Surgical Residents´ Results Seem to be Non-Inferior Comparing to More Experienced Surgeons in Femoral Neck Fracture Osteosynthesis

Purpose of the Study

Femoral neck fracture osteosynthesis is usually performed by using dynamic hip screw (DHS) or multiple parallel cannulated screws (MCS). In orthopedic surgery training, certain hip fractures are one of the most common operations performed by residents. It has been questioned, whether residents can provide as safe treatment and patient outcomes as those of more experienced surgeons. The aim of this study was to evaluate the effect of surgical experience on risk of complications by comparing the surgical performance and clinical outcomes in femoral neck osteosyntheses between surgical residents and orthopaedic surgeons.

Methods

All patients with femoral neck fracture admitted to Helsinki and Uusimaa Hospital District (HUS) Hyvinkää Hospital from 2011 to 2016 were collected as research material. 88 hip fractures (87 patients) treated with DHS or MCS osteosyntheses were included in this study. The patients were divided into 2 groups, based on the surgeon's experience: an orthopedic surgeon group (n = 68) and a surgical resident group (n = 20). All data from complications, reoperations, and the duration of operations were collected.

Results

There was no significant difference in characteristics of operated patients between orthopaedics and residents group. There was no significant difference in complications or re-operations between groups (p = 0.4, p = 0.2). Surgical residents had statistically longer surgical time (mean 76 min, 95% CI 62.92 min, mean 46 min, 95% Cl 42.51 min; p-value < 0.001). Still surgical time was not a risk factor for complication (p-value 0.5).

Conclusion

Our results show that surgical residents´ outcomes in femoral neck fracture osteosynthesis seem to be as favorable as those of orthopedic surgeons; the operations just last slightly longer.

Virtual learning in maxillofacial surgery in the post-COVID world: where are we now?

During the COVID-19 pandemic we developed a post-graduate virtual learning environment (PGVLE) in the West Midlands region for higher trainees in oral and maxillofacial surgery. We continued to develop this following the pandemic and sought to examine the trainee experience with this resource as restrictions eased. The PGVLE comprises a total of nine semesters mapping General Medical Council (GMC) learning objectives in the specialty across a total of 63 events using BigBlueButton™. Webinars are delivered on a weekly basis by subspecialty experts. Trainee feedback was sought using SurveyMonkey™ examining self-assessed confidence levels using visual analogue scores (VAS) and Likert items regarding trainers and content. A focus group was convened and the transcript analysed using grounded theory analysis (GTA). Likert items revealed overwhelmingly positive responses, with 96.2% (n = 281) of responses being positive regarding content and 97.5% (n = 475) agreeing with positive comments regarding faculty. VAS scores improved by an average of 39.0% and improvements were statistically significant for most sessions. The focus group highlighted the relevance of teaching to GMC learning objectives, the achievement of consistently high standards, the potential for conflict with clinical commitments and issues surrounding peer interaction. Satisfaction scores remain high with the PGVLE programme, which is very much here to stay in the post-graduate education of our trainees. With the easing of restrictions, we have moved to a hybrid method of learning with the potential for 'flipped classroom' methodology moving forwards.

Using video-based assessment (VBA) to document fellow improvement in safely completing the jejunojejunostomy portion of laparoscopic Roux-en-Y gastric bypass (RYGB) surgery

BACKGROUND

Surgical assessment instruments are used for formative and summative trainee evaluations. To characterize the features of existing instruments and a novel 12-item objective, procedure-specific assessment tool for Roux-en-Y Gastric Bypass (RYGB-OPSA), we evaluated the progress of a single surgical fellow over 17 consecutive surgeries.

METHODS

Seventeen consecutive RYGB videos completed between 8/2021 and 1/2022 by an academic hospital surgical fellow were de-identified and assessed by four board-certified bariatric surgeons using Global Operative Assessment of Laparoscopic Skills (GOALS), General Assessment of Surgical Skill (GASS), and RYGB-OPSA which includes the reflection of transverse colon, identification of ligament of Treitz, biliopancreatic and Roux limbs orientation, jejunal division point selection, stapler use, mesentery division, bleeding control, jejunojejunostomy (JJ) anastomotic site selection, apposition of JJ anastomotic site, JJ creation, common enterotomy closure of JJ, and integrity of anastomosis. The GASS measured economy of motion, tissue handling, appreciating operative anatomy, bimanual dexterity, and achievement of hemostasis. RYGB-OPSA and GASS items were scored "poor-unsafe," "acceptable-safe," or "good-safe." Change in performance was measured by linear trendline slope.

RESULTS

Over the course of 17 procedures, significant improvement was demonstrated by three GOALS items, GOALS overall score, GASS bimanual dexterity, and three RYGB-OPSA tasks: JJ creation, jejunal division point selection, and stapler use. Achievement of hemostasis declined but never rated "poor-unsafe." Overall RYGB-OPSA and GOALS trendlines documented significant increase across the 17 procedures.

CONCLUSION

This examination of a bariatric surgery fellow's operative training experience as measured by three surgical assessment instruments demonstrated anticipated improvements in general skills and safe completion of procedure-specific tasks. Effective surgical assessment instruments have enough sensitivity to show improvement to enable meaningful trainee feedback (low-stakes assessments) as well as the ability to determine safe surgical practice to enable promotion to greater autonomous practice.

[Intervention planning in modern renal surgery]

BACKGROUND

Three-dimensional (3D) reconstruction in renal surgery offers significant benefits in planning of the operation itself, in patient education and training fellows.

OBJECTIVE

The goal was to study the possible application and use of 3D reconstruction in modern renal surgery.

METHODS

A literature search in PubMed using keywords "3D" and "renal surgery" within the last 10 years of publication was performed.

RESULTS

The search revealed 655 articles among them 53 reviews. Relevant for this article were 120 articles which included 14 reviews. The publication statistics showed a strong increase in the last 10 years which may reflect the increasing application and demand for 3D technology in the field of renal surgery. Especially in robot-assisted minimally invasive surgery applications, the use of 3D technology was studied more often. The technical standards are not yet uniform and 3D printing in complex renal surgery remains cost- and time-intensive. Nevertheless, the results of the pioneering clinical studies showed positive results, and 3D technology can be used not only in planning the operation, but in patient education and also the training of fellows and staff. A limitation to more complex cases seems to be sensible for this is still a costly tool. To identify complex cases in renal surgery, the established renometric scoring systems should be used more broadly in daily practice to identify patients who would profit most from this technique.

CONCLUSION

In complex renal surgery, 3D reconstruction and modelling is rational; furthermore, it can be useful in patient education and in training of fellows.

Defining the Duty Hour for Surgical Trainees

OBJECTIVE

Being mindful of duty hours has become an integral part of surgical training. Violations can lead to disciplinary action by the American Council for Graduate Medical Education (ACGME), including probation or even withdrawal of accreditation. It is therefore crucial to ensure these hours are accurately reported. However, as these are often self-reported by the resident, what counts as a duty hour is at the discretion of the reporter. The goal of this study is to identify what trainees and faculty include in their definitions of a duty hour. We hypothesized that there would be discrepancies in faculty versus trainee definitions of the duty hour, and that there remains an unclear understanding of which nonclinical activities contribute to surgical trainee duty hours.

DESIGN

An anonymous, voluntary survey was conducted at a single institution. The survey contained 14 scenarios, and participants answered either "yes" or "no" as to if they believed the scenario should be counted within duty hour reporting. Analysis of the results included evaluating overall responses to determine which scenarios were more controversial, as well as chi square analysis comparing trainee (residents and fellows) versus faculty responses to each scenario.

SETTING

This survey was performed within the Department of Surgery at the University of Texas Southwestern Medical Center, a large academic institution in Dallas, TX.

PARTICIPANTS

There were 91 total faculty and trainee responses to the voluntary survey within the General Surgery Department and associated subspecialties, including 50 residents (54.9%), 4 clinical fellows (4.4%) and 37 faculty (40.7%).

RESULTS

When analyzing total responses, the most controversial scenarios were taking a short period of home call (50.6% of all respondents included this as a duty hour), making a presentation for resident education (48.4%), making a presentation related to patient care (57.1%), and making a monthly call schedule (44.0%). The least controversial topic was transit to and from work (91.2% of all respondents did not include this as a duty hour). Additionally, there were statistically significant differences between trainee and faculty perceptions when it came to attending departmental curricula (96.2% trainees included as a duty hour v 81.6% faculty, p =0.02), participating in nonmandatory journal club (5.7% trainees v 23.7% faculty, p =0.01), and attending mentorship meetings (30.2% trainees v 52.6% faculty, p =0.03).

