Acquiring surgical skills

Conscious motor processing and movement self-consciousness: two dimensions of personality that influence laparoscopic training

BACKGROUND

Identifying personality factors that account for individual differences in surgical training and performance has practical implications for surgical education. Movement-specific reinvestment is a potentially relevant personality factor that has a moderating effect on laparoscopic performance under time pressure. Movement-specific reinvestment has 2 dimensions, which represent an individual's propensity to consciously control movements (conscious motor processing) or to consciously monitor their 'style' of movement (movement self-consciousness).

OBJECTIVE

This study aimed at investigating the moderating effects of the 2 dimensions of movement-specific reinvestment in the learning and updating (cross-handed technique) of laparoscopic skills.

METHODS

Medical students completed the Movement-Specific Reinvestment Scale, a psychometric assessment tool that evaluates the conscious motor processing and movement self-consciousness dimensions of movement-specific reinvestment. They were then trained to a criterion level of proficiency on a fundamental laparoscopic skills task and were tested on a novel cross-handed technique. Completion times were recorded for early-learning, late-learning, and cross-handed trials.

RESULTS

Propensity for movement self-consciousness but not conscious motor processing was a significant predictor of task completion times both early (p = 0.036) and late (p = 0.002) in learning, but completion times during the cross-handed trials were predicted by the propensity for conscious motor processing (p = 0.04) rather than movement self-consciousness (p = 0.21).

CONCLUSION

Higher propensity for movement self-consciousness is associated with slower performance times on novel and well-practiced laparoscopic tasks. For complex surgical techniques, however, conscious motor processing plays a more influential role in performance than movement self-consciousness. The findings imply that these 2 dimensions of movement-specific reinvestment have a differential influence in the learning and updating of laparoscopic skills.

Evidence-based microsurgical skill-acquisition series part 1: validated microsurgical models--a systematic review

OBJECTIVES

The purpose of this study is to (1) systematically review all the literature pertaining to microsurgical training models and to (2) determine which of these are specific to and validated for microsurgery training.

DESIGN

PubMed, MEDLINE (OVID/EBSCO), Google Scholar, and Cochrane Central Register of Controlled Trials were searched using preset terms. The last search date was in July 2012. Articles of all languages, years of publication, sample sizes, and model types pertaining to microsurgery were included. The eligibility criteria included the use of a microsurgical training model on a subject group with statistical analysis and measures of validation. Two assessors independently reviewed the articles and their references.

RESULTS

Of the 238 articles reviewed, 9 articles met the criteria. Those excluded were predominantly model descriptions that had not been validated in a set of learners. The 9 models whose performances were assessed in a group of learners included an online curriculum, nonliving prosthetics and biologics, and the live rat femoral artery model. Each model was evaluated for content, construct, face, and criterion (concurrent and predictive) validity, as well as selection and observation/expectant bias. Content, construct, concurrent, and face validities were consistently demonstrated for all 9 models. Selection bias was also reliably well controlled with random allocation of participants to each study group. Observation/expectant bias was controlled in 6 of the 8 papers. Predictive validity, an arguably more difficult factor to measure, was only present in 1 article.

CONCLUSIONS

Despite a plethora of papers describing microsurgical learning tools, only 9 were discovered that provided validation of the proposed method of microsurgical skills acquisition. This review depicts the need for basic, yet well-designed studies that substantiate the effectiveness of microsurgical training models by using a subject group and demonstrating a statistical improvement with employment of the model. Ease of access, cost, and assessment tools used also require attention.

Effects of robotic manipulators on movements of novices and surgeons

BACKGROUND

Robot-assisted surgery is widely adopted for many procedures but has not realized its full potential to date. Based on human motor control theories, the authors hypothesized that the dynamics of the master manipulators impose challenges on the motor system of the user and may impair performance and slow down learning. Although studies have shown that robotic outcomes are correlated with the case experience of the surgeon, the relative contribution of cognitive versus motor skill is unknown. This study quantified the effects of da Vinci Si master manipulator dynamics on movements of novice users and experienced surgeons and suggests possible implications for training and robot design.

METHODS

In the reported study, six experienced robotic surgeons and ten novice nonmedical users performed movements under two conditions: teleoperation of a da Vinci Si Surgical system and freehand. A linear mixed model was applied to nine kinematic metrics (including endpoint error, movement time, peak speed, initial jerk, and deviation from a straight line) to assess the effects of teleoperation and expertise. To assess learning effects, t tests between the first and last movements of each type were used.

