Technical skills examination for general surgical trainees

Use of Low-Cost Task Trainer for Emergency Department Thoracotomy Training in General Surgery Residency Program

OBJECTIVE

Emergency department thoracotomy (EDT) is an uncommon but potentially lifesaving procedure that warrants familiarity with anatomy, instruments, and indications necessary for completion. To address this need, we developed a low-cost EDT trainer. The primary objective of this study was to compare the effectiveness of a low-cost EDT trainer to teach emergency department thoracotomy with a discussion-based teaching session. Secondary objective was to study the face validity of the low-cost EDT trainer.

DESIGN

A prospective 2-phase randomized control study was conducted. Participants were randomly divided into two groups. In phase one, baseline medical knowledge for both groups was assessed using a multiple-choice question pretest. In Group 1, each participant was taught EDT using a one-on-one discussion with a trauma surgeon, whereas Group 2 used the EDT trainer and debriefing for training. In phase 2 (1 month later), all participants completed a knowledge retention test and performed a videoed EDT using our EDT trainer, the video recordings were later reviewed by content experts blinded to the study participants using a checklist with a maximum score of 22. The participants also completed a reaction survey at the end of phase 2 of the study.

SETTING

OhioHealth Riverside Methodist Hospital, an urban tertiary care academic hospital in Columbus, Ohio.

PARTICIPANTS

Nine senior surgery residents from training years 3 to 5.

RESULTS

The mean score for the performance of the procedure for the simulation-based (Group 2) was significantly higher than that of the discussion-based (Group 1) (Rater 1: 21.2 ± 0.8 vs. 19.0 ± 2.0, p = 0.05, Rater 2: 20.4 ± 1.5 vs. 18.3±1.0, p = 0.04). Group 2 also was quicker than Group 1 in deciding to start the procedure by approximately 56 seconds. When comparing the mean pretest knowledge score to the mean knowledge retention score 30 days after training, the discussion-based group improved from 58.33% to 81.25% (p = 0.01); the simulation-trained group's scores remained at 68.33%. All the participants agreed or strongly agreed that the simulator provided a realistic opportunity to perform EDT and improved their confidence.

CONCLUSIONS

The results of this pilot study support our hypothesis that using a low-cost EDT trainer effectively improves general surgery residents' confidence and procedural skills scores in a simulated environment. Further training with low-cost simulators may provide surgical residents with deliberate practice opportunities and improve performance when learning low-frequency procedures.

Validation and reliability testing of a rating scale for objective assessment of performance in laparoscopic appendicectomy surgery

Backgrounds

To achieve a competency‐based training paradigm, the ability to obtain reliable and valid quantitative assessments of intraoperative performance is required. Through this, weaknesses can be identified and practiced, and competency assessed. This study aimed to determine the validity and reliability an objective evaluation tool for assessment of performance in laparoscopic appendicectomy (LA).

Methods

A prospective single‐blinded observational study design was used. Videos of inexperienced (performed <10 LAs) and experienced (performed >100 LAs) surgeons performing LA surgery were collected. Surgical performance during each recording was rated by two independent, blinded expert surgeons using the LA Rating Scale (LARS) and the modified Objective Structured Assessment of Technical Skill (OSATS) scale.

Results

The intraclass correlation coefficient (ICC) for LARS was 0.95 (95%CI 0.83–0.98). The ICC for each step ranged from 0.48 to 0.90, and the test–retest ICC for LARS was 0.91 (95%CI 0.69–0.98). Significant differences (P < 0.001) between median performance scores as rated by LARS were observed between the inexperienced and experienced surgeons. A Spearman's correlation coefficient of 0.87 (P < 0.001) was observed between LARS performance scores and modified OSATS scores.

Conclusion

LARS demonstrated excellent inter‐rater and test–retest reliability, and construct and concurrent validity and can be used to quantitatively evaluate performance during LA. This can potentially allow specific weaknesses to be identified and improved upon through deliberate practice. Progress can be tracked through re‐evaluation and scores of expert surgeons can be used as performance goals for credentialing in LA.

Using a validated tool to assess whole-body cadaveric simulation course on open general and emergency surgery

BACKGROUND

The Anatomy of Surgical Exposure (ASE) is a cadaver-based operative surgery simulation course that aims to teach techniques and exposures commonly used in open surgical operations. In this study, we used a validated tool to determine efficacy of assessing skills acquisition in the simulated environment. Our aims were to investigate if the ASE course improves the candidates' surgical performance, and to assess if the validated Objective Structured Assessment of Technical Skill (OSATS) template could be a useful tool for assessing technical skills.

