Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program

What errors make a laparoscopic cancer surgery unsafe? An ad hoc analysis of competency assessment in the National Training Programme for laparoscopic colorectal surgery in England

BACKGROUND

The National Training Programme for laparoscopic colorectal surgery in England was implemented to ensure training was supervised, structured, safe and effective. Delegates were required to pass a competency assessment (sign-off) before undertaking independent practice. This study described the types of errors identified and associated these errors with competency to progress to independent laparoscopic colorectal practice.

METHODS

All sign-off submissions from the start of the process in January 2008 until July 2013 were included. Content analysis was used to categorise errors. Bayes factor (BF) was used to measure the impact of individual error on assessment outcome. A smaller BF indicates that an error has stronger associations with unsuccessful assessments. Bayesian network was employed to graphically represent the reasoning process whereby the chance of successful assessment diminished with the identification of each error. Quality of the error feedback was measured by the area under the ROC curve which linked the predictions from the Bayesian model to the expert verdict.

RESULTS

Among 370 assessments analysed, 240 passed and 130 failed. On average, 2.5 different types of error were identified in each assessment. Cases that were more likely to fail had three or more different types of error (χ(2) = 72, p < 0.0001) and demonstrated poorer technical skills (CAT score <2.7, χ(2) = 164, p < 0.0001). Case complexity or right- versus left-sided resection did not have a significant impact. Errors associated with dissection (BF = 0.18), anastomosis (BF = 0.23) and oncological quality (BF = 0.19) were critical determinants of surgical competence, each reducing the odds of pass by at least fourfold. The area under the ROC curve was 0.84.

CONCLUSIONS

Errors associated with dissection, anastomosis and oncological quality were critical determinants of surgical competency. The detailed error analysis reported in this study can guide the design of future surgical education and clinical training programmes.

Risk prediction score in laparoscopic colorectal surgery training: experience from the English National Training Program

OBJECTIVE

The overall aim was to develop and validate a risk prediction score for laparoscopic colorectal surgery training cases.

BACKGROUND

Published risk prediction scores are not transferable between hospitals because they are derived from a single institution's data and are not designed for use in training situations.

METHODS

Cases from the prospectively collected database of the National Training Programme in Laparoscopic Colorectal Surgery, between July 2008 and July 2012, were analyzed. Independent risk factors for conversion were identified by the logistic regression. Converting the odds ratios into integers created a risk prediction score for conversion. The clinical impact of this score was investigated by comparing postoperative complications and the level of trainer input in high- and low-risk cases. To study whether adverse outcomes in predicted high-risk cases occur outside the National Training Programme in Laparoscopic Colorectal Surgery, 2 external data sets were examined.

RESULTS

A total of 2341 cases carried out in 42 hospitals were analyzed. Significant risk factors for conversion were body mass index, American Society of Anesthesiology classification, male sex, prior abdominal surgery, and resection type. At a risk score of more than 6, complication rates increased, including mortality (2.9% vs 0.5%, P < 0.001), anastomotic leak (4.3% vs 1.4%, P = 0.002), and a higher level of trainer input (32.2% vs 19.9% of cases, P < 0.001). Analysis of 786 external cases showed that high-risk cases had higher conversion (18.8% vs 7.1%, P < 0.001), overall complication (36.4% vs 15.0%, P < 0.001), and leak rates (4.0% vs 1.3%, P = 0.015).

CONCLUSIONS

A risk predication score to facilitate case selection in laparoscopic colorectal surgery training was developed and validated.

Technical skills assessment toolbox: a review using the unitary framework of validity

OBJECTIVE

The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity.

BACKGROUND

Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency.

METHODS

A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills.

RESULTS

A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables.

CONCLUSIONS

This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.

Methods of quality assurance in multicenter trials in laparoscopic colorectal surgery: a systematic review

OBJECTIVES

To assess the risk of bias in multicenter randomized controlled trials (RCTs) investigating laparoscopic colorectal cancer surgery and review the use of quality assurance mechanisms to reduce performance bias.

BACKGROUND

RCTs represent the criterion standard comparison for health care interventions. For trials investigating interventional techniques, performance bias can arise through variation in delivery of the intervention.

METHODS

A comprehensive systematic review was undertaken using MEDLINE and EMBASE databases to identify all large RCTs investigating laparoscopic colorectal cancer surgery. Risk of performance bias was evaluated through assessment of publications and protocols to identify methods used for quality assurance of surgical technique. In addition, the Cochrane Collaboration's "risk of bias" tool was used to evaluate other potential sources of bias.