RESULTS

All the users moved slower during teleoperation than during freehand movements (F(1,9343) = 345; p < 0.001). The experienced surgeons had smaller errors than the novices (F(1,14) = 36.8; p < 0.001). The straightness of movements depended on their direction (F(7,9343) = 117; p < 0.001). Learning effects were observed in all conditions. Novice users first learned the task and then the dynamics of the manipulator.

CONCLUSIONS

The findings showed differences between the novices and the experienced surgeons for extremely simple point-to-point movements. The study demonstrated that manipulator dynamics affect user movements, suggesting that these dynamics could be improved in future robot designs. The authors showed the partial adaptation of novice users to the dynamics. Future studies are needed to evaluate whether it will be beneficial to include early training sessions dedicated to learning the dynamics of the manipulator.

Teaching the surgical craft: surgery residents perception of the operating theater educational environment in a tertiary institution in Nigeria

Background:

The transformation of a surgical trainee into a surgeon is strongly influenced by the quality of teaching in the operating theater. This study investigates the perceptions of residents about the educational environment of the operating theater and identifies variables that may improve the operating theater education of our trainees.

Materials and Methods:

Residents in the department of surgery anonymously evaluated teaching in the operating room using the operating theater education environment measure. The residents evaluated 33 variables that might have an impact on their surgical skills within the operating theater. The variables were grouped into four subscales; teaching and training, learning opportunities, operating theater atmosphere and workload/supervision/support. Differences between male and female residents and junior and senior registrars were assessed using Mann-Whitney test. Statistical analysis was completed with the statistics package for the social sciences version 17.

Results:

A total of 33 residents were participated in this study. Twenty nine (88%) males and 4 (12%) females. 30 (90%) were junior registrars. The mean total score was 67.5%. Operating theater atmosphere subscale had the highest score of 79.2% while workload/supervision/support subscale had the least score of 48.3%. There were significant differences between male and female resident's perception of workload/supervision/support P < 0.05; however, there was no significant differences in junior registrar versus senior registrar's perception of the education environment in all the subscales P > 0.05.

Conclusion:

This study has shown a satisfactory teaching environment based on the existing local realities of means, resources and tools and highlighted the need for improvement in workload/supervision/support in our institution. An acceptable learning environment in the operating theatre will produce surgeons that are technically competent to bridge the gap in the enormous unmet need for surgical care in Nigeria.

Does learning in clinical context in anatomical sciences improve examination results, learning motivation, or learning orientation?

The preclinical compulsory elective course "Ready for the Operating Room (OR)!?" [in German]: "Fit für den OP (FOP)"] was implemented for students in their second year, who were simultaneously enrolled in the gross anatomy course. The objective of the study was to determine whether the direct practical application of anatomical knowledge within the surgical context of the course led to any improvement in learning motivation, learning orientation, and ultimately examination results in the gross anatomy course, as compared with a control group. Within the scope of five teaching sessions, the students learned surgical hand disinfection, suturing techniques, and the identification of commonly used surgical instruments. In addition, the students attended five surgical demonstrations performed by surgical colleagues on cadavers. Successful learning of these basic skills was then assessed based on an Objectively Structured Practical Examination. Learning motivation and learning orientation in both subgroups was determined using the SELLMO-ST motivation test and the Approaches and Study Skills Inventory test. While a significant increase in work avoidance was identified in the control group, this was not the case for FOP participants. Similarly, an increase in the "deep approach" to learning, as well as a decrease in the "surface approach," was able to be documented among the FOP participants following completion of the course. The results suggest that students enrolled in the gross anatomy course, who were simultaneously provided with the opportunity to learn in clinical context, were more likely to be successful at maintaining learning motivation and learning orientation required for the learning process, than students who attended the gross anatomy course alone.

Play to become a surgeon: impact of Nintendo Wii training on laparoscopic skills

BACKGROUND

Video-games have become an integral part of the new multimedia culture. Several studies assessed video-gaming enhancement of spatial attention and eye-hand coordination. Considering the technical difficulty of laparoscopic procedures, legal issues and time limitations, the validation of appropriate training even outside of the operating rooms is ongoing. We investigated the influence of a four-week structured Nintendo® Wii™ training on laparoscopic skills by analyzing performance metrics with a validated simulator (Lap Mentor™, Simbionix™).