CONCLUSIONS

There is no consensus as to what nonclinical activities formally count towards a duty hour. There are also significant differences identified between faculty and trainee definitions, which could have implications for duty hour reporting and ACGME violations. Further research is required to obtain a clearer picture of the surgical opinion on defining the duty hour, and hopefully this will reduce duty hour violations and better optimize surgical trainee education.

A Multi-institution Study on the Association of Virtual Reality Skills with Continence Recovery after Robot-assisted Radical Prostatectomy

BACKGROUND

Virtual reality (VR) simulators are increasingly being used for surgical skills training. It is unclear what skills are best improved via VR, translate to live surgical skills, and influence patient outcomes.

OBJECTIVE

To assess surgeons in VR and live surgery using a suturing assessment tool and evaluate the association between technical skills and a clinical outcome.

DESIGN, SETTING, AND PARTICIPANTS

This prospective five-center study enrolled participants who completed VR suturing exercises and provided live surgical video. Graders provided skill assessments using the validated End-To-End Assessment of Suturing Expertise (EASE) suturing evaluation tool.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A hierarchical Poisson model was used to compare skill scores among cohorts and evaluate the association of scores with clinical outcomes. Spearman's method was used to assess correlation between VR and live skills.

RESULTS AND LIMITATIONS

Ten novices, ten surgeons with intermediate expertise (median 64 cases, interquartile range [IQR] 6-80), and 26 expert surgeons (median 850 cases, IQR 375-3000) participated in this study. Intermediate and expert surgeons were significantly more likely to have ideal scores in comparison to novices for the subskills needle hold angle, wrist rotation, and wrist rotation needle withdrawal (p < 0.01). For both intermediate and expert surgeons, there was positive correlation between VR and live skills for needle hold angle (p < 0.05). For expert surgeons, there was a positive association between ideal scores for VR needle hold angle and driving smoothness subskills and 3-mo continence recovery (p < 0.05). Limitations include the size of the intermediate surgeon sample and clinical data limited to expert surgeons.

CONCLUSIONS

EASE can be used in VR to identify skills to improve for trainee surgeons. Technical skills that influence postoperative outcomes may be assessable in VR.

PATIENT SUMMARY

This study provides insights into surgical skills that translate from virtual simulation to live surgery and that have an impact on urinary continence after robot-assisted removal of the prostate. We also highlight the usefulness of virtual reality in surgical education.

Assessing textbook outcomes following major liver surgery in association with obesity at a referral academic center

INTRODUCTION

Outcomes of major surgeries in tertiary educational hospitals have been complicated by the referral of high-risk patients and the participation of trainees in surgical procedures. We analyzed outcomes of major hepatectomies in a tertiary academic setting emphasizing the role of training and obesity on textbook outcomes (TO).

MATERIALS AND METHODS

971 adult patients who underwent open major hepatectomy (Mesohepatectomy [n = 111], hemihepatectomy [n = 610], and extended hepatectomy [n = 250]) were evaluated. A TO was defined as: a negative resection margin, no grade B/C bile leak, no major complications, no in-hospital mortality, and no 30-day readmission. TOs were compared following operations performed by senior surgeons and those performed by junior surgeons under the supervision of senior surgeons and between patients with and without obesity.

RESULTS

TO was achieved in 70.1% of patients overall (78.4% in mesohepatectomy, 73.1% in hemihepatectomy, and 59.2% in extended hepatectomy). The rate of TO was similar following operations performed by and supervised by a senior surgeon (69.3% vs 71.0%, p = 0.570). The rate of TO was significantly lower in patients with obesity (41.5% vs 74.6%, p < 0.001). Factors including increased age (odds ratio [OR] for 10-year increase = 0.83, 95% confidence interval [CI]: 0.73-0.96, p = 0.009), obesity (OR = 0.25, 95%CI: 0.16-0.37, p < 0.001), biliodigestive anastomosis (OR = 0.27, 95%CI: 0.19-0.40, p < 0.001), and portal vein resection (OR = 0.49, 95%CI: 0.28-0.87, p = 0.014) lower the rate of TO.

CONCLUSION

Promising outcomes are possible after major hepatectomy in an academic setting. Obese patients and those undergoing more complex surgeries had a higher risk of poor postoperative outcomes.

DMEK surgical training: An instructional guide on various wet-lab methods

Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of the Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques, such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection, and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be more challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool, especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and nonhuman models with instructional videos. This article should eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques.

An ex vivo model for education and training of unilateral cleft lip surgery

BACKGROUND

Unilateral cleft lip surgery is a complex procedure, and the outcome depends highly on the surgeon's experience. Digital simulations and low-fidelity models seem inadequate for effective surgical education and training. There are only few realistic models for haptic simulation of cleft surgery, which are all based on synthetic materials that are costly and complex to produce. Hence, they are not fully available to train and educate surgical trainees. This study aims to develop an inexpensive, widely available, high-fidelity, ex vivo model of a unilateral cleft lip using a porcine snout disc.

METHODS

A foil template was manufactured combining anatomical landmarks of the porcine snout disc and the anatomical situation of a child with a unilateral cleft. This template was used to create an ex vivo model of a unilateral cleft lip from the snout disc. Millard II technique was applied on the model to proof its suitability. The individual steps of the surgical cleft closure were photo-documented and three-dimensional scans of the model were analysed digitally. Sixteen surgical trainees were instructed to create a unilateral cleft model and perform a unilateral lip plasty. Their self-assessment was evaluated by means of a questionnaire.

RESULTS

The porcine snout disc proved highly suitable to serve as a simulation model for unilateral cleft lip surgery. Millard II technique was successfully performed as we were able to perform all steps of unilateral cleft surgery, including muscle suturing. The developed foil-template is reusable on any porcine snout disc. The creation of the ex vivo model is simple and inexpensive. Self-assessment of the participants showed a strong increase in comprehension and an eagerness to use the model for surgical training.

CONCLUSIONS

A porcine snout disc ex vivo model of unilateral cleft lips was developed successfully. It shows many advantages, including a haptic close to human tissue, multiple layers, low cost, and wide and rapid availability. It is therefore very suitable for teaching and training beginners in cleft surgery and subsequently improving surgical skills and knowledge. Further research is needed to finally assess the ex vivo model's value in different stages of the curriculum of surgical residency.

Short learning curve in transition from laparoscopic to robotic-assisted rectal cancer surgery: a prospective study from a Finnish Tertiary Referral Centre

The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien-Dindo III-IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.

Evaluation of augmented reality technology in global urologic surgery

BACKGROUND

The COVID-19 pandemic drastically reduced opportunities for surgical skill sharing between high-income and low to middle-income countries. Augmented reality (AR) technology allows mentors in one country to virtually train a mentee in another country during surgical cases without international travel. We hypothesize that AR technology is an effective live surgical training and mentorship modality.

METHODS

Three senior urologic surgeons in the US and UK worked with four urologic surgeon trainees across the continent of Africa using AR systems. Trainers and trainees individually completed post-operative questionnaires evaluating their experience.

RESULTS

Trainees rated the quality of virtual training as equivalent to in-person training in 83% of cases (N = 5 of 6 responses). Trainers reported the technology's visual quality as "acceptable" in 67% of cases (N = 12 of 18 responses). The audiovisual capabilities of the technology had a "high" impact in the majority of the cases.

CONCLUSION

AR technology can effectively facilitate surgical training when in-person training is limited or unavailable.

Anterior cruciate ligament reconstruction learning curve study - Comparison of the first 50 consecutive patients of five orthopaedic surgeons during a 5-year follow-up

BACKGROUND

The goal of all surgical and orthopaedic training is to ensure necessary education and surgical skills without compromising the quality of operations or patient safety. Anterior cruciate ligament reconstruction (ACLR) is a common multi-staged orthopaedic surgical procedure with a learning curve. Previous studies focus mainly on learning or the learning curve of one surgeon and tunnel placements. The aims of this study were to define the learning curve in arthroscopic ACLRs, define the number of procedures needed before the surgical "knifetime" plateaus, examine the effect of experience on complications, and identify possible individual differences in the surgical learning curve.

METHODS

The study included the first 50 consecutive ACLR operations of five orthopaedic surgeons, thus, a total of 250 patients. For comparison and statistical analysis, patients were arranged into five groups, each comprising 50 patients (=order group). Order group 1 comprised the first 10 patients operated on by each of the five surgeons, group 2 patients 11-20, group 3 patients 21-30, group 4 patients 31-40, and group 5 the last 10 patients. The learning curve was defined with a LOESS curve. Surgical time and complications, including graft failure and postoperative knee instability, were analysed between order groups and between surgeons.