RESULTS

The literature search identified 48 publications, reporting upon 8 individual RCTs. All studies used mechanisms for quality assurance of laparoscopic colorectal surgery. Methods employed included credentialing of surgeons or units through assessment of experience and expertise, standardization of surgical technique, and monitoring. None report the use of structure objective assessment tools for accrediting expertise. All 8 were assessed as low risk of bias using the Cochrane tool. A framework is proposed for use as a model for quality assurance in future surgical trials.

CONCLUSIONS

Consideration of risk of performance bias is important when appraising trials investigating an interventional technique. Laparoscopic colorectal surgery RCTs have all employed quality assurance mechanisms to reduce risk of performance bias. Further research is indicated to investigate adopting objective assessment tools for quality assurance within multicenter RCTs.

Objective assessment of technique in laparoscopic colorectal surgery: what are the existing tools?

Assessment can improve the effectiveness of surgical training and enable valid judgments of competence. Laparoscopic colon resection surgery is now taught within surgical residency programs, and assessment tools are increasingly used to stimulate formative feedback and enhance learning. Formal assessment of technical performance in laparoscopic colon resection has been successfully applied at the specialist level in the English "LAPCO" National Training Program. Objective assessment tools need to be developed for training and assessment in laparoscopic rectal cancer resection surgery. Simulation may have a future role in assessment and accreditation in laparoscopic colorectal surgery; however, existing virtual reality models are not ready to be used for assessment of this advanced surgery.

Development and evaluation of a cadaveric training curriculum for low rectal cancer surgery in the English LOREC National Development Programme

AIM

The National Development Programme for Low Rectal Cancer in England (LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision.

METHOD

Three sites were commissioned for the cadaveric workshops, each delivering the same training curriculum. Training was undertaken in pairs using a fresh-frozen cadaveric model under the supervision of expert mentors. Global assessment score (GAS) forms were developed to promote reflective learning. Feedback on the impact of the workshop was obtained from a sample of delegates at the end of the course, and also after 3-23 months via an online questionnaire.

RESULTS

Overall 112 consultant colorectal surgeons attended one of 15 cadaveric technical skills training workshops. Seventy-six per cent of delegates reported easy identification of anatomy in the cadaveric model; 67% found tissue planes easy to interpret. Ninety-six per cent of delegates felt the workshop would influence their future practice; 96% reported increased awareness of important anatomy. Only 2% of delegates wished to pursue supplementary formal training from LOREC.

CONCLUSION

Fresh-frozen cadavers could provide an effective training model for low rectal surgery. A structured 1-day cadaveric workshop has facilitated the dissemination of technical skills for management of low rectal cancer. Attending the cadaveric workshop enhanced delegates' confidence in performing this procedure.

Effective teaching and feedback strategies in the or and beyond

Maintaining a standard of excellence for graduating surgical residents requires a comprehensive and consistent approach to surgical education. The omnipresent and increasing barriers to education must also be recognized and addressed. The implementation of effective teaching strategies is largely dependent on the resources available at each institution and the vision of education. Unfortunately, allocating time for surgeons to teach both inside and outside the operating room has become a foreign concept to administration. Furthermore, the reduction in case numbers performed by trainees now demands "quality over quantity" to ensure success. Quality teaching moments will only be realized when emphasis is placed on preparation, useful instruction during the procedure, and postoperative feedback. Ideal preparation entails a detailed discussion between the trainee and surgeon about the specific learning goals for the case. During the procedure, the faculty surgeon must strive to maximize the experience through effective communication while performing an efficient and safe operation. Numerous validated objective assessment tools exist for postprocedure evaluation but are grossly underutilized. Surgical education must thoughtfully be approached with the same fervor and detail as patient care. As faculty, it is our responsibility to train the next generation of surgeons and therefore "every case must count."

Simulation and its role in training

Despite its short history, surgical simulation has been successfully introduced into surgical residency programs in an effort to augment training. A wide range of simulator types and levels of complexity have proven an effective teaching method for surgical trainees. They have been used for training in areas such as general surgery, urology, gynecology, and ophthalmology among others. Coincident with the introduction of simulators is the need for objective evaluation of skills learned on them, which has led to the development and validation of multiple evaluation tools. This article evaluates the drivers for simulation, types of simulators, training, and evaluation of them especially as it pertains to laparoscopic colorectal surgery.