METHODOLOGY/PRINCIPAL FINDINGS

We performed a prospective randomized study on 42 post-graduate I-II year residents in General, Vascular and Endoscopic Surgery. All participants were tested on a validated laparoscopic simulator and then randomized to group 1 (Controls, no training with the Nintendo® Wii™), and group 2 (training with the Nintendo® Wii™) with 21 subjects in each group, according to a computer-generated list. After four weeks, all residents underwent a testing session on the laparoscopic simulator of the same tasks as in the first session. All 42 subjects in both groups improved significantly from session 1 to session 2. Compared to controls, the Wii group showed a significant improvement in performance (p<0.05) for 13 of the 16 considered performance metrics.

CONCLUSIONS/SIGNIFICANCE

The Nintendo® Wii™ might be helpful, inexpensive and entertaining part of the training of young laparoscopists, in addition to a standard surgical education based on simulators and the operating room.

Simulators in surgery

The introduction of minimally invasive surgery has demonstrated the need for training surgical skills outside the operating room using animal models or simulators. As laparoscopic surgery involves displaying images on a screen, virtual reality simulation of the surgical tasks is feasible. Different types of simulators have become available. The existing trainers can be divided into three groups: mechanical, hybrid, and virtual reality. This article aims at giving an overview of the different simulators available and the potential of simulators in the education of surgeons with focus on virtual reality simulators. All simulators aim at training psychomotoric skills and some simulators also allow training in decision-making and anatomical orientation. In the future virtual reality simulators may become a tool for training and validation of surgical skills and monitoring the training progress.

Retrospective adjustment of self-assessed medical competencies - noteworthy in the evaluation of postgraduate practical training courses

Aim: The efficacy of postgraduate practical training courses is frequently evaluated by self-assessment instruments. The present study analyses the effect of a basic course in laparoscopic surgery on self-assessed medical competencies.

Methods: The 3-day course included teaching of knowledge and training of practical skills. In relation to course evaluation, a questionnaire for self-assessment was applied

at the beginning of the course ('pre-course'),

at the end of the course ('post-course') and

at the end of the course to reassess pre-course competencies ('retrospective pre-course').

Results: 89 out of 110 participants (81%) attending 10 courses completed all the questionnaires; 83% were postgraduate trainees in surgery and 82% were inexperienced as an independent surgeon. At the beginning of the course most trainees rated themselves as 'moderately competent' or 'fully competent' with respect to the various task levels as well as to specific areas of medical competencies. At the end of the course however pronounced retrospective revisions of self-assessment to lower ratings became apparent. Statistically significant differences were seen for the task 'performing surgical procedures under supervision' and for most of the practical skills trained during the course (p <0.01). In contrast, no significant differences were observed for knowledge taught during the course as well as for 'ability to work in a team' and 'ability to concentrate', which were not foci of the course.

Conclusions: Surgeons with little experience change their self-assessment of pre-course competencies to a lower level after participation in a practical postgraduate training course. Evaluations comparing 'pre-course' and 'post-course' ratings only – without 'retrospective pre-course' ratings – may underestimate the training effects. This phenomenon needs to be taken into account when evaluations are dependent exclusively on self-assessment instruments.

Opportunities for learning in the surgical workplace and how they can be exploited: a practical guide

Training times and the working week have been shortened but the amount needed to be learned remains the same. This article demonstrates how trainees in surgery can incorporate learning opportunities into their normal working day.

Simulation in surgery: a review

The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these technical skills can be learnt away from the operating theatre. The aim of this review article is to discuss the importance of surgical simulation today and its various types, exploring the effectiveness of simulation in the clinical setting and its challenges for the future. Surgical simulation offers the opportunity for trainees to practise their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance. This enables better patient safety and standards of care. Surgical simulators can be divided into organic or inorganic simulators. Organic simulators, consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. Inorganic simulators comprise virtual reality simulators and synthetic bench models. Current evidence suggests that skills acquired through training with simulators, positively transfers to the clinical setting and improves operative outcome. The major challenge for the future revolves around understanding the value of this new technology and developing an educational curriculum that can incorporate surgical simulators.

Sim one, do one, teach one: considerations in designing training curricula for surgical simulation

Although there is considerable interest in the use of simulation for the acquisition of fundamental surgical skills through goal-directed practice in a safe environment, there is little evidence guiding educators on how best to implement simulation within surgical skills curricula. This article reviews the application of the expert performance model in surgery and the role of simulation in surgical skills acquisition. The focus is on implementation of deliberate practice, highlighting the principles of part-task training, proficiency-based training and overtraining. With resident and educator time at a premium, the identification of an optimally effective and efficient training strategy has significant implications for how surgical skills training is incorporated into residency programs, which is critical in today's environment.

