Bakgrund: Inom förlossningsvården används en typ av bedövning kallad pudendusblockad (PDB). Denna bedövning kan administreras på två olika sätt; antingen genom så kallad inre eller yttre teknik. Den yttre tekniken introducerades 2015, dess praktiska för- och nackdelar är ännu inte utförligt dokumenterade i litteraturen.  Syfte: Att utforska barnmorskors erfarenheter av yttre pudendusblockad vid inspektion och suturering postpartum.  Metod: Studien genomfördes med en kvalitativ design. Insamlad data består av intervjuer från totalt tio barnmorskor från två sjukhus i södra Sverige. Dataanalysen genomfördes med kvalitativ innehållsanalys.  Resultat: Resultaten av studien indikerar bland annat att yttre PDB är en uppskattad bedövningsteknik i regionerna, de intervjuade barnmorskorna angav att de använde yttre PDB i majoriteten av alla förlossningar. Över lag var också samtliga deltagare positiva till bedövningen; den upplevs framför allt som en säker smärtlindring, lätt att administrera och kvinnorna ansågs väl bedövade inför suturering. Några väsentliga negativa aspekter kunde enligt deltagarna ej påvisas.  Slutsats: Yttre PDB är en uppskattad bedövningsform som används i stor utsträckning på båda sjukhusen. / Background: Pudendal nerve block (PNB) is a common anesthetic used in maternity care. This anesthesia can be administered in two different ways; either through the so-called inner or outer technique. The outer technique introduces 2015, its practical pros and cons have not yet been thoroughly described in literature.  Purpose: To explore midwives experiences of outer pudendal nerve block during inspection and suturing after delivery.  Method: The study is conducted with a qualitative design. Collected data consists of interviews from a total of ten midwives from two hospitals in southern Sweden. Data has been analyzed with qualitative content analysis. Result: The results of the study indicate for instance that outer PNB is an appreciated technique for anesthesia in the examined geographical region, the interviewees stated that they use outer PNB in the majority of all cases. Furthermore, every interviewee was positive towards the treatment; most importantly, it is viewed as a safe method, easy to administer and patients are well anaesthetized for suturing. No primary negative aspect could be concluded from the interviews.  Conclusion: Outer PNB is an appreciated technique that is used to a large extent at the hospitals surveyed in this study.

<p>  </p> <p>Knot tying boards are low fidelity surgical simulators used to practice tying suture, but devices on the market currently provide no feedback and no way of changing out bands. A simple-to-use knot tying board with interchangeable bands capable of measuring force was designed. This board is comparable in cost to products currently available on the market. The knot tying board was then prototyped and tested. Four MD students completed trials of one-handed and two-handed knot tying with three throws per trail. In testing, the knot tying board was capable of measuring force data, such as peak force during knot tying and the final force the knot exerts on the bands. The device used in conjunction with experienced surgical skills coaches could prove a powerful tool for providing feedback to trainees, and a similar approach could be used with other low fidelity surgical simulators to improve feedback.</p>

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In surgery, suturing is the use of needle and thread to join cut and/or damaged anatomical structures together. This repair strategy is highly versatile and is universal for all types of surgery as the goal is to restore, repair or improve function and/or appearance. The needles are almost always curved in shape, and it is handled and maneuvered by surgeons with a special tool called: needle driver. The versatility of this setup has proven its worth over time as needle drivers are one of the indispensable instruments in all types of surgery. We are entering a future where robots can be programmed to execute tasks with much higher level of precision and speed compared to humans. Medical robotics in surgery has gained ground over the past decades due to promising clinical results. A straightforward step in this direction would be to create a solution that enables the robot to grip needle driver. The purpose of this study was to develop a gripper tool that enables a collaborative robot to perform suturing with one of the most common types of needle drivers used in surgery. The Double Diamond design framework was employed. The selected content in the predefined