Training faculty in nontechnical skill assessment: national guidelines on program requirements

OBJECTIVE

To develop guidelines for a faculty training program in nontechnical skill assessment in surgery.

BACKGROUND

Nontechnical skills in the operating room are critical for patient safety. The successful integration of these skills into workplace-based assessment is dependent upon the availability of faculty who are able to teach and assess them. At present, no guidelines exist regarding the training requirements for such faculty in surgical contexts.

METHODS

The development of the guidelines was carried out in several stages: stage 1-a detailed literature review on current training for nontechnical skill assessors; stage 2-semistructured interviews with a multidisciplinary panel (consisting of clinicians and psychologists/human factors specialists) of experts in surgical nontechnical skills; and stage 3-interview findings fed into an Expert Consensus Panel (ECP) Delphi approach to establish consensus regarding training requirements for faculty assessing nontechnical skills in surgery.

RESULTS

The ECP agreed that training in nontechnical skill assessment should be delivered by a multidisciplinary team consisting of clinicians and psychologists/human factors specialists. The ECP reached consensus regarding who should be targeted to be trained as faculty (including proficiency and revalidation requirements). Consensus was reached on 7 essential training program content elements (including training in providing feedback/debriefing) and 8 essential methods of evaluating the effectiveness of a "train-the-trainers" program.

CONCLUSIONS

This study provides evidence-based guidelines that can be used to guide the development and evaluation of programs to educate faculty in the training and assessment of nontechnical skills. Uptake of these guidelines could accelerate the development of surgical expertise required for safe and high-quality patient care.

Is competency assessment at the specialist level achievable? A study for the national training programme in laparoscopic colorectal surgery in England

OBJECTIVES

To develop, validate, and implement a competency assessment tool (CAT) for technical surgical performance in the context of a summative assessment process for the National Training Programme in Laparoscopic Colorectal Surgery (NTP).

BACKGROUND

The NTP is an educational initiative by the National Cancer Action Team in England to safely increase the uptake of laparoscopic colorectal surgery. It is the first competency-based national educational initiative for specialist surgeons (consultants), and performance assessment is an integral part of the program.

METHODS

Content validity was sought using expert opinion by semistructured interviews and the Delphi method. For validity and reliability studies, NTP apprentices and experts were asked to submit video-recorded cases. Construct validity was established between delegates who passed the assessment and those who failed. Concurrent validity was tested by comparing scores with error counts as identified by observational clinical human reliability analysis. A fully crossed design, using generalizability theory methods and D-studies, was used for reliability.

FINDINGS

Interviews and the Delphi method revealed a list of characteristics for assessment. A hybrid structure combining task-specific and generic items was used to include important characteristics into the assessment format. Fifty-four cases were submitted. Overall reliability reached G(ACI) = 0.803 when using 2 cases and 2 assessors. Experts scored significantly better than apprentices (3.19 vs 2.60; P = 0.004), and apprentices who passed had better scores than those who failed (2.95 vs 2.28; P < 0.001). There was an inverse correlation between CAT scores and observational clinical human reliability analysis error counts (ρ = -0.520, P < 0.001). The combination of both methods reached overall sensitivity of 100%, specificity of 83.3%, a positive predictive value of 93.8%, and a negative predictive value of 100%.

CONCLUSIONS

The CAT can reliably assess technical performance in laparoscopic colorectal surgery. The use of CATs to judge specialist technical performance before embarking on independent practice of new procedures is achievable on a national scale and can be adapted by other specialties.

Clinical and educational proficiency gain of supervised laparoscopic colorectal surgical trainees

BACKGROUND

The self-taught learning curve in laparoscopic colorectal surgery (LCS) is between 100 and 150 cases. Supervised training has been shown to shorten the proficiency gain curve of senior specialist surgeons. Little is known about the learning curve of LCS trainees undergoing mentored training. The aim of this study was to analyze the proficiency gain curve and clinical outcomes of English surgical trainees during laparoscopic colorectal surgery fellowships.

METHODS

In 2010 the educational, Web-based platform from the National Training Program in Laparoscopic Colorectal Surgery in England was newly available to surgical trainees undertaking a laparoscopic colorectal fellowship. These fellows were asked to submit clinical outcomes, including patient demographics and case specifications. In addition, self-perceived performance was evaluated using a validated task-specific self-assessment form [global assessment scale (GAS) range 1-6]. Proficiency gain curves and learning rates were evaluated using risk-adjusted (RA) cumulative sum (CUSUM) curves.