Ready for the OR? - Clinical anatomy and basic surgical skills for students in their preclinical education

Medical students’ first experience in the operating theatre often takes place during their electives and is therefore separated from the university’s medical curriculum. In the winter term 2009/10, the Institute of Anatomy and Cell Biology at the University of Ulm implemented an elective called “Ready for the OR” for 2nd year medical students participating in the dissection course. We attempted to improve learning motivation and examination results by transferring anatomical knowledge into a surgical setting and teaching basic surgical skills in preparation of the students’ first participation in the OR. Out of 69 online applicants, 50 students were randomly assigned to the Intervention Group (FOP) or the Control Group. In 5 teaching session students learned skills like scrubbing, stitching or the identification of frequently used surgical instruments. Furthermore, students visited five surgical interventions which were demonstrated by surgical colleagues on donated bodies that have been embalmed using the Thiel technique. The teaching sessions took place in the institute’s newly built “Theatrum Anatomicum” for an ideal simulation of a surgical setting. The learning outcomes were verified by OSPE. In a pilot study, an intervention group and a control group were compared concerning their examination results in the dissection course and their learning motivation through standardized SELLMO-test for students. Participants gained OSPE results between 60.5 and 92% of the maximum score. “Ready for the OR” was successfully implemented and judged an excellent add-on to anatomy teaching by the participants. However, we could not prove a significant difference in learning motivation or examination results. Future studies should focus on the learning orientation, the course’s long-term learning effects and the participants’ behavior in a real surgery setting.

Laparoscopic Simulators : Are They Useful!

BACKGROUND

Laparoscopic surgery has changed the face of medical care forever. The benefits of laparoscopic open surgery have been demonstrated in virtually all major abdominal surgical procedures. Laparoscopy has introduced a new skill set that must be mastered and requires dedicated training. The teaching of laparoscopic operative skills in the clinical setting is constrained by the complexity of procedures, medicolegal and ethical concerns, fiscal and time limitations. This has created the need for formal training outside the operating room. Simulator-based training holds great promise in enhancing surgical education and providing a safe, cost-effective means for practicing techniques prior to their use in the operating room.

METHODS

The surgical residents of two batches were recruited for the study. The residents were randomized to either a group that received training on a simulator or a controlled group that did not receive the training or to a group that received training twice.

RESULT

The residents who received training on a simulator demonstrated better psychomotor skills in the operation theatre than those who did not. Training in simulator environment can contribute to the development of technical skills relevant to the performance of laparoscopic surgery in vivo. Training at regular intervals will benefit the residents in gaining significant improvement of their psychomotor skills.

CONCLUSION

Laparoscopic trainer is a promising tool for training in laparoscopic surgery.

Simulation training and its effect on long-term resident performance in central venous catheterization

INTRODUCTION

Simulation is a safe alternative to practicing procedural skills on patients. However, few published studies have examined the long-term effect of simulation technology on bedside procedures such as central venous catheter (CVC) insertion.

METHODS

To determine whether simulation-based teaching improves procedural comfort, performance, and clinical events in CVC insertion, over traditional methods of procedural teaching, and to assess the long-term effect of this training, we conducted a prospective, randomized controlled trial with 53 postgraduate year-1 and postgraduate year-2 medical residents at a tertiary-care teaching hospital. At the start of the study, we assessed all residents' procedural comfort and previous training and experience with CVCs. We then measured their baseline performance in placing CVCs on simulators, using a validated assessment tool (pretest). For the intervention group, we reassessed performance immediately after simulation training (posttest). All subjects then placed actual CVCs as clinically indicated while on their medical intensive care unit rotations, under the supervision of critical care faculty. We measured clinical events associated with these CVCs. After their medical intensive care unit rotations, we reassessed CVC insertion skills on simulators and procedural comfort of all subjects (delayed posttest).

RESULTS

Intervention subjects demonstrated a significant improvement in skills immediately after simulation training. At delayed posttesting, performance diminished somewhat in the intervention subjects and was not significantly different from control subjects; however, a significant increase over pretest scores persisted in both groups.

CONCLUSIONS

A CVC insertion simulation course improves procedural skills. These skills decline over time, and simulation conferred no long-term additional benefit over traditional methods of procedural teaching.