RESULTS

Median surgical time was 105 (interquartile range 82-124) min. The learning curve showed the first steep decline in surgical time and started to settle slowly after 20 reconstructions. Surgical time was significantly longer when order group 1 was compared with order group 2 (p = 0.031), and when order group 1 was compared separately with order groups 3, 4, and 5 (p < 0.001). Operation order alone explained only 17.1% of the alteration in surgical time. No significant difference emerged in graft failure rate between the order groups or the surgeons. Objective instability of the knee showed a significant difference when order group 1 was compared separately with order group 3 and with order group 4 (p = 0.004). Surgical time differed between surgeons (p < 0.001), and the shape of the learning curve showed great individual variability.

CONCLUSION

In the first 10 to 20 ACLR operations, the surgical time was longer and the complication rate higher, but thereafter both started to settle down. We recommend that first 10-20 ACLR operations should be supervised.

Online case-based educational meetings can increase knowledge, skills, and widen access to surgical training:The nationwideVirtualTrauma & Orthopaedic Meetingseries

BACKGROUND

Access to surgical training is challenging for undergraduate and early postgraduate trainees due to a greater focus on developing generic knowledge and skills, and a drive to recruit greater numbers into internal medicine and primary care. COVID-19 accelerated the declining access to surgical training environments. Our aims were to: 1) establish the feasibility of an online, specialty-specific, case-based surgical training series, and 2) evaluate its suitability for meeting the needs of trainees.

METHODS

A nationwide audience of undergraduate and early postgraduate trainees were invited to a series of bespoke online case-based educational meetings in Trauma & Orthopaedics (T&O) over a six month period. The six sessions, which simulated real-world clinical meetings, were constructed by Consultant sub-specialists and involved the presentation of cases by registrars, followed by structured discussion of basic principles, radiological interpretation, and management strategies. Mixed qualitative and quantitative analyses were conducted.

RESULTS

There were 131 participants (59.5% male), consisting mostly of doctors in training (58%) and medical students (37.4%). The mean quality rating was 9.0/10 (SD 1.06), further supported by qualitative analysis. 98% enjoyed the sessions, 97% reported improved knowledge of T&O, and 94% reported a direct benefit to clinical practice. There was a significant improvement in knowledge of T&O conditions, management plans, and radiological interpretation (p = <0.05).

CONCLUSION

Structured virtual meetings, underpinned by bespoke clinical cases, may widen access to T&O training, increase flexibility and robustness of learning opportunities, and mitigate the effects of reduced exposure on preparation for surgical careers and recruitment.

Current practises and the future of robotic surgical training

INTRODUCTION

This study reviews the current state of robotic surgery training for surgeons, including the various curricula, training methods, and tools available, as well as the challenges and limitations of these.

METHODS

The authors carried out a literature search across PubMed, MEDLINE, and Google Scholar using keywords related to 'robotic surgery', 'computer-assisted surgery', 'simulation', 'virtual reality', 'surgical training', and 'surgical education'. Full text analysis was performed on 112 articles.

TRAINING PROGRAMMES

The training program for robotic surgery should focus on proficiency, deliberation, and distribution principles. The curricula can be broadly split up into pre-console and console-side training. Pre-Console and Console-Side Training: Simulation training is an important aspect of robotic surgery training to improve technical skill acquisition and reduce mental workload, which helps prepare trainees for live procedures.

OPERATIVE PERFORMANCE ASSESSMENT

The study also discusses the various validated assessment tools used for operative performance assessments.

FUTURE ADVANCES

Finally, the authors propose potential future directions for robotic surgery training, including the use of emerging technologies such as AI and machine learning for real-time feedback, remote mentoring, and augmented reality platforms like Proximie to reduce costs and overcome geographic limitations.

CONCLUSION

Standardisation in trainee performance assessment is needed. Each of the robotic curricula and platforms has strengths and weaknesses. The ERUS Robotic Curriculum represents an evidence-based example of how to implement training from novice to expert. Remote mentoring and augmented reality platforms can overcome the challenges of high equipment costs and limited access to experts. Emerging technologies offer promising advancements for real-time feedback and immersive training environments, improving patient outcomes.

Career goals of surgeons in Switzerland

PURPOSE

Recent studies from the United States and Germany have shown a general decline in the number of surgical residents, as trainees increasingly prioritize a positive work-life balance. The current study sought to evaluate the career goals of surgeons in Switzerland.

METHODS

Members of the Swiss College of Surgeons, being surgical consultant or attending regardless of specialty, were surveyed online as to their purported career goals, future employment ideals, aspired leadership positions, and managerial training.

RESULTS

A total of 269 questionnaires were analysed. Most participants (93%) were board- certified and 30% of participants were female. With regard to desired specialty, 50% of participants intended to pursue a career in visceral surgery followed by general surgery, traumatology, hand and plastic surgery, vascular surgery and thoracic surgery. Regardless of specialty, 53% of respondents strived for the position of senior physician, while 28% indicated a desire to become chief physician. In terms of work environment, most participants preferred to seek employment at a cantonal hospital, followed by a rural hospital, a university hospital, private practice or a non-clinical setting. About half of respondents favoured the option of part time employment of 80% or less and about a quartile intended to retire before 62 years of age.

CONCLUSION

The current study found that surgeons in Switzerland remain highly motivated to pursue leadership positions in their respective fields. Going forward, the challenge will lie in reconciling the needs of the respective departments with the personal ambition, career opportunities, and desired work-life balance of young trainees.

How many cases do instructor class pediatric surgeons need to experience to be an independent operator in performing advanced endoscopic surgery? A nationwide survey to establish an ideal curriculum for pediatric endoscopic surgery in Japan

PURPOSE

To ensure the safe spread of pediatric endoscopic surgery, it is essential to build a training curriculum, and a survey of the current situation in Japan is necessary. The present study assessed an efficient training curriculum by clarifying instructor class pediatric surgeons' experiences, including autonomy when performing advanced endoscopic surgeries.

METHODS

An online nationwide questionnaire survey was conducted among pediatric surgeons who had Endoscopic Surgical Skill Qualification (ESSQ) and board-certified instructors who had skills comparable to ESSQ. We assessed participants' training experience, opinions concerning the ideal training curriculum, and the correlation between surgical experience and the level of autonomy. The Zwisch scale was used to assess autonomy.

RESULTS

Fifty-two participants responded to the survey (response rate: 86.7%). Only 57.7% of the respondents felt that they had received sufficient endoscopic surgery training. Most respondents considered an educational curriculum for endoscopic surgery including off-the-job training essential during the training period. Autonomy had been acquired after experiencing two to three cases for most advanced endoscopic surgeries.

CONCLUSION

This first nationwide survey in Japan showed that instructor class pediatric surgeons acquired autonomy after experiencing two to three for most advanced endoscopic surgeries. Our findings suggest that training, especially off-the-job training, has been insufficient.

Otolaryngology resident familiarity with surgical instruments and preoperative setup: A pilot study

OBJECTIVE

This study was designed to determine otolaryngology (ORL) residents' ability to prepare the operating room independently for ORL surgical cases and their familiarity with ORL surgical instruments and related equipment.

METHODS

A 24-question, one-time, anonymous survey was distributed to otolaryngology-head and neck surgery program directors for distribution among their residents in the United States in November 2022. Residents in every post-graduate year were surveyed. Spearman's ranked correlation and Mann-Whitney U test were used.

RESULTS

The response rate among program directors was 9.5 % (11/116 programs), while the response rate among residents was 51.5 % (88/171 residents). A total of 88 survey responses were completed. 61 % of ORL residents who responded were able to name most instruments used in surgical cases. The most recognized surgical instruments by ORL residents were microdebrider (99 %) and alligator forceps (98 %); the least recognized were bellucci micro scissors (72 %) and pituitary forceps (52 %); and all instruments except the microdebrider showed significantly increased recognition with increasing post graduate training year (PGY), p ≤ 0.05. ORL residents were most able to set up independently the electrocautery (77 %) and laryngoscope suspension (73 %), while they were least able to set up the robot laser (6.8 %) and coblator (26 %) independently. All instruments showed significant positive correlations with increasing PGY; the strongest correlation was found in laryngoscope suspension, r = 0.74. 48 % of ORL residents reported that there were times when surgical techs and nurses were not available. Only 54 % of ORL residents reported being able to set up instruments when alone in the operating room, including 77.8 % of PGY-5 residents. Only 8 % of residents reported receiving education related to surgical instruments from their residency program, while 85 % thought that ORL residencies should have courses or educational materials about surgical instruments.

CONCLUSION

ORL residents' familiarity with surgical instruments and preoperative setup improved throughout their training. However, specific instruments had much lower recognition than others and a lower ability for independent setup. Nearly half of ORL residents reported being unable to set up surgical instruments in the absence of surgical staff. Implementation of surgical instrument education may improve these deficiencies.