RESULTS

Of 654 cases 608 were included for analysis. The clinical outcomes included 9.2 % conversions, 16.9 % complications, 4 % reoperations, 2.6 % readmissions and a 0.8 % in-hospital mortality rate. RA CUSUM curves for complications and reoperation do not show a learning effect. However, the RA CUSUM curve for conversion has an inflection point at 24 cases. The GAS CUSUM curves for 'setup' and 'exposure' have inflection points at case 15 and case 29 respectively. The curves for 'mobilization of colon,' 'vascular pedicle' and 'anastomosis' plateau towards the end of the training period. 'Flexure' and 'mesorectum' do not of reach a plateau by case 40.

CONCLUSIONS

Supervised fellowships provide training in LCS without compromising patient safety. Forty cases are required for the fellows to feel confident to perform the majority of tasks except dissection of the mesorectum and flexure, which will require further training.

Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases

BACKGROUND

The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available.

OBJECTIVE

The aim of this study was to analyze the length of the learning curve of laparoscopic colorectal surgeons and to recommend a case selection framework at the early stage of independent practice.

DATA SOURCES

Medline (1988-2010, October week 4) and Embase (1988-2010) were used for the literature review, databases were retrieved from the authors, and expert opinion was surveyed.

STUDY SELECTION

Studies describing the learning curve of laparoscopic or laparoscopically assisted colorectal surgery were selected.

INTERVENTION

No interventions were performed.

MAIN OUTCOME MEASURES

Learning curves were analyzed by using risk-adjusted, bootstrapped cumulative sum curves. Conversions and complications were independent variables in a multilevel random-effects regression model. Recommendations are based on analysis of ORs and a structured expert opinion gauging process.

RESULTS

Twenty-three studies were identified, showing great disparity on the length of the learning curve. Seven studies, representing 4852 cases (19 surgeons), were analyzed. Risk-adjusted cumulative sum charts demonstrated the length of the learning curves to be 152 cases for conversions, 143 for complications, 96 for operating time, 87 for blood loss, and 103 for length of stay. Body mass index and pelvic dissection (rectum), especially in male patients, independently increased the risk of complication and conversion. The expert survey revealed that increasing T stage and complicated inflammatory disease are likely to increase the complexity of the case. Based on this evidence, a framework for case selection in training was proposed.

LIMITATIONS

The generalizability of the study results maybe reduced because of inconsistent data quality and individual variations in the length of the learning curve

CONCLUSIONS

This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.

Can virtual reality simulation be used for advanced bariatric surgical training?

INTRODUCTION

Laparoscopic bariatric surgery is a safe and effective way of treating morbid obesity. However, the operations are technically challenging and training opportunities for junior surgeons are limited. This study aims to assess whether virtual reality (VR) simulation is an effective adjunct for training and assessment of laparoscopic bariatric technical skills.

METHODS

Twenty bariatric surgeons of varying experience (Five experienced, five intermediate, and ten novice) were recruited to perform a jejuno-jejunostomy on both cadaveric tissue and on the bariatric module of the Lapmentor VR simulator (Simbionix Corporation, Cleveland, OH). Surgical performance was assessed using validated global rating scales (GRS) and procedure specific video rating scales (PSRS). Subjects were also questioned about the appropriateness of VR as a training tool for surgeons.

RESULTS

Construct validity of the VR bariatric module was demonstrated with a significant difference in performance between novice and experienced surgeons on the VR jejuno-jejunostomy module GRS (median 11-15.5; P = .017) and PSRS (median 11-13; P = .003). Content validity was demonstrated with surgeons describing the VR bariatric module as useful and appropriate for training (mean Likert score 4.45/7) and they would highly recommend VR simulation to others for bariatric training (mean Likert score 5/7). Face and concurrent validity were not established.

CONCLUSION

This study shows that the bariatric module on a VR simulator demonstrates construct and content validity. VR simulation appears to be an effective method for training of advanced bariatric technical skills for surgeons at the start of their bariatric training. However, assessment of technical skills should still take place on cadaveric tissue.

The feasibility and acceptability of integrating regular centralised laboratory-based skills training into a surgical training programme

BACKGROUND

Traditional laboratory-based skills training provides mass training that does not match clinical experience and is not tailored to individual needs. This compromises the transfer and retention of skills into clinical practice.

AIM

To demonstrate the feasibility of integrating a centralised programme of laboratory-based surgical skills training into a higher surgical training programme and to evaluate its effectiveness and acceptability to trainees.