[Learning curve and iatrogenic injuries in laparoscopic cholecystectomies]

OBJECTIVE

The aim of this study is to analyze surgeon's proficiency, based on the different aspects of his learning curve as a risk factor for iatrogenic biliary tract injuries associated with Laparoscopic Cholecystectomy.

METHODS

a retrospective study was conducted using the report information from charts of patients January 1992 through December 2007; at Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro. Analysis from data collected from charts of 2285 patients who had undergone laparoscopic cholecystectomies. Data from surgeons involved with this type of surgery was also analyzed.

RESULTS

a total of six injuries (0.26%) were found. This result is similar to that found in international publications. All injuries had occurred in the surgeon's second phase of the learning curve with more than 50 video surgeries.

CONCLUSION

it was conclude that Video surgery Certificate and previous training are not related to biliary tract injuries in this series. Surgeon's age was not a risk factor in this study. There was statistical significance between surgeons' experience and injuries.

Microrobots for minimally invasive medicine

Microrobots have the potential to revolutionize many aspects of medicine. These untethered, wirelessly controlled and powered devices will make existing therapeutic and diagnostic procedures less invasive and will enable new procedures never before possible. The aim of this review is threefold: first, to provide a comprehensive survey of the technological state of the art in medical microrobots; second, to explore the potential impact of medical microrobots and inspire future research in this field; and third, to provide a collection of valuable information and engineering tools for the design of medical microrobots.

Increased stress levels may explain the incomplete transfer of simulator-acquired skill to the operating room

BACKGROUND

Proficiency-based simulator training in laparoscopic suturing leads to improved operative performance, but the skill transfer is incomplete. The objective of this study was to examine the stress level of trainees during the transition from the simulator to the operating room (OR) and its impact on performance.

METHODS

Novices (n = 20) were randomized into training and control groups. After the training group achieved proficiency in laparoscopic suturing, both groups were tested on a live porcine, laparoscopic Nissen fundoplication model. Participant performance was assessed using an objective score. Stress level was evaluated by recording beat-to-beat heart rate (BBHR) and short-term heart rate variability (STHRV) at baseline, after achieving proficiency (only the training group) and in the OR. Repeated measurement analysis of variance (ANOVA) and t test were used for analysis.

RESULTS

Baseline simulator performance and data for heart rate variability were similar for both groups. After achieving simulator proficiency, the trained group demonstrated the anticipated decrease in performance (mean average + or - SEM) in the OR (524 + or - 17 vs 290 + or - 95; P < .001), and an increase in BBHR (98 + or - 14 vs115 + or - 18; P < .001) but not STHRV (4.1 + or - 0.8 vs 3.7 + or - 0.9; P = .5). A similar but lesser increase of the BBHR was observed in the control group compared to the study group.

CONCLUSION

BBHR was a more sensitive measure of stress level compared with STHRV. The increased BBHR observed in the OR that reflects stress and performance anxiety may explain the incomplete transfer of simulator-acquired skill in novice learners.

Psychomotor control in a virtual laparoscopic surgery training environment: gaze control parameters differentiate novices from experts

Background

Surgical simulation is increasingly used to facilitate the adoption of technical skills during surgical training. This study sought to determine if gaze control parameters could differentiate between the visual control of experienced and novice operators performing an eye-hand coordination task on a virtual reality laparoscopic surgical simulator (LAP Mentor™). Typically adopted hand movement metrics reflect only one half of the eye-hand coordination relationship; therefore, little is known about how hand movements are guided and controlled by vision.

Methods

A total of 14 right-handed surgeons were categorised as being either experienced (having led more than 70 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The eight experienced and six novice surgeons completed the eye-hand coordination task from the LAP Mentor basic skills package while wearing a gaze registration system. A variety of performance, movement, and gaze parameters were recorded and compared between groups.

Results

The experienced surgeons completed the task significantly more quickly than the novices, but only the economy of movement of the left tool differentiated skill level from the LAP Mentor parameters. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools.

Conclusion

The findings of the study provide support for the utility of assessing strategic gaze behaviour to better understand the way in which surgeons utilise visual information to plan and control tool movements in a virtual reality laparoscopic environment. It is hoped that by better understanding the limitations of the psychomotor system, effective gaze training programs may be developed.

Disparity between resident and attending physician perceptions of intraoperative supervision and education

BACKGROUND

As part of an ongoing evaluation of our residency program, a needs assessment was performed to assess resident and attending perspectives on current methods of surgical skills training in the operating room.