four phases were: 1) Discover: Observation, MoSCoW Prioritization, Brainstorming, Choosing a Sample, Fast Visualisation, 2) Define: Assessment criteria, 3) Develop: Physical prototyping 4) Deliver: Final testing and Evaluation. In the first phase, Discover, clinical and technical demands were formulated. In the second phase, Define, numerous design ideas were generated and drafted on paper whereof the one with highest assessment score was chosen for physical prototyping. In phase three, Develop, the selected design idea was modelled in cardboard, clay and silicon, and 3D printed. Multiple design iterations were guided by feedback from clinical and technical experts and resulted in a final prototype design that was accepted by the experts. In phase four, Deliver, the final prototype was subjected to final testing and evaluation. Observation of five live and one video recording of surgical procedures on real patients were made. The insights gained were confirmed with the lead and co-surgeons of each procedure and were summarized in 24 clinically important observations relevant for the gripper tool design. Careful analysis of the previously designed gripper tool, live observation of the robot’s motion pattern and range, and interview with robotic engineer were summarized in ten technically important observations. The observations were then used to formulate the clinical and technical demands that the gripper tool design aims to fulfill, followed by prioritizing the demands and design features according by MoSCoW method and brainstorming on how to improve previous gripper tool design. To limit the scope of the design challenge, one of the five types of needle drivers used in pediatric heart surgery in Lund was selected in the method Choosing a Sample. To further characterize the clinical and technical demands, a test bench was set up to Define and measure force vectors applied on the needle driver when held by a surgeon during suturing. The radial forces vectors in six directions perpendicular to the tip of the needle driver ranged from 1.6 N to 3.8 N. The axial force along the length of the needle driver was 7.6 N towards the tip and 8.4 N towards the back end. The clockwise and counterclockwise torque along the length axis of the needle driver was 0.2 Nm and 0.18 Nm, respectively. The set of defined demands were sufficient to sketch numerous ideas of gripper tool designs according to the Fast Visualization method. These designs were then used in the Define phase to communicate the design ideas with surgeons, robotic and product development engineers. The most promising idea was advanced to the Develop phase where physical prototypes were produced in cardboard, clay and silicon and 3D printed. Inadequacies were found during design feedback with interviews and testing together with clinical and technical experts, and design actions were taken to arrive at the final prototype. The final prototype was brought into the Deliver phase for final testing and evaluation. The gripper tool could handle lager force loads than the human surgeon in all the stability tests. However, deflection of the needle driver occurred with the gripper tool unlike when the surgeon was subject to stability testing. One pediatric heart surgeon and one robotic engineer was asked to generate a composite score of fulfillment rate from 1–5, where 1 is bad, 3 satisfactory, and 5 excellent after final testing of the gripper tool was carried out. The final prototype of the gripper tool fulfills all clinical and technical demands at the level of 4, and 3–5, respectively. In conclusion, the design methodology used in this study was useful in the development of a gripper tool design that respects both clinical and technical demands. This suggest that the methodology may be used in similar setting of design challenges in the field between medical and technical innovation. The gripper tool fulfilled the demands, although further refinement in the choice of material, further testing and investigation of regulatory aspects are required before it can be implemented in the operating room. / Vid operation är suturering användningen av nål och tråd för att sammanfoga snittad och/eller skadade anatomiska strukturer. Denna reparationsstrategi är mycket mångsidig och universell för alla typer av kirurgi eftersom målet är att återställa reparera eller förbättra funktion och/eller anatomisk defekt. Nålarna är nästan alltid krökta i sin form och de hanteras och manövreras av kirurgerna med ett speciellt verktyg som kallas: nålförare. Mångsidigheten i denna uppställning har visat sig över tid eftersom nålförare är ett av