Effects of standardized language on remote ultrasound-guided percutaneous nephrolithotomy training: A mixed-methods explorative pilot study

Background

Remote teaching of procedural skills has demonstrated equivalence in knowledge acquisition compared to in-person teaching. Variations in terminology for probe and needle movements may serve as a barrier in remote training of ultrasound (US)-guided renal access for percutaneous nephrolithotomy (PCNL). This pilot study investigated the utility of standardized terminology in remote training of US-guided renal access for PCNL.

Hypothesis

Standardization of verbal terminology to describe US probe and needle movement instruction improves remote teaching of US-guided renal access.

Methods

Fifteen urology residents (PGY1-6) were stratified by year and randomized into two groups. We provided participants with images illustrating US probe and needle movements labeled with predetermined standardized terminology for the intervention group and images without labels for the control group. Both groups were asked to perform US-guided renal access on a training mannequin with a remote faculty educator with (intervention) or without (control) use of standardized movement instructions. Quantitative outcomes included number of attempts and time to achieve access. All trainees completed pre- and post-session surveys and participated in focus groups; authors conducted thematic analysis of focus group transcripts.

Results

Differences in primary outcomes between groups, including number of attempts and time to achieve access of the renal pole, were not statistically significant. Analysis of focus group interviews revealed that the use of standardized terminology in the setting of remote training can reduce trainee confusion by clarifying ambiguity in educator feedback.

Discussion

Use of standardized terminology during remote surgical skills training allows for more effective feedback to trainees.

A national survey of surgical training in gynaecology: 2014-2021

OBJECTIVES

Over the last decade barriers to surgical training have been identified, including reducing access to theatre lists, reducing numbers of major surgical procedures being performed, increasing numbers of trainees and reduction in working hours since the introduction of the European Work Time Directive (EWTD). We aimed to assess the impact of these challenges on training in gynaecology over time.

STUDY DESIGN

We designed a study which aimed to assess both trainers and trainees perception of gynaecological surgical training in Ireland. The purpose of this was to identify confidence levels and challenges and to highlight potential areas for future improvement of surgical training in gynaecology. A a cross-sectional survey was distributed to all trainees and trainers registered with the Royal College of Physicians of Ireland Obstetrics and Gynaecology higher specialist training programme in 2014, 2017 and again in 2021.

RESULTS

During the study period trainees' confidence that the training programme prepared them to perform gynaecological surgery fell significantly. This fall in confidence was most evident for trainees' ability to perform abdominal hysterectomy (40.9% vs 15.2%, χ2 = 4.61, p =.03) and vaginal hysterectomy (31.8% vs 12.1%, χ2 = 4.58, p =.03) when comparing 2014 with 2021. All trainees reporteded that gynaecology was not given adequate time in the training programme to prepare them to practice independently as consultants. Themes identified by participants to improve training included dedicated access to theatre time with a named trainer, increased simulation training and subspecialisation at later stages of training.

CONCLUSION

Our findings show an overall decrease in trainees' and trainers' confidence in the surgical training available in gynaecology over an eight-year period.. This is particularly true for major gynaecology procedures. Efforts must be made to ensure trainees have improved access to surgical training in gynaecology. Potential solutions include improving access to simulation and incorporation of subspecialist training into later stages of training.

Gaze behavior is related to objective technical skills assessment during virtual reality simulator-based surgical training: a proof of concept

PURPOSE

Simulation-based training allows surgical skills to be learned safely. Most virtual reality-based surgical simulators address technical skills without considering non-technical skills, such as gaze use. In this study, we investigated surgeons' visual behavior during virtual reality-based surgical training where visual guidance is provided. Our hypothesis was that the gaze distribution in the environment is correlated with the simulator's technical skills assessment.

METHODS

We recorded 25 surgical training sessions on an arthroscopic simulator. Trainees were equipped with a head-mounted eye-tracking device. A U-net was trained on two sessions to segment three simulator-specific areas of interest (AoI) and the background, to quantify gaze distribution. We tested whether the percentage of gazes in those areas was correlated with the simulator's scores.

RESULTS

The neural network was able to segment all AoI with a mean Intersection over Union superior to 94% for each area. The gaze percentage in the AoI differed among trainees. Despite several sources of data loss, we found significant correlations between gaze position and the simulator scores. For instance, trainees obtained better procedural scores when their gaze focused on the virtual assistance (Spearman correlation test, N = 7, r = 0.800, p = 0.031).

CONCLUSION

Our findings suggest that visual behavior should be quantified for assessing surgical expertise in simulation-based training environments, especially when visual guidance is provided. Ultimately visual behavior could be used to quantitatively assess surgeons' learning curve and expertise while training on VR simulators, in a way that complements existing metrics.

Observational Learning in Surgical Skill Development

Observation plays a key role in the development of surgical skills, as it allows trainees to learn from experts and improve their performance through trial-and-error practice. This process, known as motor learning, involves the creation of new neural pathways that enable precise control of surgical instruments through hand movements. In recent years, there has been a shift towards minimally invasive surgery, which requires surgeons to continually learn new motor skills to control specialized instrumentation. Motor learning can be enhanced through repetition and the observation of expert performances. Observational learning is particularly useful when it is used in combination with physical practice, as it can provide hints and clues about important aspects of the task that may not be immediately apparent through verbal instruction alone. The role of mirror neurons, which are activated both when an action is performed and when it is observed, is also important in the process of observational learning. By understanding the mechanisms behind observational learning and the factors that influence its effectiveness, trainers can optimize the use of this method in surgical training.

Review of the validity of DOPS as an assessment tool for the procedural skills of surgical trainees

INTRODUCTION

Surgical trainees at all stages are mandated to use workplace-based assessments (WBAs) to gain feedback from their trainers. Direct observation of procedural skills (DOPS) is a tool to assess hands-on surgical skills. This review of the literature seeks to ascertain how valid DOPS are as an assessment tool for the procedural skills of surgical trainees according to the American Psychology Association (APA) validity framework.

METHODS

Relevant literature was identified through a structured search of Medline, CINAHL and Web of Science databases, with further papers included on citation review. Following this, papers meeting the inclusion and exclusion criteria were included in the final review specifying those investigating WBAs including DOPS, assessments in practice rather than simulation and specifically for postgraduate surgical trainees.

FINDINGS

Sixteen papers were included in the final analysis. Extracted data from the returned papers were assessed for evidence of validity in each of the five domains on the APA framework: validity based on consequence, response process, reliability, content and relationship to other variables. There are studies that show good parameters for reliability and validity for specific DOPS used in endoscopy and otolaryngology. However, there is confusion over the purpose of DOPS among trainers and trainees as to whether they should be used formatively or summatively. Recent changes to the surgical curriculum have sought to address this, and further work into the impact of this needs to be done.

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice.

Integrating simulation into surgical training: a qualitative case study of a national programme

BACKGROUND

Applying simulation-based education (SBE) into surgical curricula is challenging and exacerbated by the absence of guidance on implementation processes. Empirical studies evaluating implementation of SBE interventions focus primarily on outcomes. However, understanding the processes involved in organising, planning, and delivering SBE adds knowledge on how best to develop, implement, and sustain surgical SBE. This study used a reform of early years surgical training to explore the implementation of a new SBE programme in Scotland. It aimed to understand the processes that are involved in the relative success (or failure) when implementing surgical SBE interventions.

METHODS

This qualitative case study, underpinned by social constructionism, used publicly available documents and the relevant surgical SBE literature to inform the research focus and contextualise data obtained from semi-structured interviews with core surgical trainees (n = 46), consultant surgeons (n = 25), and key leaders with roles in surgical training governance in Scotland (n = 7). Initial data coding and analysis were inductive. Secondary data analysis was then undertaken using Normalisation Process Theory (NPT). NPTs' four constructs (coherence, cognitive participation, collective action, reflexive monitoring) provided an explanatory framework for scrutinising how interventions are implemented, embedded, and integrated into practice, i.e. the "normalisation" process.

RESULTS

Distributed leadership (individual SBE initiatives assigned to faculty but overall programme overseen by a single leader) and the quality improvement practise of iterative refinement were identified as key novel processes promoting successful normalisation of the new SBE programme. Other processes widely described in the literature were also identified: stakeholder collaboration, personal contacts/relational processes, effective communication, faculty development, effective leadership, and tight programme management. The study also identified that learners valued SBE activities in group- or team-based social environments over isolated deliberate practice.

CONCLUSIONS

SBE is most effective when designed as a comprehensive programme aligned to the curriculum. Programmes incorporating both group-based and isolated SBE activities promote deliberate practice. Distributed leadership amongst faculty attracts wide engagement integral to SBE programme implementation, while iterative programme refinement through regular evaluation and action on feedback encourages integration into practice. The knowledge contributed by critically analysing SBE programme implementation processes can support development of much needed guidance in this area.