METHODS

Participants included obstetrics-gynecology residents and faculty at a university program. Two surveys were developed and validated. Results were analyzed with 2-sample t tests, comparing Likert scores. Findings were significant if the difference between means was >1.

RESULTS

Thirty of 31 residents and 40 of 60 attending physicians responded to the survey. Residents and attending physicians agreed that the surgical skills training program needs improvement (difference in mean, -0.39; confidence interval [CI]: -0.98 to 0.20). The areas of most disagreement were regarding feedback on surgical skills and instrument handling (difference in mean, 2.53; CI: 1.81-3.26, and difference in mean, 2.24; CI: 1.44-3.05).

CONCLUSIONS

A significant proportion of surgical skills training during residency occurs as on-the-job training, and operating room time provides a key learning opportunity. This report demonstrates that there is a noteworthy difference in the perception of attending physicians and residents about the quality of teaching and feedback that is currently occurring in the operating room. The difference in perspectives among residents and attending physicians reported in this survey suggests a need for improved communication and systematic feedback in order to capitalize on operating room time as a critical surgical skills training arena.

Surgical training in resource-limited countries: moving from the body to the bench--experiences from the basic surgical skills workshop in Enugu, Nigeria

Increasingly, many institutions and surgical groups are resorting to laboratory simulations when teaching surgical skills. The Association of Surgeons of Great Britain and Ireland partnered with the West African College of Surgeons and Johnson and Johnson Corporation to introduce basic surgical skills (BSS) training into West Africa. The local faculty at the University of Nigeria Teaching Hospital, Enugu, was able to use the opportunity of this partnership to establish a regular basic surgical skills training programme. The achievement in Enugu shows that, with a dedicated team of local faculties, giving the local medical trainers a short introduction to the practicalities of organizing and conducting BSS is enough to jump start the programme in resource-poor countries. The Enugu example is a model that should be emulated by centres in other resource-poor countries to make the course a regular feature of their surgical training.

Experimental trial of transvaginal cholecystectomy: an ex vivo analysis of the learning process for a novel single-port technique

BACKGROUND

Interest in natural orifice transluminal endoscopic surgery (NOTES) has expanded, and the first experiences with patients using different techniques have been reported. However, no work has addressed the learning process or the limitations of the procedures. The relation between inexperience and complications became a major concern after the introduction of laparoscopic surgery. This study investigates the learning process for a new technique using specially designed instruments in an ex vivo model before clinical application.

METHODS

Specially designed instruments and a single-port technique using the Tuebingen Trainer were used to evaluate instrument and surgeon performance (learning curve) in terms of time and errors. A total of 90 procedures performed by three surgeons were evaluated. Group and individual learning curves were plotted.

RESULTS

All the surgeons showed a reduction in both mean cholecystectomy time (subject A: 27.2 vs 16.6 min; subject B: 21.4 vs 19.22 min; subject C: 21 vs 19.7 min) and mean errors (subject A: 2.8 vs 1.6; subject B: 3.5 vs 2.6; subject C: 3.5 vs 2). A plateau was reached after approximately 15 procedures. Group learning curve analysis showed a significant reduction in time between the first group (mean, 24.97 +/- 5.8 min) and last group (mean, 19.30 +/- 3.09 min; F[1,28] = 11.83; p = 0.001) for 15 procedures, as well as reduced technical errors in the fifth group, from 3.7 +/- 1.65 to 1.6 +/- 1.04 (F[1,28] = 8.90; p < 0.01), demonstrating a learning effect. The number of optic and access port position changes were recorded, setting a standard for normal instrument performance.

CONCLUSION

This study shows that the tasks of cholecystectomy can be learned safely in a reasonable number of simulations with the new instruments. Although this is a new technique, prior laparoscopic surgery experience is helpful. The technique offers an advantage over those using flexible endoscopes.

Current assessment and future directions of surgical skills laboratories

BACKGROUND

Educational, medicolegal, and financial constraints have pushed surgical residency programs to find alternative methods to operating room teaching for surgical skills training. Several studies have demonstrated that the use of skills laboratories is effective and enhances performance; however, little is known about the facilities available to residents.

STUDY DESIGN

A survey was distributed to 40 general surgery program directors who, in an earlier questionnaire, indicated that they had skills laboratory facilities at their institutions. The survey included the following sections: demographics, facilities, administrative infrastructure, curriculum, learners, and opinions/thoughts of program directors.