METHODS

Participants (n = 33) undertook supervised assessment of specific procedures at 10 cadaveric stations over a 2-year period; performance was marked using the OSATS template. This template utilizes a seven-item score to assess general and specific surgical techniques and knowledge using a 5-point Likert scale. Experienced tutors assessed each surgery for each participant; individual and comparative data over the 3-day course was used to provide each participant specific feedback at course completion.

RESULTS

Average OSATS scores did not improve significantly over the 3-day OSATS course. There was a significant positive correlation observed between surgical trainees and OSATS total scores (P = 0.001, r = 0.747), number of years of post-graduation, and total OSATS scores (P = 0.001, r = 0.527).

CONCLUSIONS

Our findings indicate that those on the surgical training pathway and those who had graduated earlier, had an overall higher score than those not yet on surgical training. The template was able to provide on-site specific candidate feedback by the end of the course, identifying areas of improvement of technical surgical skills.

Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence

PURPOSE

Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries.

METHOD

Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries.

RESULTS

From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified.

CONCLUSIONS

This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Towards Development of an Open Surgery Competency Assessment for Residents (OSCAR) Tool - A Systematic Review of the Literature and Delphi Consensus

OBJECTIVE

Competency-based education has mandated accurate intra-operative assessment tools. We aimed to define consensus-based open surgical skills perceived by experts as critical for assessment.

DESIGN

A mixed-method design was employed: systematic review and e-Delphi methodology.

SETTING

The study was performed at McGill University-affiliated large tertiary academic centers in Montreal, Quebec, Canada.

PARTICIPANTS

Per PRISMA guidelines, a peer-reviewed search strategy was employed. Studies published in English and those describing technical skill assessment of open abdominal surgery were included; subspecialty-specific skills, conference abstracts, academic memoirs were excluded. Most-cited skills were subjected to e-Delphi methodology to identify those deemed essential by experts, based a 3-point Likert scale. Eighteen McGill University-affiliated general surgeons, representing a variety of subspecialties of General Surgery, were invited to answer the questionnaire.

RESULTS

Around 120 of 4285 references were retained for analysis. The 12 most cited skills included suturing, tissue and instrument handling, movement economy, instrument knowledge, knot tying, flow, knowledge of procedure, completion time, dissection technique, knowledge of anatomy and sterile technique; 6 of these achieved high or perfect scores and agreement after 2 rounds of survey: suturing, sterile technique, knot tying, knowledge of anatomy, knowledge of procedure, and tissue handling. Median standard deviation decreased (0.495 to 0.450) from first to second round, indicating improvement in consensus.

CONCLUSION

These results will help develop and validate the OSCAR (objective structured clinical assessment rubric) assessment tool for immediate intra-operative feedback of open technical skills for surgical trainees.

The Very Experienced Time-honoUred Surgeons (VETUS) project

Senior surgeons who completed their formal surgical training before the video-assisted thoracoscopic surgery (VATS) lobectomy era have had more experience with lobectomy via thoracotomy while their thoracoscopic training background contrasts from younger surgeons. However, this does not seem to have an unfavourable effect on their performance. Despite the literature recognising the critical points of influence of the learning curve for resident surgeons, limited data are focusing on the incremental performance of VATS lobectomy by senior surgeons. The Very Experienced Time-honoUred Surgeons (VETUS) project aims to understand this trend in the VATS group and to introduce an approach to the VATS lobectomy involving senior surgeon. The VETUS project is based on a self-assessment program where the senior surgeon (independently and in complete anonymity) follows a 1-year approach to training in VATS lobectomy. At predefined time intervals, the surgeon will be called to evaluate his performance according to a number of variables such as the choice of VATS lobectomy indications, the number of the port used and length of utility incision, time spent in dissecting the hilar structures and the overall percentage of VATS lobectomy performed in 1 year compared to open. The self-assessment of the VETUS project is a unique opportunity to define the path of a systematic approach to training outside the traditional modalities with the ultimate aim of supporting quality of standardised VATS lobectomy throughout the country.

Working volume: validity evidence for a motion-based metric of surgical efficiency

BACKGROUND

The aim of this study was to evaluate working volume as a potential assessment metric for open surgical tasks.

