visual preferences have a significant improvement in psychomotor skill performance.

Ethical approval

The study was approved by the Institutional Ethical Committee and was also registered with the CTRI.

Informed consent

Written informed consent was also taken from all participants before the start of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Seagull FJ, Rooney DM. Filling avoid: Developing a standard subjective assessment tool for surgical simulation through focused review of current practices. Surgery 2014;156:718-22.  Back to cited text no. 1
    
2.
Chipman JG, Schmitz CC. Using objective structured assessment of technical skills to evaluate a basic skills simulation curriculum for first-year surgical residents. J Am Coll Surg 2009;209:364-70.e2.  Back to cited text no. 2
    
3.
Kim RH, Gilbert T, Ristig K. The effect of surgical resident learning style preferences on American Board of Surgery in-training examination scores. J Surg Educ 2015;72:726-31.  Back to cited text no. 3
    
4.
Mereu L, Carri G, Albis Florez ED, Cofelice V, Pontis A, Romeo A, et al. Three – Step model course to teach intracorporeal laparoscopic suturing. J Laparoendosc Adv Surg Tech A 2013;23:26-32.  Back to cited text no. 4
    
5.
Kothari R, Somashekar U, Sharma D, Thakur DS, Kumar V. A simple and safe extracorporeal knotting technique. JSLS 2012;16:280-2.  Back to cited text no. 5
    
6.
Lwin AT, Lwin T, Naing P, Oo Y, Kidd D, Cerullo M, et al. Self-directed interactive video-based instruction versus instructor-led teaching for Myanmar house surgeons: A randomized, noninferiority trial. J Surg Educ 2018;75:238-46.  Back to cited text no. 6
    
7.
Chow SC, Shao J, Wang H. Sample Size Calculation in Clinical Research. New York, NY: Marcel Dekker; 2003.  Back to cited text no. 7
    
8.
Yousef AM, Chatti MA, Schroeder U. The state of video-based learning: A review and future perspectives. Int J Adv Life Sci 2014;6:122-35.  Back to cited text no. 8
    
9.
Custers EJ, Regehr G, McCulloch W, Peniston C, Reznick R. The effects of modeling on learning a simple surgical procedure: See one, do one or see many, do one? Adv Health Sci Educ Theory Pract 1999;4:123-43.  Back to cited text no. 9
    
10.
Truong M, Tobias C, Ratan R. A prospective trial: Traditional versus video-based teaching for minimally invasive gynecologic surgery. Obstet Gynecol 2017 1;129:94S.  Back to cited text no. 10
    
11.
Brooks KD, Acton RD, Hemesath K, Schmitz CC. Surgical skills acquisition: Performance of students trained in a rural longitudinal integrated clerkship and those from a traditional block clerkship on a standardized examination using simulated patients. J Surg Educ 2014;71:246-53.  Back to cited text no. 11
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
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