RESULTS

Of the 34 program directors that completed the survey, 76% are from a university program. The average facility is 1400 square feet, and most skills laboratories are located in the hospital. Nearly all skills facilities have dry laboratories (90%), and the most common equipment is box trainers (90%). Average start-up costs were $450,000. Sixty-two percent of programs have a skills curriculum for residents. Responders agreed that skills laboratories have a high value and should be part of residency curricula.

CONCLUSIONS

The results of this survey provide a preliminary view of skills laboratories. There is variation in the size, location, and availability of simulators in skills laboratory facilities. Variations also exist in types of curricula formats, subspecialties who make use of the laboratory, and some administrative approaches. There is strong agreement among respondents that skills laboratories are a necessary and valuable component of residency education. Results also indicated concerns for recruiting faculty to teach in the skills laboratory, securing ongoing funding, and implementing a skills laboratory curriculum.

A NEW SURGICAL EDUCATION AND TRAINING PROGRAMME

Educating and training tomorrow's surgeons has evolved to become a sophisticated and expensive exercise involving a wide range of learning methods, opportunities and stakeholders. Several factors influence this process, prompting those who provide such programmes to identify these important considerations and develop and implement appropriate responses. The Royal Australasian College of Surgeons embarked on this course of action in 2005, the outcome of which is the new Surgical Education and Training programme with the first intake to be selected in 2007 and commence training in 2008. The new programme is competency based and shorter than any designed previously. Implicitly, it recognizes in the curriculum and assessment development and processes, the nine roles and their underpinning competencies identified as essential for a surgeon. It is an evolution of the previous programme retaining that which has been found to be satisfactory. There will be one episode of selection directly into the candidate's specialty of choice and those accepted will progress in an integrated and seamless fashion, provided they meet the clinical and educational requirements of each year. The curriculum and assessment in the basic sciences include both generic and specially aligned components from the commencement of training in each of the nine surgical specialties. Born of necessity and developed through extensive research, discussion and consensus, the implementation of this programme will involve many challenges, particularly during the transition period. Through cooperation, commitment and partnerships, a more efficient and better outcome will be achieved for trainees, their trainers and their patients.

Laboratory-based vascular anastomosis training: A randomized controlled trial evaluating the effects of bench model fidelity and level of training on skill acquisition

BACKGROUND

Although there is growing evidence that practice on bench model simulators can improve the acquisition of technical skill in surgery, the degree to which these models have to approximate real-world conditions (model fidelity) to optimize learning is unclear. Previous research suggests that low-fidelity models may be adequate for novice learners. The purpose of this study was to assess the effect of model fidelity and surgical expertise on the acquisition of vascular anastomosis skill.

METHODS

Twenty-seven surgical residents participated in this institutional review board-approved study. Junior residents (postgraduate year 1 and 2) and senior residents (postgraduate year 4 or higher) were randomized into two groups: low-fidelity (n = 13) and high-fidelity (n = 14) model training. Both groups were given a 3-hour hands-on training session: the low-fidelity group used plastic models, and the high-fidelity group used human cadaver arms (brachial arteries) to practice graft-to-arterial anastomosis. One week later, all subjects participated in an animal laboratory in which they performed a single vascular anastomosis on a live, anesthetized pig (femoral artery). A blinded vascular surgeon scored candidate performance in the animal laboratory by using previously validated end points, including a checklist and final product analysis score.

RESULTS

Acquisition of skill was significantly affected by model fidelity and level of training as measured by both the checklist (P = .03) and final product analysis (P = .01; Kruskal-Wallis). Specifically, junior residents practicing on high-fidelity models scored better on the checklist (P = .05) and final product analysis (P = .04). Senior residents practicing on high-fidelity models scored better on final product analysis (P < .05).

CONCLUSIONS

Training in the laboratory does improve skill when assessed in a realistic setting. Both expertise groups showed better skill transfer from the bench model to live animals when practicing on high-fidelity models. For vascular anastomosis, it is important to provide appropriate model fidelity for trainees of different abilities to optimize the effectiveness of bench model training.

Resident continuity of care experience: a casualty of ambulatory surgery and current patient admission practices

BACKGROUND

The purpose of this study was to define and assess the impact of changes in health care delivery on the current continuity of care experience of surgical residents.

METHODS

This 4-week, prospective cohort study included all patients who underwent a general surgical procedure at the University of British Columbia if a resident was present at the operation. The residents' perioperative involvement in each patient's care was recorded.