METHODS

Surgical attendings (n = 6), residents (n = 4), and medical students (n = 5) performed a suturing task on simulated connective tissue (foam), artery (rubber balloon), and friable tissue (tissue paper). Using a motion tracking system, effective working volume was calculated for each hand. Repeated measures analysis of variance assessed differences in working volume by experience level, dominant and/or nondominant hand, and tissue type.

RESULTS

Analysis revealed a linear relationship between experience and working volume. Attendings had the smallest working volume, and students had the largest (P = .01). The 3-way interaction of experience level, hand, and material type showed attendings and residents maintained a similar working volume for dominant and nondominant hands for all tasks. In contrast, medical students' nondominant hand covered larger working volumes for the balloon and tissue paper materials (P < .05).

CONCLUSIONS

This study provides validity evidence for the use of working volume as a metric for open surgical skills. Working volume may provide a means for assessing surgical efficiency and the operative learning curve.

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.

[Providing of a virtual simulator perineal anatomy (Pelvic Mentor®) in learning pelvic perineology: results of a preliminary study]

INTRODUCTION

Medical and surgical simulation is in high demand. It is widely used in North America as a method of education and training of medical students and surgical residents. Learning anatomy and vaginal surgery are based on palpation recognition of different structures. The absence of visual control of actions learners is a limiting factor for the reproducibility of surgical techniques prolapse and urinary incontinenence. However, this reproducibility is the only guarantee of success and safety of these minimally invasive surgeries.

METHODS

We evaluated the contribution of an educational module perineal anatomy using a system combining anatomic mannequin and a computerized 3D virtual simulator (Pelvic Mentor®, Simbionix) in the knowledge of pelvic-perineal anatomical structures for eight residents of obstetrics and gynecology hospitals in Paris.

RESULTS

The self-study training module has led to substantial improvements in internal rating with a proportion of structures recognized from 31.25 to 87.5 % (P<0.001) for the front compartment and 20 to 85 % (P<0.001) for the posterior compartment.

CONCLUSION

The preliminary results suggest that the 3D virtual simulator enhances and facilitates learning the anatomy of the pelvic floor.

Tools for the direct observation and assessment of psychomotor skills in medical trainees: a systematic review

CONTEXT

The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties.

METHODS

An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system.

RESULTS

A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence.

CONCLUSIONS

Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited.

Open surgical simulation in residency training: a review of its status and a case for its incorporation

BACKGROUND

With the increase in minimally invasive approaches to surgical disease and nonoperative management for solid organ injury, the open operative experience of current surgical residents has decreased significantly. This deficit poses a potentially adverse impact on both surgical training and surgical care. Simulation technology, with the potential to foster the development of technical skills in a safe, nonclinical environment, could be used to remedy this problem. In this study, we systematically review the current status of simulation technology in the training of open surgical skills with the aim of clarifying its role and promise in the education of surgical residents.

METHODS

A systematic search of the PubMed database was performed with keywords: "surgical simulation," "skill," "simulat," "surgery," "surgery training," "validity," "surgical trainer," "technical skill," "surgery teach," "skill assessment," and "operative skill." The retrieved studies were screened, and additional studies identified by a manual search of the reference lists of included studies.

RESULTS

Thirty-one studies were identified. Most studies used low fidelity bench models designed to train junior residents in more basic surgical skills. Six studies used complex open models to train senior residents in more advanced surgical techniques. "Boot camp" and workshops have been used by some authors for short periods of intense training in a specialized area, with good results.

CONCLUSIONS

Despite the increasing use of simulation in the technical training of surgical residents, few studies have focused on the use of simulation in the training of open surgical skills. This is particularly true with regard to skills required to competently perform technically challenging open maneuvers under urgent, life-threatening circumstances. In an era marked by a decline in open operative experience, there is a need for simulation-based studies that not only promote and evaluate the acquisition of such less commonly performed techniques but also determine the efficacy with which they can be transferred from a simulated environment to a patient in an operating room.

Validation of a novel method for assessing competency in polypectomy

BACKGROUND

There is a gap in the formal assessment of technical skills in polypectomy that is now considered an integral part of colonoscopy. Polypectomy has been shown to reduce the incidence of colorectal cancer but does have associated complications. Polypectomy competency assessment should arguably be a part of the certification process for all endoscopists. A polypectomy competency assessment tool (Direct Observation of Polypectomy Skills [DOPyS]) has been developed and its reliability examined. This study examined the ability of the DOPyS to reliably distinguish between endoscopists with different levels of experience, ie, its construct validity.