de oumbärliga instrumenten vid alla typer av operationer. Vi går in i en framtid där robotar kan programmeras för att utföra uppgifter med mycket högre precision och hastighet jämfört med människor. Medicinska robotar inom kirurgi har varit på frammarsch senaste årtionden på grund av goda kliniska resultat. Ett steg i denna riktning skulle vara att skapa en lösning som gör det möjligt för en robot att greppa nålföraren. Syftet med denna studie var att utveckla ett gripdon som möjliggör för en kollaborativ robot att utföra suturering med hjälp av en av de vanligaste typerna av nålförare som används vid operation. Design metodiken Double Diamond användes för att beskriva design processensen. Det valda metoderna i de fyra för definierade faser var: 1) Discover: Observation, MoSCoW Prioritization, Brainstorming, Choosing a Sample, Fast Vissualization, 2) Define: Assessment criteria, 3) Develop: Physical Prototyping, 4) Deliver: Final testing and Evaluation. I första fasen, Discover, formulerades kliniska och tekniska krav. I den andra fasen, Define, definierades flera designidéer som skissades på papper, varav den med den högsta poängen valdes i Assessment criteria. I fas tre, Develop, modellerades den valda designidén i kartong, lera och silikon samt 3D-printades. Flera designiterationer gjordes baserat på feedback från kliniska och tekniska experter vilket resulterade i en slutlig prototypdesign som godkändes av experterna. I fas fyra, Deliver, testades och utvärderades den slutliga prototypen. Observation av fem realtids och en videoinspelning av kirurgiska ingrepp på riktiga patienter gjordes. Insikterna som gjordes bekräftades med kirurgerna som genomförde operationen och sammanfattades i 24 kliniskt viktiga observationer som var relevanta för gripdon designen. Noggrann realtids observation av robotens rörelsemönster samt analys av det tidigare utformade gripdonen och intervju med en robotingenjör sammanfattades i tio tekniskt viktiga observationer. Observationerna användes för att formulera kliniska och tekniska krav som gripdons designen strävar efter att uppfylla, följt av prioritering av kraven och designegenskaper enligt MoSCoW-metoden och brainstorming kring hur tidigare gripdons design kan förbättras. För att begränsa designutmaningens omfattning valdes en av de fem typer av nålförare som används vid barnhjärtkirurgi i Lund genom metoden Chossing a sample. För att ytterligare karakterisera de kliniska och tekniska kraven upprättades en testbänk för att definiera och mäta kraftvektorer som appliceras på nålföraren när den hålls av en kirurg under suturering. De radiella krafterna i sex riktningar vinkelrätt mot nålförarens spets varierade från 1,6 N till 3,8 N. Den axiella kraften längs nålförarens längd var 7,6 N mot spetsen och 8,4 N mot bakänden. Medurs och moturs vridmoment längs nålförarens längdaxel var 0,2 Nm respektive 0,18 Nm. Dom definierade kraven låg till grund för skisser av flertal gripdondesign idéer enligt Fast Visualization. Dessa skisser användes sedan i Define fasen för att kommunicera designidéer med kirurger samt robot- och produktutvecklingsingenjörer. Den mest lovande idén togs till Develop fasen där fysiska prototyper togs fram i kartong, lera och silikon samt genom 3D-printning. Förbättringspunkter hittades under testning och återkoppling med intervjuer tillsammans med kliniska och tekniska experter. Designåtgärder baserat på återkopplingen gjordes för att komma fram till den slutliga prototypen. Slutlig testning och utvärdering av den slutliga prototypen genomfördes i Deliver fasen. Gripdons designen kunde hantera större belastningar än den mänskliga kirurgen i alla stabilitetstester. Böjning av nålföraren uppstod dock i testerna med gripverktyget till skillnad från testerna med kirurgen var föremål för stabilitetsprovning. En barnhjärtkirurg och en robotingenjör poängsatte uppfyllnadsgrad av de kliniska respektive tekniska kraven efter att slutlig testning av gripdonet utförts. Uppfyllnadsgraden poängsattes från 1–5 där 1 var dålig, 3 tillfredsställande och 5 utmärkt. Gripdonets slutliga prototyp uppfyller alla kliniska och tekniska krav på nivå 4 respektive 3–5. Designmetodiken som användes i denna studie var användbar för utvecklingen av gripdon som uppfyller både de kliniska och tekniska kraven. Detta tyder på att denna metod kan användas i liknande designutmaningar inom området mellan medicinsk och teknisk innovation. Gripdonet uppfyllde kraven även om ytterligare förfining i materialvalet, ytterligare testning och undersökning av regulatoriska aspekter krävs innan den kan användas under riktiga operationer i operationssalen.