RESULTS

Of the 592 eligible cases, 74.8% were elective same-day admissions, 5.4% elective previously admitted patients, and 19.8% emergencies. The overall rate of assessment was 27% preoperatively, 84% postoperatively on the ward, and <1% in oupatient clinic postdischarge. Elective cases were associated with significantly lower rates of preoperative assessment compared with emergency cases (15% versus 74%, P < .001).

CONCLUSIONS

Changes in health care delivery have outpaced changes in the structure of surgical education, resulting in suboptimal continuity of care experiences for trainees. Residency programs must adapt their curricula to include adequate ambulatory experience.

Surgical skill acquisition with self-directed practice using computer-based video training

BACKGROUND

Computer-based video training (CBVT) provides flexible opportunities for surgical trainees to learn fundamental technical skills, but may be ineffective in self-directed practice settings because of poor trainee self-assessment. This study examined whether CBVT is effective in a self-directed learning environment among novice trainees.

METHODS

Thirty novice trainees used CBVT to learn the 1-handed square knot while self-assessing their proficiency every 3 minutes. On reaching self-assessed skill proficiency, trainees were randomized to either cease practice or to complete additional practice. Performance was evaluated with computer and expert-based measures during practice and on pretests, posttests, and 1-week retention tests.

RESULTS

Analyses revealed performance improvements for both groups (all P < .05), but no differences between the 2 groups (all P > .05) on all tests.

CONCLUSIONS

CBVT for the 1-handed square knot is effective in a self-directed learning environment among novices. This lends support to the implementation of self-directed digital media-based learning within surgical curricula.

Surgical Education for the Twenty-first Century: Beyond the Apprentice Model

Traditionally, surgery has been taught by an apprentice model, where the learner imitates the actions of a skilled mentor. Although effective, this model is inefficient because it requires learners to be exposed to a large number of surgeries performed by a limited number of dedicated teaching faculty. In addition, competence is proved with subjective evaluations. Because of changes in modern medical practice, specifically reimbursement issues, resident work hour restrictions, and need for reliable and valid credentials, the critical components of the apprentice model are eroding. A paradigm shift is needed in modern surgical education.

Effect of training on patient outcomes following lobectomy

BACKGROUND

Little is known about the effect of surgical training on outcomes in thoracic surgery. The impact of surgeon training on outcomes following lung resection was examined, focusing on lobectomy as a marker operation.

METHODS

328 consecutive patients who underwent lobectomy at our institution between 1 October 2001 and 30 June 2003 were studied. Data were collected prospectively during the patient's admission as part of routine clinical practice and validated by a designated audit officer. Patient characteristics and postoperative outcomes were compared between trainee led and consultant led operations.

RESULTS

In 115 cases (35.1%) the operation was performed by a trainee thoracic surgeon as the first operator. There were no significant differences in patient characteristics between the two groups. In-hospital mortality was similar for operations led by trainees and consultants (3.5% and 2.8%, respectively; p > 0.99). Outcomes in the two groups did not differ significantly with respect to respiratory, cardiovascular, renal, neurological, chest infection, bleeding, and gastrointestinal complications. Survival rates at 1 year were 82.6% for procedures led by trainees compared with 81.7% for procedures led by consultants (p = 0.83).

CONCLUSIONS

With appropriate supervision, trainee thoracic surgeons can perform lobectomies safely without compromising short or intermediate term patient outcome.

Changes in caseload and the potential impact on surgical training: a retrospective review of one hospital's experience

BACKGROUND

Recent reforms to the training grades have provoked debate about both quality and quantity of training. The bulk of previous research into this area has been qualitative, and little is known about the quantity of training opportunities. This study aimed to determine if the number of elective operations available to trainees was stable.

METHODS

The number of elective procedures carried out in each surgical specialty (General & Vascular Surgery, Urology, Orthopaedics, ENT) in a large district general hospital was analysed in 6 month periods and adjusted for the number of basic surgical trainees in each specialty. In order to allow comparison between specialties, results for each 6 month period were calculated as a percentage of those for the first period.

RESULTS

The number of elective operations available per trainee fell in 3 of the 4 specialties, with a rise in Orthopaedics. Overall, the number of operations available to each trainee was 56% of that less than a decade ago.

CONCLUSION

The number of operations available in a conventional hospital setting is decreasing. Introduction of the Modernizing Medical Careers reforms must take account of this if they are to succeed in improving the quality of surgical training.