Three-Dimensional Printing Applications in Thoracic Surgery

Advances in technology allowing the combination of medical imaging and three-dimensional printing have greatly benefitted thoracic surgery, allowing for the creation of complex prostheses. Surgical education is also a significant application of three-dimensional printing, especially for the development of simulation-based training models. Aiming to show how three-dimensional printing can benefit patients and clinicians in thoracic surgery, an optimized method to create patient-specific chest wall prosthesis using three-dimensional printing was developed and clinically validated. An artificial chest simulator for surgical training was also developed, replicating the human anatomy with high realism and accurately simulating a minimally invasive lobectomy.

Vascular Surgery In-Training Examination performance following implementation of the Vascular Surgical Council on Resident Education curriculum

OBJECTIVE

The Vascular Surgery Surgical Council on Resident Education (VSCORE) program is a standardized curriculum intended to prepare Vascular Surgery trainees for the annual Vascular Surgery In-Training Examination (VSITE). This study evaluated the performance of 0+5 and 5+2 Vascular Surgery trainees on the VSITE prior to and following implementation of the VSCORE curriculum.

METHODS

VSITE scores, measured as percentage of questions correct, were collected for Vascular Surgery trainees at a United States academic medical center between 2015 and 2022. The VSITE scores were compared for the periods prior to (2015-2021) and following (2022) implementation of the VSCORE curriculum.

RESULTS

Fifty-seven VSITE scores were evaluated, including 46 examinations completed prior to and 11 after the implementation of the VSCORE curriculum. The mean VSITE score across all training levels (post-graduate year [PGY] 1-7) increased significantly from 68.4% ± 1.5% prior to implementation of VSCORE curriculum to 76.5% ± 3.1% following implementation (P = .03). Two-way analysis of variance identified pre- and post-VSCORE implementation as a statistically significant categorical variable when residents were stratified into junior (PGY 1-2), senior (PGY 3-5), and fellow (PGY 6-7) training levels (P < .001). The mean change in score between consecutive years also increased following VSCORE implementation (14.1% ± 2.3%) compared with the pre-VSCORE era (5.7% ± 1.7%; P = .002) CONCLUSIONS: The implementation of the VSCORE curriculum at an academic medical center improved VSITE scores across vascular surgery trainees at all levels.

The Impact of Surgical Expertise on the Cost-Effectiveness of Stapes Surgery

INTRODUCTION

Otosclerosis is the primary cause of conductive hearing loss with normal otoscopy. As the condition worsens, certain patients may develop a sensorineural component. Patients with successful surgeries may still need hearing aids, which creates a dilemma for health professionals as there are insufficient data to make informed decisions. This study investigated the influence of the surgeon's proficiency level, individual patient factors (e.g., age at the time of intervention and survival rates), and surgery costs on the cost-effectiveness of stapes surgery.

METHODS

We performed a cost-effectiveness analysis using an adapted Markov model incorporating annual all-cause mortalities. In addition, we introduced sensitivity analyses to address the effects of surgical expertise on adults with bilateral conductive hearing loss due to otosclerosis. A model was developed based on a decision tree with treatment options and complication scenarios for otosclerosis patients undergoing stapes surgery or receiving hearing aids. Annual all-cause mortality was considered. A sensitivity analysis was performed assigned to different training levels ("experts" and "less experienced") to simulate the effects of surgical experience on the cost-effectiveness of surgical outcomes. Successful surgery was defined as closing of the air-bone gap to 10 dB or less. Based on published data, "experts" were simulated with a 93.7% success rate, and "less experienced" were manufactured with a 68.9% success rate.

RESULTS

Stapes surgery provides improved quality of life (QoL) compared to hearing aids with lower cumulative costs up to 87 years of age in the case of "expert" surgeons and up to 78 years of age, when performed by "less experienced" surgeons.

CONCLUSIONS

Primary stapes surgery is highly cost-effective and delivers improved QoL compared to hearing aids with lower cumulative costs. Additionally, undergoing stapes surgical training remains highly cost-effective.

What Is the Effect of Resident Involvement on Short-Term Outcomes after Distal Radius Fracture Surgery?

Background: The objective of this study was to assess whether resident involvement in distal radius fracture open reduction internal fixation (ORIF) affect 30-day postoperative complication, hospital readmission, reoperation and operative time. Methods: A retrospective study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database by querying the Current Procedural Terminology (CPT) codes for distal radius fracture ORIF from 1 January 2011 to 31 December 2014. A final cohort of 5,693 adult patients who underwent distal radius fracture ORIF during the study period were included. Baseline patient demographics and comorbidities, intraoperative factors, including operative time and 30-day postoperative outcomes, including complications, readmission and reoperations, were collected. Bivariate statistical analyses were performed to identify variable associated with complication, readmission, reoperation and operative time. The significance level was adjusted using a Bonferroni correction as multiple comparisons were performed. Results: In this study of 5,693 patients who underwent distal radius fracture ORIF, 66 patients had a complication, 85 patients were readmitted and 61 patients underwent reoperation within 30 days of surgery. Resident involvement in the surgery was not associated with 30-day postoperative complication, readmission or reoperation, but was associated with longer operative time. Moreover, 30-day postoperative complication was associated with older age, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension and bleeding disorder. Thirty-day readmission was associated with older age, ASA classification, diabetes mellitus, COPD, hypertension, bleeding disorder and functional status. Thirty-day reoperation was associated with higher body mass index (BMI). Longer operative time was associated with younger age, male sex and the absence of bleeding disorder. Conclusions: Resident involvement in distal radius fracture ORIF is associated with longer operative time, but no difference in rates of episode-of-care adverse events. Patients may be reassured that resident involvement in distal radius fracture ORIF does not negatively impact short-term outcomes. Level of Evidence: Level IV (Therapeutic).

Multifunctional high-simulation 3D-printed hydrogel model manufacturing engineering for surgical training

Advanced bionic organ models with vivid biological structures and wetness and softness are essential for medical-surgical training. Still, there are many challenges in the preparation process, such as matching mechanical properties, good feedback on surgical instruments, reproducibility of specific surgical scenarios, and distinguishability between structural levels. In this paper, we achieved tissuemimicking dual-network (DN) hydrogels with customizable stiffness by adjusting the composition of the hydrogel matrix and the immersion time of the ionic solution to match different biological soft tissues precisely. Combined with advanced threedimensional (3D) printing fabrication techniques, various performance-tunable bionic hydrogel organ models with structural complexity and fidelity, including kidney, liver, pancreas, and vascular tissues, were perfectly fabricated. The simulation and applicability of the model were also simulated for the forced change of the suture needle in the puncture and suture of a single tissue and between different tissues, the cutting of substantive organs by ultrasonic scalpel, the coagulation and hemostasis of blood vessels, the visualization of the internal structure under ultrasound, and the microwave ablation of liver tumors. By constructing advanced biomimetic organ models based on hydrogel with specific and tunable properties, the development of surgical training, medical device testing, and medical education reform will be significantly promoted.

Using hand pose estimation to automate open surgery training feedback

PURPOSE

This research aims to facilitate the use of state-of-the-art computer vision algorithms for the automated training of surgeons and the analysis of surgical footage. By estimating 2D hand poses, we model the movement of the practitioner's hands, and their interaction with surgical instruments, to study their potential benefit for surgical training.

METHODS

We leverage pre-trained models on a publicly available hands dataset to create our own in-house dataset of 100 open surgery simulation videos with 2D hand poses. We also assess the ability of pose estimations to segment surgical videos into gestures and tool-usage segments and compare them to kinematic sensors and I3D features. Furthermore, we introduce 6 novel surgical dexterity proxies stemming from domain experts' training advice, all of which our framework can automatically detect given raw video footage.

RESULTS

State-of-the-art gesture segmentation accuracy of 88.35% on the open surgery simulation dataset is achieved with the fusion of 2D poses and I3D features from multiple angles. The introduced surgical skill proxies presented significant differences for novices compared to experts and produced actionable feedback for improvement.

CONCLUSION

This research demonstrates the benefit of pose estimations for open surgery by analyzing their effectiveness in gesture segmentation and skill assessment. Gesture segmentation using pose estimations achieved comparable results to physical sensors while being remote and markerless. Surgical dexterity proxies that rely on pose estimation proved they can be used to work toward automated training feedback. We hope our findings encourage additional collaboration on novel skill proxies to make surgical training more efficient.