OBJECTIVE

To determine the construct validity of the DOPyS.

DESIGN

Videos of 32 polypectomies (endoscopic view only) were collected from 2 expert (> 1000 colonoscopies) endoscopists (17 polyps) and 6 intermediate-level (100-500 colonoscopies) endoscopists (15 polyps). The videos were edited to include only the entire polypectomy procedure, arranged in random order, and assessed blindly by 4 experienced endoscopists, only 2 of whom were familiar with polypectomy assessment by using the DOPyS before scoring. The differences in overall competency scores (range 1-4; competency, scores ≥ 3) for the expert and intermediate groups were compared by using the Fisher exact test.

SETTING

Single center.

RESULTS

The analysis suggested that both trained assessors familiar with the DOPyS could reliably distinguish between the expert and intermediate endoscopists (P = .049 and P < .001), with the expert group scoring higher than the intermediate one. For the assessors with no previous experience of the DOPyS, no such difference could be seen (P = .71 and P = .15).

LIMITATIONS

Small sample and polyp size.

CONCLUSIONS

The results of the analysis suggested that the DOPyS could reliably differentiate between polypectomies performed by endoscopists of different levels of experience, but only if the assessors were trained in the use of the assessment tool. Training is therefore required to use this tool reliably.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center

INTRODUCTION

Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations.

METHOD

We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum.

RESULTS

Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France.

CONCLUSION

As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

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.

Observational tools for assessment of procedural skills: a systematic review

BACKGROUND

Assessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment.

METHODS

Included studies reported tools for observational assessment of technical skills. A total of 106 articles were included.

RESULTS

Three main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse.

CONCLUSIONS

There is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level.

Ex vivo technical skills training transfers to the operating room and enhances cognitive learning: a randomized controlled trial

BACKGROUND

Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated.

METHODS

We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script.

RESULTS

The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03).

CONCLUSIONS

Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.

Development and validation of a novel method for assessing competency in polypectomy: direct observation of polypectomy skills

BACKGROUND

Despite its ubiquitous use over the past 4 decades, there is no structured, formal method with which to assess polypectomy.

OBJECTIVE

To develop and validate a new method with which to assess competency in polypectomy.

DESIGN

Polypectomy underwent task deconstruction, and a structured checklist and global assessment scale were developed (direct observation of polypectomy skills [DOPyS]). Sixty bowel cancer screening polypectomy videos were randomly chosen for analysis and were scored independently by 7 expert assessors by using DOPyS. Each parameter and the global rating were scored from 1 to 4 (scores ≥3 = competency). The scores were analyzed by using generalizability theory (G theory).

SETTING

Multicenter.

RESULTS

Fifty-nine of the 60 videos were assessable and scored. The majority of the assessors agreed across the pass/fail divide for the global assessment scale in 58 of 59 (98%) polyps. For G-theory analysis, 47 of the 60 videos were analyzed. G-theory analysis suggested that DOPyS is a reliable assessment tool, provided that it is used by 2 assessors to score 5 polypectomy videos all performed by 1 endoscopist. DOPyS scores obtained in this format would reflect the endoscopist's competence.

LIMITATIONS

Small sample and polyp size.

CONCLUSIONS

This study is the first attempt to develop and validate a tool designed specifically for the assessment of technical skills in performing polypectomy. G-theory analysis suggests that DOPyS could reliably reflect an endoscopist's competence in performing polypectomy provided a requisite number of assessors and cases were used.

[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.

Contemporary virtual reality laparoscopy simulators: quicksand or solid grounds for assessing surgical trainees?

BACKGROUND

A demand for safe, efficient laparoscopic training tools has prompted the introduction of virtual reality (VR) laparoscopic simulators, which might be used for performance assessment. The purpose of this review is to determine the value of VR metrics in laparoscopic skills assessment.

DATA SOURCES

An exhaustive search of the MEDLINE and EMBASE databases was performed to identify publications concerning construct, concurrent and predictive validation of VR simulators. Of 643 publications found, 42 were included in this review. Studies into all 3 types of validation showed a large heterogeneity in study design. Although concurrence of VR metrics with box trainer metrics, mental aptitude tests, and in vivo surgical performance was generally weak, several metrics demonstrated construct validity in selected simulators.

CONCLUSIONS

Using the right simulator, tasks, and metrics, trainees' and experts' laparoscopic skills can reliably be compared. However, VR simulators cannot yet predict levels of real life surgical skills.

[Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory]

BACKGROUND

The complexity of laparoscopic surgery makes specific training out of the operating rooms necessary to shorten learning curves and to minimise morbidity rates. Our aim was to analyse the increase in laparoscopic skills after completion of a laboratory training program.

MATERIAL AND METHODS

Prospective study of surgical resident training based on anastomosis performance on an "endotrainer". The program consisted of 4 weeks per year (20h per week) between 2004 and 2007. The outcome measures were the time and number of anastomosis necessary to perform a proper anastomosis. Upon completion, the anastomosis was checked by both trainee and evaluator and quality was assessed. Time and technical failures (loose suture, edge eversion, leakage) were recorded.

RESULTS

Twelve surgical residents were trained. They performed 189 jejuno-jejunal anastomoses (JJA), mean 15.8 per resident and 197 gastro-jejunal anastomoses (GJA), mean 16.4 per resident. The performance mean time was 72.7 min for JJA and 87.2 for GJA. There was a marked reduction in time from the beginning to completion of training. The percentage of flawed anastomosis decreased with training: 26.6%, 21.8%, 17.1%, 17%, 16.1% and 10.5% after 20, 40, 60, 80, 100 and 120 h, respectively. Bearing in mind reduction in both performance time and flawed anastomosis rate, it appears that after 70 h of training the learning curve reaches a plateau zone.

CONCLUSIONS

Intestinal anastomosis (either JJA or GJA) performed in "endotrainer" is a suitable model for laparoscopic training, without the need of live animals. After a training period of 70 hours, the improvement seems of little benefit.

Low-fidelity exercises for basic surgical skills training and assessment

BACKGROUND

The goal of this study was to develop and validate low-fidelity exercises for basic surgical skills training and assessment.

METHODS

Five low-fidelity exercises were developed and administered to 40 participants. Participants were classified as novice or proficient based on level of training. Objective metrics were used for scoring. The cost for assembling 1 complete set of 5 exercises and all necessary supplies for practice and evaluation was $150. Once this set was assembled, the subsequent cost for replacement material was $5/participant examined.

RESULTS

Twenty-four participants were categorized as novice and 16 as proficient. Proficient participants scored significantly higher than novice participants (P <.05) for exercises assessing needle-driving skills, 2-hand coordination, and knot tying, thus establishing construct validity. Cronbach's alpha coefficient for internal consistency was .78, which demonstrates the exercises' reliability as a testing instrument.

CONCLUSIONS

These data provide preliminary evidence of construct validity and internal consistency for a cost-effective series of low-fidelity basic surgical skills exercises.

The future of patient safety: Surgical trainees accept virtual reality as a new training tool

Background

The use of virtual reality (VR) has gained increasing interest to acquire laparoscopic skills outside the operating theatre and thus increasing patients' safety. The aim of this study was to evaluate trainees' acceptance of VR for assessment and training during a skills course and at their institution.

Methods

All 735 surgical trainees of the International Gastrointestinal Surgery Workshop 2006–2008, held in Davos, Switzerland, were given a minimum of 45 minutes for VR training during the course. Participants' opinion on VR was analyzed with a standardized questionnaire.

Results

Fivehundred-twenty-seven participants (72%) from 28 countries attended the VR sessions and answered the questionnaires. The possibility of using VR at the course was estimated as excellent or good in 68%, useful in 21%, reasonable in 9% and unsuitable or useless in 2%. If such VR simulators were available at their institution, most course participants would train at least one hour per week (46%), two or more hours (42%) and only 12% wouldn't use VR. Similarly, 63% of the participants would accept to operate on patients only after VR training and 55% to have VR as part of their assessment.

Conclusion

Residents accept and appreciate VR simulation for surgical assessment and training. The majority of the trainees are motivated to regularly spend time for VR training if accessible.

Objective assessment of technical performance

Technical skills are essential to the practice of surgery. They can be taught in the operating room and in the surgical skills laboratory. The use of simulators allows the development of reproducible curricula with measurement of performance using objective metrics. The goal of those designing metrics for the simulation laboratory should be to establish measures that are consistent with those of high quality surgery in the operating room. Once these metrics have been shown to be reliable, valid, practical to use, and meaningful to the learner, they can form the basis of a learning program based on the acquisition of proficiency. Performance in the skills laboratory should ultimately be predictive of performance in the clinical setting.