The goal of this project is to develop virtual surgical simulation software in order to simulate the suturing and knot tying processes associated with surgical thread. State equations are formulated using Lagrangian mechanics, which is useful for the conservation of energy. Solver methods are developed with theory based in Differential Algebraic Equations (DAEs) which concern governing Ordinary Differential Equations (ODEs) that are constraint with Algebraic Equations (AE). An implicit integration scheme and Newton's method is used to solve the system in each step. Furthermore, a collision response process based on the Linear Complementarity Problem (LCP) is implemented to handle collisions and measure their forces. Models have been developed to represent the different types of objects. A spline model is used to represent the suture and mass-spring model for the tissue. They were both selected for their efficiency and base on real physical properties. The spline model was also chosen as it is continuous and can be evaluated at any point along the length. Other objects are also defined such as rigid bodies. The Lagrangian multiplier method is used to define the constraints in the model. This allows for the construction of complex models. An important constraint is the suturing constraint, which is created when a sufficient force is applied by the suture tip on to the tissue. This constraint allows only a sliding point along the suture to pass through a specific point on the tissue. This results in a virtual suturing model which can be built on for use in surgical simulations. Further investigations would be interesting to increase performance, accuracy and scope of the simulator. / Det här projektet syftar till att utveckla mjukvara för virtuell simulering av kirurgi som involverar knytande av suturtråd. Lagranges ekvationer används för att härleda energibevarande tillståndsekvationer. Lösningsmetoderna grundar sig i teori från området Differential-Algebraiska Ekvationer (DAEer), som avser att kontrollera Ordinära Differentialekvationer (ODEer) med algebraiska bivillkor. Ett implicit integrationsschema och Newtons metod används för att lösa systemet i varje steg. Utöver det så implementeras en kollisionsrespons-process baserad på det linjära komplementaritetsproblemet (LCP) för att hantera kollisioner och mäta deras krafter. Modeller har utvecklats för att representera olika typer av objekt. En spline-modell används för att representera suturtråden och ett mass-fjäder system för vävnaden. Valet baserades på deras höga prestanda samt starka anknytning till objektens fysiska egenskaper. Spline-modellen valdes också då dess kontinuitet innebär att den går att evaluera för en godtycklig punkt inom dess domän. Andra objekt, såsom stela kroppar, finns också definierade. Lagrangemultiplikator används för att definiera bivillkor i modellen. Detta tillåter konstruktionen av komplexa modeller. Ett viktigt bivillkor är sutur-bivillkoret som uppstår när tillräcklig kraft från spetsen på den kirurgiska nålen appliceras på vävnaden. Detta bivillkor tillåter att endast en glidande punkt längsmed suturen passerar genom en specifik punkt på vävnaden. Detta resulterar i en virtuell modell för stygn som kan byggas vidare på för användning i kirurgiska simulationer. Det vore intressant med ytterligare undersökningar för att förbättra prestandan, precisionen och simulatorns omfattning.