Factors which Influence Postgraduate Career Choice among Final-Year Medical Students

BACKGROUND

Non-communicable disease incidence is rising amidst an increasing burden of poor access to surgical resources in "low-and middle-income countries. This calls for an increasing number of surgeons. However, intake into surgical residency training" programmes is reducing due to the decreasing number of applications. This paper looks at the factors which determine postgraduate career choices in order to guide training programme designs and arouse more interest in surgically related "specialties."

MATERIALS AND METHODS

An online questionnaire was sent to the final year medical students' class online social media platform yearly from 2016 to 2020 prospectively. Completed questionnaire forms were returned online. The data were analyzed using SPSS version 21. Age, sex, rating of the surgical clerkship programme, and factors influencing postgraduate uptake were analyzed. All students below the final year were excluded.

RESULTS

A total of 118 completed forms were received. The ages were 21 - 36 years (Mean 24.96±2.74). Males were 70 (59.3%) and females were 48 (40.7%). Overall, all the respondents (100.0%) scored the clerkship programme above average. Only 35 (29.7%) respondents were interested in undertaking a postgraduate course related to general surgery and its subspecialties. The factors which influenced the respondents' career choices were personal satisfaction, affluence, prestige, better patient outcomes, the diligence of lecturers, the need to have more time for one's self, less stress, and the best clerkship experience.

CONCLUSION

The major factors found to influence career choices include personal satisfaction, affluence, prestige, better patient outcomes, the diligence of lecturers, the need to have more time to one's self, less stress, and the best clerkship experience. Age and year of graduation do not significantly influence postgraduate career choice.

Eye gaze metrics for skill assessment and feedback in kidney stone surgery

PURPOSE

Surgical skill assessment is essential for safe operations. In endoscopic kidney stone surgery, surgeons must perform a highly skill-dependent mental mapping from the pre-operative scan to the intraoperative endoscope image. Poor mental mapping can lead to incomplete exploration of the kidney and high reoperation rates. Yet there are few objective ways to evaluate competency. We propose to use unobtrusive eye-gaze measurements in the task space to evaluate skill and provide feedback.

METHODS

We capture the surgeons' eye gaze on the surgical monitor with the Microsoft Hololens 2. To enable stable and accurate gaze detection, we develop a calibration algorithm to refine the eye tracking of the Hololens. In addition, we use a QR code to locate the eye gaze on the surgical monitor. We then run a user study with three expert and three novice surgeons. Each surgeon is tasked to locate three needles representing kidney stones in three different kidney phantoms.

RESULTS

We find that experts have more focused gaze patterns. They complete the task faster, have smaller total gaze area, and the gaze fewer times outside the area of interest. While fixation to non-fixation ratio did not show significant difference in our findings, tracking the ratio over time shows different patterns between novices and experts.

CONCLUSION

We show that a non-negligible difference holds between novice and expert surgeons' gaze metrics in kidney stone identification in phantoms. Expert surgeons demonstrate more targeted gaze throughout a trial, indicating their higher level of proficiency. To improve the skill acquisition process for novice surgeons, we suggest providing sub-task specific feedback. This approach presents an objective and non-invasive method to assess surgical competence.

Toward the validation of VR-HMDs for medical education: a systematic literature review

The latest technological advancements in the domain of virtual reality (VR) have created new opportunities to use VR as a training platform for medical students and practitioners more broadly. Despite the growing interest in the use of VR as a training tool, a commonly identified gap in VR-training for medical education is the confidence in the long-term validity of the applications. A systematic literature review was undertaken to explore the extent of VR (in particular head-mounted displays) applications for medical training with an additional focus on validation measures. The papers included in this review discussed empirical case studies of specific applications; however, these were mostly concerned with human-computer interaction and were polarized between demonstrating that a conceptual technology solution was feasible for simulation or looked at specific areas of VR usability with little discussion on validation measures for long-term training effectiveness and outcomes. The review uncovered a wide range of ad hoc applications and studies in terms of technology vendors, environments, tasks, envisaged users and effectiveness of learning outcomes. This presents decision-making challenges for those seeking to adopt, implement and embed such systems in teaching practice. The authors of this paper then take a wider socio-technical systems perspective to understand how the holistic training system can be engineered and validated effectively as fit for purpose, through distillation of a generic set of requirements from the literature review to aid design specification and implementation, and to drive more informed and traceable validation of these types of systems. In this review, we have identified 92 requirement statements in 11 key areas against which a VR-HMD training system could be validated; these were grouped into design considerations, learning mechanisms and implementation considerations.

A proposal to standardize its implementation during surgical training

Laparoscopic inguinal hernia repairs are underused in our country and do not fulfil to the recommendations of the European Hernia Society (EHS) guidelines. Thus, it is essential to establish measures that increase its use. We propose that the Spanish Association of Surgeons (AEC) promote these actions and that they should be incorporated into the specialty program. The proposed measures include Standardization of learning; reinforce anatomical knowledge; regulated practices with simulators; promote the use of the open posterior approach; rotations through centers of excellence; accreditation of specialized units and use a registry of activity as quality control.

"It's making me think outside the box at times": a qualitative study of dynamic capabilities in surgical training

Craft specialties such as surgery endured widespread disruption to postgraduate education and training during the pandemic. Despite the expansive literature on rapid adaptations and innovations, generalisability of these descriptions is limited by scarce use of theory-driven methods. In this research, we explored UK surgical trainees' (n = 46) and consultant surgeons' (trainers, n = 25) perceptions of how learning in clinical environments changed during a time of extreme uncertainty (2020/2021). Our ultimate goal was to identify new ideas that could shape post-pandemic surgical training. We conducted semi-structured virtual interviews with participants from a range of working/training environments across thirteen Health Boards in Scotland. Initial analysis of interview transcripts was inductive. Dynamic capabilities theory (how effectively an organisation uses its resources to respond to environmental changes) and its micro-foundations (sensing, seizing, reconfiguring) were used for subsequent theory-driven analysis. Findings demonstrate that surgical training responded dynamically and adapted to external and internal environmental uncertainty. Sensing threats and opportunities in the clinical environment prompted trainers' institutions to seize new ways of working. Learners gained from reconfigured training opportunities (e.g., splitting operative cases between trainees), pan-surgical working (e.g., broader surgical exposure), redeployment (e.g., to medical specialties), collaborative working (working with new colleagues and in new ways) and supervision (shifting to online supervision). Our data foreground the human resource and structural reconfigurations, and technological innovations that effectively maintained surgical training during the pandemic, albeit in different ways. These adaptations and innovations could provide the foundations for enhancing surgical education and training in the post-pandemic era.

GlobalSurgBox: A Portable Surgical Simulator for Surgical Trainees Worldwide

OBJECTIVES

Identify barriers to surgical simulation in multiple countries across the income spectrum. Evaluate whether a novel, portable surgical simulator (GlobalSurgBox) would be valuable to surgical trainees and overcome these barriers.

DESIGN

Trainees from high-, middle-, and low-income countries were instructed on how to perform surgical skills using the GlobalSurgBox. Participants were sent an anonymized survey after 1 week to evaluate practicality and helpfulness of the trainer.

SETTING

Academic medical centers in 3 countries: USA, Kenya, and Rwanda.

PARTICIPANTS

48 medical students, 48 surgery residents, 3 medical officers, and 3 cardiothoracic surgery fellows.

RESULTS

99.0% of respondents agreed surgical simulation was an important aspect of surgical education. Despite 60.8% having access to simulation resources, only 3 of 40 (7.5%) US trainees, 2 of 12 (16.7%) of Kenyan trainees, and 1 of 10 (10.0%) Rwandan trainees used these resources routinely. 38 (95.0%) US trainees, 9 (75.0%) Kenyan trainees, and 8 (80.0%) Rwandan trainees with access to simulation resources stated there were barriers to using them. The frequently cited barriers included lack of convenient access and lack of time. After using the GlobalSurgBox, 5 (7.8%) US participants, 0 (0%) Kenyan participants, and 5 (38.5%) Rwandan participants reported lack of convenient access as a continued barrier to simulation. 52 (81.3%) US trainees, 24 (96.0%) Kenyan trainees, and 12 (92.3%) Rwandan trainees stated the GlobalSurgBox was a good facsimile of the operating room. 59 (92.2%) US trainees, 24 (96.0%) Kenyan trainees, and 13 (100%) Rwandan trainees stated the GlobalSurgBox better prepared them for clinical settings.

CONCLUSIONS

A majority of trainees across all 3 countries reported multiple barriers to simulation in their current surgical training. The GlobalSurgBox eliminates many of these barriers by providing a portable, affordable, and realistic way to practice skills needed in the operating room.