METHODS

Laboratory-based skills training was provided at a central site, delivered by consultants and tailored to the trainees' level of clinical experience. Each trainee was expected to attend one session a month for 11 months a year. Evaluation was conducted through attendance records, structured evaluations by participants, independent qualitative questionnaires and web interviews.

RESULTS

Forty-two specialist surgical trainees in the North West London higher surgical training programme participated in laboratory-based skills sessions delivered by 19 consultants over a period of two years. The average attendance was 70.5% for trainees and 100% for trainers. All sessions were rated by trainees as well-organised and useful with an average score of more than 4 out of 5. Trainees felt that the Skills Programme can complement surgical training by allowing practice under expert supervision in a safe environment.

CONCLUSIONS

Centralising laboratory-based skills training and integrating it into a clinical programme is feasible and acceptable and represents a paradigm shift in surgical training. Involvement of trainees in designing the content is valuable.

'Trainee' evaluation of the English National Training Programme for laparoscopic colorectal surgery

AIM

The aim of this study was to review trainees' opinions of the training they had received through the National Training Programme (NTP).

METHOD

An online questionnaire was distributed to NTP trainees who had completed five or more training episodes within the programme. Demographic data were collected. Opinion was given using a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). Percentages, mean values and SD were presented. ANOVA and Mann-Whitney U-tests were used to examine the impact of different factors on ratings and the difference between ratings, respectively.

RESULTS

Fifty-four registered trainees fulfilled the inclusion criteria, and 37 (69% response rate) completed the questionnaire. Teaching sessions were organized using an inreach (11%), in-house (11%), outreach (27%) or combination (51%) system of training. Trainees felt that their trainers seldom cancelled sessions (93%), that it was easy to organize (92%) and consent (100%) the patient, and that their hospital was supportive of training (97%). Trainees stated that overall their trainers were excellent at training (Likert scale = 4.71 ± 0.46) and that they received regular feedback (87%). The only variable to have a significant impact on the level of NTP approval was whether the trainee was able to choose his or her trainer (supportive of NTP, chose trainer P = 0.050; critical of NTP, chose trainer P = 0.020).

CONCLUSION

The large majority of trainees was highly satisfied with the training received in this innovative programme, irrespective of region or training structure used, thus demonstrating acceptability of the programme in its current form.

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Laparoscopic colorectal surgery (LCRS) is a safe, effective and cost-efficient option for the treatment of various benign and malignant conditions. However, its implementation to surgical practice is still limited. That is mainly due to its association with a steep learning curve. We performed a review of the literature to determine whether quality training in LCRS can reduce that learning curve and lead to better clinical outcomes. We concluded that a structured training program with pre-clinical phase focused on basic skill acquisition and a clinical phase focused on mentoring from experts can shorten the learning curve and improve clinical outcomes.

Validation of a questionnaire for the assessment of pain following ventral hernia repair--the VHPQ

PURPOSE

The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia.

METHODS

The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4 weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3 years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people.

RESULTS

For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p < 0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1 week postoperative (p < 0.05). Kappa levels for test-retest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p < 0.05) in the test-retest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p < 0.05) and more interference with daily activities (p < 0.05) than a non-operated group from the general population.

CONCLUSION

The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.

Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study

OBJECTIVE

The Department of Health's Enhanced Recovery Partnership Programme (ERPP) started a spread and adoption scheme of Enhanced Recovery After Surgery (ERAS) throughout England. In preparation for widespread adoption the ERPP wished to obtain expert consensus on appropriate outcome measures for ERAS, emerging techniques being widely adopted and proposed methods for the continued development and sustainability of ERAS in the National Health Service. The aim of this study was to interrogate expert opinion and define areas of consensus on these issues.

DESIGN

A Delphi technique using three rounds of reiterative questionnaires was used to obtain consensus.

PARTICIPANTS

Experts were chosen from teams with experience of delivering a successful ERAS programme across different surgical specialties and across various disciplines.

SETTING

The first two rounds of the questionnaire were completed online and a final, third round was undertaken in a meeting using interactive voting.

RESULTS

86 experts took part in this study. Consensus statements agreed that patient experience data should be recorded, analysed and reviewed at regular ERAS meetings. Recent developments in regional analgesia, the increased use of intraoperative monitoring for fluid management and cardio-pulmonary exercise testing were the main emerging techniques identified. National standards for those outcome measures would be welcomed. To sustain success in ERAS, the experts highlighted clinical champions and the presence of a dedicated ERAS facilitator as essential elements. For future networking, a unanimous agreement was achieved on the formation a national network to facilitate spread and adoption of ERAS and to promote research and education across surgery.