Social-comparative feedback (i.e., providing a learner with information regarding his/her performance relative to a group average) has been shown to influence a learner’s psychological and behavioural outcomes during motor skill acquisition (Avila, Chiviacowsky, Wulf, & Lewthwaite, 2012; Eliasz, 2012; Lewthwaite & Wulf, 2010; McKay, Lewthwaite, & Wulf, 2012; Stoate, Wulf, & Lewthwaite, 2012; Wulf, Chiviacowsky, & Cardozo, 2014; Wulf, Chiviacowsky, & Lewthwaite, 2010, 2012; Wulf & Lewthwaite, 2016). This research indicates that motor skill acquisition is facilitated when learners believe they are performing better than the average, regardless of their actual performance. It has been suggested (Wulf & Lewthwaite, 2016) that a better-than-average mindset enhances psychological factors such as self-efficacy and motivation and in turn, actual behaviour. However, there is also evidence to suggest that self-efficacy (having state-like properties) and motivation (having both state and trait-like properties) are related in terms of their affective influence on learning (Bandura, 1997; Schunk, 1990, 1991, 1995) but the relationship between the two constructs and its subsequent outcomes remain unclear. Even though individual differences in motivation have been suggested to influence self-efficacy beliefs, they have been largely ignored in this line of research. There is also evidence to suggest that learners possessing high levels of motivation (whether that may be at a trait or state level) may not interpret feedback in the same manner (Aronson, 1992; Festinger, 1957; Frey, 1986; Harmon-Jones, 2012; Harmon-Jones & Harmon-Jones, 2002; Harmon-Jones, Harmon-Jones, Fearn, Sigelman, & Johnson, 2008; Harmon-Jones & Mills, 1999; Harmon-Jones, Schmeichel, Inzlicht, & Harmon- Jones, 2011; Steele, 1988). Therefore, the goal of this dissertation is use both theoretical and applied perspectives to examine the degree to which social- comparative feedback affects psychological and behavioural outcomes in highly- motivated learners (e.g., medical trainees) learning procedural skills. Independent of actual performance, we provided manipulated feedback information to novice pre-clerkship medical trainees while they were learning motor skills to suggest that they were performing better or worse than the average. The first study used a basic sequential key-press learning task (Eliasz, 2012) and a basic suturing task to explore the role of social-comparative feedback in medical trainees and tested whether features of the task were important (i.e., basic laboratory task or technical skill task) during the interpretation of this feedback. The second study used the same experimental paradigm to extend our results to a relevant medical education context (i.e., medical trainees learning basic suturing techniques). The final study examined whether the credibility of the feedback provider (i.e., expert versus peer) played a role in how social-comparative feedback was being internalized by novice medical trainees. Our initial study demonstrated that, compared to those receiving positive or no social-comparative feedback, medical trainees receiving negative social- comparative feedback during motor skill acquisition had significant difficulties in learning both the laboratory and technical skill task. These findings suggested that compared to other learners, novice medical trainees (a subset of highly-motivated learners), responded differently to social-comparative feedback. The second study replicated this pattern and revealed that medical trainees receiving below-average feedback during technical skill acquisition experienced significant detriments to their performance, learning and self-efficacy. Our final study found that regardless of the feedback source (hypothetical expert versus another peer), the experience of receiving negative social-comparative feedback impacted self- reported psychological measures and the immediate performance of a basic surgical technique. This dissertation provides, to the best of our knowledge, the first demonstration that medical trainees, a subset of highly-motivated learners, interpret social-comparative feedback differently than other learners studied in the literature. More specifically, receiving positive social-comparative feedback did not facilitate the learning process as found in previous studies with non-medical learners, while the delivery of negative social-comparative feedback, irrespective of task or feedback provider, was psychologically and behaviourally detrimental to novice medical trainees learning motor skills. / Dissertation / Doctor of Philosophy (PhD) / This dissertation includes three original studies designed to examine the effects of social-comparative feedback during skill acquisition in highly- motivated learners (e.g., medical trainees). Regardless of actual task performance, novice medical trainees who were provided with feedback during the learning process indicating that they were performing worse than the group average, experienced significant detriments to their psychological and behavioural outcomes. This effect was present regardless of the task being learned (i.e., key- pressing or suturing) or who was delivering the feedback (i.e., a hypothetical ‘expert’ or ‘peer’). Receiving better-than-average feedback did not result in any additional psychological and behavioural benefits. Contrary to the research with non-medical students, where “you are above-average” social-comparative feedback facilitates learning and “you are below-average” social-comparative feedback is no different than a control condition, these studies suggest that the experience of receiving below-average feedback during the learning process can be detrimental for highly-motivated novice learners. These findings are important to consider in both the context of feedback delivery and remediation as they provide evidence that novice medical trainees, regardless of the task and feedback provider, experience difficulty in receiving information that they are performing relatively poorly compared to their peers.