Telestration with augmented reality improves surgical performance through gaze guidance

BACKGROUND

In minimally invasive surgery (MIS), trainees need to learn how to interpret the operative field displayed on the laparoscopic screen. Experts currently guide trainees mainly verbally during laparoscopic procedures. A newly developed telestration system with augmented reality (iSurgeon) allows the instructor to display hand gestures in real-time on the laparoscopic screen in augmented reality to provide visual expert guidance (telestration). This study analysed the effect of telestration guided instructions on gaze behaviour during MIS training.

METHODS

In a randomized-controlled crossover study, 40 MIS naive medical students performed 8 laparoscopic tasks with telestration or with verbal instructions only. Pupil Core eye-tracking glasses were used to capture the instructor's and trainees' gazes. Gaze behaviour measures for tasks 1-7 were gaze latency, gaze convergence and collaborative gaze convergence. Performance measures included the number of errors in tasks 1-7 and trainee's ratings in structured and standardized performance scores in task 8 (ex vivo porcine laparoscopic cholecystectomy).

RESULTS

There was a significant improvement 1-7 on gaze latency [F(1,39) = 762.5, p < 0.01, ηp2 = 0.95], gaze convergence [F(1,39) = 482.8, p < 0.01, ηp2 = 0.93] and collaborative gaze convergence [F(1,39) = 408.4, p < 0.01, ηp2 = 0.91] upon instruction with iSurgeon. The number of errors was significantly lower in tasks 1-7 (0.18 ± 0.56 vs. 1.94 ± 1.80, p < 0.01) and the score ratings for laparoscopic cholecystectomy were significantly higher with telestration (global OSATS: 29 ± 2.5 vs. 25 ± 5.5, p < 0.01; task-specific OSATS: 60 ± 3 vs. 50 ± 6, p < 0.01).

CONCLUSIONS

Telestration with augmented reality successfully improved surgical performance. The trainee's gaze behaviour was improved by reducing the time from instruction to fixation on targets and leading to a higher convergence of the instructor's and the trainee's gazes. Also, the convergence of trainee's gaze and target areas increased with telestration. This confirms augmented reality-based telestration works by means of gaze guidance in MIS and could be used to improve training outcomes.

Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course

Background

The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce a vascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas.

Methods

The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail.

Results

In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. A fundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with a surgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries.

Conclusion

The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

A mechanically validated open-source silicone model for the training of gastric perforation sewing

BACKGROUND

Gastrointestinal perforation is commonly seen in emergency departments. The perforation of the stomach is an emergency situation that requires immediate surgical treatment. The necessary surgical skills require regular practical training. Owing to patient`s safety, in vivo training opportunities in medicine are restricted. Animal tissue especially porcine tissue, is commonly used for surgical training. Due to its limiting factors, artificial training models are often to be preferred. Many artificial models are on the market but to our knowledge, none that mimic the haptic- and sewing properties of a stomach wall at the same time. In this study, an open source silicone model of a gastric perforation for training of gastric sewing was developed that attempts to provide realistic haptic- and sewing behaviour.

METHODS

To simulate the layered structure of the human stomach, different silicone materials were used to produce three different model layups. The production process was kept as simple as possible to make it easily reproducible. A needle penetration setup as well as a systematic haptic evaluation were developed to compare these silicone models to a real porcine stomach in order to identify the most realistic model.

RESULTS

A silicone model consisting of three layers was identified as being the most promising and was tested by clinical surgeons.

CONCLUSIONS

The presented model simulates the sewing characteristics of a human stomach wall, is easily reproducible at low-costs and can be used for practicing gastric suturing techniques.

TRIAL REGISTRATIONS

Not applicable.

Learning laparoscopic hysterectomy: analysis of different surgeons' individual learning curves

OBJECTIVE

The aim of this study was to examine the development of surgical skills among surgeons learning total laparoscopic hysterectomy (TLH), using differences in complication rates between surgeons with different levels of experience and analyzing the development of individual operating times.

STUDY DESIGN

This retrospective, single-center cohort study included 576 total laparoscopic hysterectomy procedures conducted between January 2015 and December 2019 at the municipal hospital in Karlsruhe, Germany. All TLHs were performed by eight surgeons, two of whom were experienced and six inexperienced. Complications were graded using the Clavien-Dindo classification.

RESULTS

No differences in complication rates were seen between experienced and inexperienced surgeons. With growing numbers of procedures, most surgeons quickly became faster, leading to reduced operating times. However, experienced surgeons who had performed more than 100 procedures also became faster, not reaching a time plateau after adjustment for weight of the uterus, presurgery score, and adnexal score.

CONCLUSIONS

Learning laparoscopic hysterectomy in routine practice is safe for patients, and surgeons rapidly become faster as growing numbers of procedures are performed. Operating times for experienced surgeons who have carried out more than 100 operations also improve, and a time plateau is not reached.

Tracking and evaluating motion skills in laparoscopy with inertial sensors

BACKGROUND

Analysis of surgical instrument motion is applicable in surgical skill assessment and monitoring of the learning progress in laparoscopy. Current commercial instrument tracking technology (optical or electromagnetic) has specific limitations and is expensive. Therefore, in this study, we apply inexpensive, off-the-shelf inertial sensors to track laparoscopic instruments in a training scenario.

METHODS

We calibrated two laparoscopic instruments to the inertial sensor and investigated its accuracy on a 3D-printed phantom. In a user study during a one-week laparoscopy training course with medical students and physicians, we then documented and compared the training effect in laparoscopic tasks on a commercially available laparoscopy trainer (Laparo Analytic, Laparo Medical Simulators, Wilcza, Poland) and the newly developed tracking setup.

RESULTS

Eighteen participants (twelve medical students and six physicians) participated in the study. The student subgroup showed significantly poorer results for the count of swings (CS) and count of rotations (CR) at the beginning of the training compared to the physician subgroup (p = 0.012 and p = 0.042). After training, the student subgroup showed significant improvements in the rotatory angle sum, CS, and CR (p = 0.025, p = 0.004 and p = 0.024). After training, there were no significant differences between medical students and physicians. There was a strong correlation between the measured learning success (LS) from the data of our inertial measurement unit system (LS_IMU) and the Laparo Analytic (LS_Lap) (Pearson's r = 0.79).

CONCLUSION

In the current study, we observed a good and valid performance of inertial measurement units as a possible tool for instrument tracking and surgical skill assessment. Moreover, we conclude that the sensor can meaningfully examine the learning progress of medical students in an ex-vivo setting.

Examining impact forces during posterior spinal fusion to implement in a novel physics-driven virtual reality surgical simulator

This study aims to understand the impact forces that surgeons apply to the human spine during a posterior spinal fusion procedure towards the development of a novel spine surgical simulator for training medical residents. The foci of this study are impact forces during graft placement and spinal interbody cage insertion. This study examined the lumbar intervertebral discs of two male cadaveric specimens. Impact forces were collected during graft and spinal cage insertion over multiple levels. An impulse hammer and a camera were used to collect impact forces and displacements, respectively. The results demonstrated a logarithmic relationship between impact forces and cumulative displacement during graft placement. This was also observed between cumulative displacement and number of impacts during spinal cage insertion. A linear relationship was observed for the impact forces and number of impacts during graft placement. Results suggest that surgeons rely on the feedback experienced from impact forces during graft insertion to gauge the amount of graft that was placed in a specific area of the disc. Impact forces during cage insertion provide information about any encountered obstacles. When developing surgical simulators, designing the force feedback system should require modelling these behaviors to effectively impart corresponding skills on a trainee.

Comprehension of fundamental knowledge about pediatric endoscopic surgery: a cross-sectional study in Japan

BACKGROUND

Pediatric endoscopic surgery has become an alternative to conventional techniques with the development of medical equipment. However, there is no formal, standardized curriculum for pediatric endoscopic surgery, and its requirement remains elusive. The purpose of this study is to determine the baseline knowledge of pediatric surgeons that is considered essential for pediatric laparoscopic and thoracoscopic surgery.

METHODS

Sixteen web-based multiple-choice questions based on the fundamental cognitive knowledge of pediatric endoscopic surgery were administered. The questions were created based on the fields covered by the Fundamentals of Laparoscopic Surgery ™ (FLS) certification examination blueprints and eight specific diseases of pediatric surgery. Pediatric surgeons and pediatric surgical trainees participated in this study voluntarily.

RESULTS

A total of 122 surgeons participated through the Japanese Society of Pediatric Surgeons. The response rate was 95% (122/128). The total mean examination score of all participants was 79.4% (77.3-81.4%). There were no significant differences in total scores between the board-certified pediatric surgeons without an endoscopic surgical skill qualification and the non-board-certified pediatric surgeons (80.4% vs. 77.1%, p = 0.12). The endoscopic surgical skill-qualified surgeons had significantly higher percentages of correct responses in specific subjects than board-certified pediatric surgeons and surgeons without pediatric board certification (94.3% vs. 82.9%, p = 0.02; 94.3% vs. 77.5%, p = 0.0002). The FLS original subjects' scores were not significantly different among them. The mean score of surgeons who had experienced more than 200 cases of endoscopic surgery, including adult cases, was 83.2% (80.4-85.9%).