CONCLUSIONS

Consensus was achieved on regular measurement and review of patient experience in ERAS. Agreement was reached on the role of regional analgesia and the use of oesophageal Doppler for intraoperative goal-directed fluid therapy. In order to facilitate the further spread and adoption of best practices and to promote research and education, an ERAS-UK network was recommended.

Observational clinical human reliability analysis (OCHRA) for competency assessment in laparoscopic colorectal surgery at the specialist level

BACKGROUND

There are no valid and reliable tools to assess competency in advanced laparoscopic surgery at a specialist level. The observational clinical human reliability analysis (OCHRA) may have the required characteristics of such a tool. The aim of this study was to evaluate construct and concurrent validity of OCHRA for competency assessment at a specialist level.

METHODS

Thirty-two video-recorded laparoscopic colorectal resections, performed by experts and delegates of the National Training Program in England, were evaluated. Each video was analysed using OCHRA by identifying errors enacted during surgery. The number of tissue-handling, instrument-misuse, and consequential errors was recorded using video-rating software. Times spent on dissecting (D) and on exposing (E) tissues were also measured (D/E ratio). In addition, two independent expert surgeons globally assessed each video regarding competency (pass vs. fail). Logistic regression was used to predict outcomes.

RESULTS

A total of 399 errors were identified. There was a significant difference when comparing the expert, pass, and fail groups for total errors (median counts for experts = 4, pass = 10, fail = 17; P < 0.001). When comparing the pass and fail groups excluding experts, differences could be found for tissue-handling errors (7 vs. 12; P = 0.005), but not for consequential errors (4 vs. 7; P = 0.059) and instrument-handling errors (4 vs. 5; P = 0.320). The D/E ratio was significantly lower for delegates than for experts (0.6 vs. 1.0; P = 0.001). When all four independent variables were used to predict delegates who passed or failed, the area under the receiver operating characteristic curve was 0.867, sensitivity was 71.4%, and specificity was 90.9%.

CONCLUSION

OCHRA is a valid tool for assessing competency at a specialist level in advanced laparoscopic surgery. It has the potential to be used for recertification and revalidation of specialists.

The National Training Programme for Laparoscopic Colorectal Surgery in England: a new training paradigm

AIM

The National Training Programme in laparoscopic colorectal surgery was set up in 2008 to introduce laparoscopic colorectal surgery nationwide in a safe and structured way.

METHOD

Over 150 consultant surgeons were enrolled; they received regular and supervised hands on training, and the operative outcome and the structured sign-off process were monitored continuously.

RESULTS

Over 1000 training cases have been recorded with clinical outcomes comparable to established experts; 1/3 elective colorectal resections in England are performed laparoscopically.

CONCLUSION

This successful and novel training model may be a training paradigm for other surgical and interventional specialities.

Analysis of laboratory-based laparoscopic colorectal surgery workshops within the English National Training Programme

BACKGROUND

This study aimed to determine and compare the opinions of trainees and trainers attending courses using two simulation models (fresh frozen cadavers or anaesthetized pigs) and to assess trainees' degree of insight into both the difficulty of different procedures and their operative performance in the simulated environment.

METHODS

Trainers and trainees attending the training courses completed questionnaires. Performance was evaluated using the Global Assessment Score (GAS).

RESULTS

Data were collected over a 12-month period from 26 trainers and 77 trainees. The overall satisfaction was high after attendance at either course (4.50 vs. 4.49; p=0.83). When the opinions of the trainees and trainers in cadaveric and animal courses were compared, the findings rated the animal model as superior in terms of tissue quality (3.97 vs. 3.55; p=0.02), persistence of air leak (1.43 vs. 2.40; p<0.001), and lack of disturbance by odor (4.24 vs. 3.41; p<0.001). The cadaveric model provided more realistic simulation for port placement (4.02 vs. 3.11; p<0.001) and anatomy (4.25 vs. 3.00; p<0.001) and was perceived to be superior as a training model (4.53 vs. 3.61; p=0.001). The trainees demonstrated good insight into procedure difficulty and their operative performance. The trainees and trainers were shown to have a good concordance of scores. The trainees were more inclined to underrate and the peers to overrate their performance.

CONCLUSIONS

Trainees appear to have a good insight into procedure difficulty and their ability. Both training models have advantages and disadvantages, but overall, the cadaveric model is perceived to have a higher fidelity and greater educational value.