CONCLUSIONS

A knowledge gap exists between surgeons, board-certified pediatric surgeons, and endoscopic surgical skill-qualified surgeons in Japan. In the field of pediatric surgery, an effective formal curriculum, such as FLS, is required to help address this vast knowledge gap for the safe conduct of endoscopic surgeries.

Video-based learning of coping strategies for common errors improves laparoscopy training-a randomized study

AIMS

The aim of this study was to investigate whether shifting the focus to solution orientation and developing coping strategies for common errors could increase the efficiency of laparoscopic training and influence learning motivation. The concept of coping has been particularly defined by the psychologist Richard Lazarus [Lazarus and Folkman in Stress, appraisal, and coping, Springer publishing company, New York, 1984]. Based on this model, we examined the use of observational learning with a coping model for its effectiveness as a basic teaching model in laparoscopic training.

METHODS

55 laparoscopically naive medical students learned a standardized laparoscopic knot tying technique with video-based instructions. The control group was only offered a mastery video that showed the ideal technique and was free from mistakes. The intervention group was instructed on active error analysis and watched freely selectable videos of common errors including solution strategies (coping model) in addition to the mastery videos.

RESULTS

There was no statistically significant difference between the intervention and control groups for number of knot tying attempts until proficiency was reached (18.8 ± 5.5 vs. 21.3 ± 6.5, p = 0.142). However, there was a significantly higher fraction of knots achieving technical proficiency in the intervention group after first use of the coping model (0.7 ± 0.1 vs. 0.6 ± 0.2, p = 0.026). Additionally, the proportion of blinded attempts that met the criteria for technical proficiency was significantly higher for the intervention group at 60.9% vs. 38.0% in control group (p = 0.021). The motivational subscore "interest" of the validated score on current motivation (QCM) was significantly higher for the intervention group (p = 0.032), as well as subjective learning benefit (p = 0.002) and error awareness (p < 0.001).

CONCLUSION

Using video-based learning of coping strategies for common errors improves learning motivation and understanding of the technique with a significant difference in its qualitative implementation in laparoscopy training. The ability to think in a solution-oriented, independent way is necessary in surgery in order to recognize and adequately deal with technical difficulties and complications.

Advancing Urology Resident Surgical Autonomy

PURPOSE OF REVIEW

This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy.

RECENT FINDINGS

Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.

Towards best practice in developing motor skills: a systematic review on spacing in VR simulator-based psychomotor training for surgical novices

OBJECTIVE

Repeated practice, or spacing, can improve various types of skill acquisition. Similarly, virtual reality (VR) simulators have demonstrated their effectiveness in fostering surgical skill acquisition and provide a promising, realistic environment for spaced training. To explore how spacing impacts VR simulator-based acquisition of surgical psychomotor skills, we performed a systematic literature review.

METHODS

We systematically searched the databases PubMed, PsycINFO, Psychology and Behavioral Sciences Collection, ERIC and CINAHL for studies investigating the influence of spacing on the effectiveness of VR simulator training focused on psychomotor skill acquisition in healthcare professionals. We assessed the quality of all included studies using the Medical Education Research Study Quality Instrument (MERSQI) and the risk of bias using the Cochrane Collaboration's risk of bias assessment tool. We extracted and aggregated qualitative data regarding spacing interval, psychomotor task performance and several other performance metrics.

RESULTS

The searches yielded 1662 unique publications. After screening the titles and abstracts, 53 publications were retained for full text screening and 7 met the inclusion criteria. Spaced training resulted in better performance scores and faster skill acquisition when compared to control groups with a single day (massed) training session. Spacing across consecutive days seemed more effective than shorter or longer spacing intervals. However, the included studies were too heterogeneous in terms of spacing interval, obtained performance metrics and psychomotor skills analysed to allow for a meta-analysis to substantiate our outcomes.

CONCLUSION

Spacing in VR simulator-based surgical training improved skill acquisition when compared to massed training. The overall number and quality of available studies were only moderate, limiting the validity and generalizability of our findings.

Objective psychomotor laparoscopic skills evaluation using a low-cost wearable device based on accelerometry: construct and concurrent validity study

BACKGROUND

Motion analysis of surgical maneuvers provides useful quantitative information for the objective evaluation of the surgeons. However, surgical simulation laboratories for laparoscopic training do not usually integrate devices that help quantify the level of skills of the surgeons due to their limited resources and the high costs of new technologies. The purpose of this study is to present the construct and concurrent validity of a low-cost motion tracking system, based on a wireless triaxial accelerometer, employed to objectively evaluate psychomotor skills of surgeons during laparoscopic training.

METHODS

An accelerometry system, a wireless three-axis accelerometer with appearance of wristwatch, was placed on the dominant hand of the surgeons to register the motion during the laparoscopy practice with the EndoViS simulator, which simultaneously recorded the motion of the laparoscopic needle driver. This study included the participation of 30 surgeons (6 experts, 14 intermediates and 10 novices) who performed the task of intracorporeal knot-tying suture. Using 11 motion analysis parameters (MAPs), the performance of each participant was assessed. Subsequently, the scores of the three groups of surgeons were statistically analyzed. In addition, a validity study was conducted comparing the metrics between the accelerometry-tracking system and the EndoViS hybrid simulator.

RESULTS

Construct validity was achieved for 8 of the 11 metrics examined with the accelerometry system. Concurrent validity demonstrated that there is a strong correlation between the results of the accelerometry system and the EndoViS simulator in 9 of 11 parameters, showing reliability of the accelerometry system as an objective evaluation method.

CONCLUSION

The accelerometry system was successfully validated. This method is potentially useful to complement the objective evaluation of surgeons during laparoscopic practice in training environments such as box-trainers and simulators.

Surgical training with phantoms in strabismus surgery

BACKGROUND AND PURPOSE

Simulation in surgical learning responds to ethical and pragmatic needs. Our purpose is to describe the effects on surgical skills of conducting a surgical training workshop on strabismus surgery with phantoms. Concern for patient safety makes it necessary to consider the use of simulators (virtual and three-dimensional physical) and animal models that allow the applicant to safely practice the procedures before facing a real case.

MATERIAL AND METHODS

Realization of a workshop with previous theoretical content and real practice with phantoms designed to simulate strabismus surgery (eyeball, 6 muscles, conjunctiva, eyelid and tenon capsule inserted in the skull) of real anatomical dimensions. Satisfaction survey and subjective evaluation of learning by the student and the expert tutor according to the Kirkpatrick evaluation model.

RESULTS

Total, 100% of the 26 students attending two courses (15 students in one course and 11 students in another course) and 100% of the 3 tutors who participated in both courses completed the survey. 20 were resident doctors and 20 specialists in ophthalmology. The overall satisfaction of the students was 8.2 (±0.68).

CONCLUSIONS

According to the results of the Kirkpatrick training actions evaluation survey, the perception of students and tutors is that training with phantoms in strabismus surgery can help improve the skills necessary for safe and independent practice. The ultimate goal being to improve patient safety.

The Learning Curve for Radical Nephrectomy for Kidney Cancer: Implications for Surgical Training

Although radical nephrectomy (RN) is the most common treatment for kidney cancer, no data on the learning curve for RN are available. In this study we investigated the effect of surgical experience (EXP) on RN outcomes using data for 1184 patients treated with RN for a cT1-3a cN0 cM0 renal mass. EXP was defined as the total number of RNs performed by each surgeon before the patient's operation. The primary study outcomes were all-cause mortality, clinical progression, Clavien-Dindo grade ≥2 postoperative complications (CD ≥2), and the estimated glomerular filtration rate (eGFR). Secondary outcomes were operative time, estimated blood loss, and length of stay. Multivariable analyses adjusted for case mix revealed no evidence of association between EXP and all-cause mortality (p = 0.7), clinical progression (p = 0.2), CD ≥2 (p = 0.6), or 12-mo eGFR (p = 0.9). Conversely, EXP was associated with shorter operative time (estimate -0.9; p < 0.01). Mortality, cancer control, morbidity, and renal function might not be affected by EXP. The very large cohort examined and the extensive follow-up support the validity of these negative findings.

Patient summary

For patients with kidney cancer undergoing surgical removal of a kidney, those treated by novice surgeons have similar clinical outcomes to those treated by experienced surgeons. Thus, this procedure represents a convenient scenario for surgical training if longer operating theatre time can be planned.