The effect of warm-up on surgical performance: a systematic review

The Impact of Just-in-Time Simulation Training for Healthcare Professionals on Learning and Performance Outcomes: A Systematic Review

ABSTRACT

Although just-in-time training (JIT) is increasingly used in simulation-based health professions education, its impact on learning, performance, and patient outcomes remains uncertain. The aim of this study was to determine whether JIT simulation training leads to improved learning and performance outcomes. We included randomized or nonrandomized interventional studies assessing the impact of JIT simulation training (training conducted in temporal or spatial proximity to performance) on learning outcomes among health professionals (trainees or practitioners). Of 4077 citations screened, 28 studies were eligible for inclusion. Just-in-time training simulation training has been evaluated for a variety of medical, resuscitation, and surgical procedures. Most JIT simulation training occurred immediately before procedures and lasted between 5 and 30 minutes. Despite the very low certainty of evidence, this systematic review suggests JIT simulation training can improve learning and performance outcomes, in particular time to complete skills. There remains limited data on better patient outcomes and collateral educational effects.

Effect of pre-operative warm-up on trainee intraoperative performance during robot-assisted hysterectomy: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The objective was to study the effect of immediate pre-operative warm-up using virtual reality simulation on intraoperative robot-assisted laparoscopic hysterectomy (RALH) performance by gynecology trainees (residents and fellows).

METHODS

We randomized the first, non-emergent RALH of the day that involved trainees warming up or not warming up. For cases assigned to warm-up, trainees performed a set of exercises on the da Vinci Skills Simulator immediately before the procedure. The supervising attending surgeon, who was not informed whether or not the trainee was assigned to warm-up, assessed the trainee's performance using the Objective Structured Assessment for Technical Skill (OSATS) and the Global Evaluative Assessment of Robotic Skills (GEARS) immediately after each surgery.

RESULTS

We randomized 66 cases and analyzed 58 cases (30 warm-up, 28 no warm-up), which involved 21 trainees. Attending surgeons rated trainees similarly irrespective of warm-up randomization with mean (SD) OSATS composite scores of 22.6 (4.3; warm-up) vs 21.8 (3.4; no warm-up) and mean GEARS composite scores of 19.2 (3.8; warm-up) vs 18.8 (3.1; no warm-up). The difference in composite scores between warm-up and no warm-up was 0.34 (95% CI: -1.44, 2.13), and 0.34 (95% CI: -1.22, 1.90) for OSATS and GEARS respectively. Also, we did not observe any significant differences in each of the component/subscale scores within OSATS and GEARS between cases assigned to warm-up and no warm-up.

CONCLUSION

Performing a brief virtual reality-based warm-up before RALH did not significantly improve the intraoperative performance of the trainees.

Origami Box Folding Exercise: A laparoscopic box simulation training and assessment method in facilitating laparoscopic psychomotor skills with minimal preparation

OBJECTIVE

Laparoscopic box simulation training is widely recognized as an assessment tool to facilitate psychomotor skills especially for novice surgeons. However, current commercialized training modules including pegs, gauze, clips, pins etc. are generally costly and relatively inaccessible. We introduce a simple and pioneer surgical training drill, the Origami Box Folding Exercise (OBFE), based on the validated evaluating system of objective structured assessment of technical skills (OSATS) constructed with the scoring system of procedure-specific checklist (PSC) and global rating scale (GRS).

MATERIALS AND METHODS

Face and content validation of the OBFE and OSATS are evaluated by five endoscopic experts from two medical centers in Taiwan. This is a prospective observational study analyzing the pre-test/post-test result of OBFE from 37 participants in two individual workshops as training and evaluating method for laparoscopic psychomotor skills. Both the pre and post tests are video recorded with a time limit of 5 min graded by two independent evaluators based on the OSATS scoring system.

RESULTS

The reliability of PSC, GRS, and intergroup value between PSC and GRS were 0.923, 0.926 and 0.933, respectively. Inter-rater reliability of PSC, GRS, and both were 0.985, 0.932 and 0.977, respectively. Construct validity of PSC and GRS were statistically significant, with p-value 0.006 and 0.001, respectively.

CONCLUSION

OBFE enhances laparoscopic psychomotor skills with requirement of a single piece of paper. The associated OSATS tool for a 5-min OBFE test was validated. OBFE training is an efficient training and assessment system to promote psychomotor skills in laparoscopic box simulation drill which requires simple and economical preparation.

The impact of case order and intraoperative staff changes on spine surgical efficiency

BACKGROUND CONTEXT

Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency.

PURPOSE

This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases.

STUDY DESIGN/ SETTING

Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy.

OUTCOME MEASURES

Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions.

METHODS

Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups.

RESULTS

A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time.

CONCLUSIONS

Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.

Refreshing medical students' intravenous-cannulation skills: a blinded observer three-arm randomised comparison of mental imagery, part-task trainer simulation and written instructions

INTRODUCTION

Intravenous cannulation is a core competence in medicine, but is considered challenging to learn. This study investigates the effectiveness of three educational strategies used to refresh the intravenous cannulation skills of first-year medical students: mental imagery, part-task trainer simulation and written instructions.

MATERIALS AND METHODS

In this single-centre randomised controlled trial, first-year medical students were assigned to one of three different refresher tutorials on intravenous cannulation. Six months after their compulsory 4 hour instructor-led intravenous-cannulation course, each student was randomised to a 6 min self-learning tutorial: a mental imagery audioguide session, hands-on intravenous cannulation on a part-task trainer or reading written instructions.Immediately after the refresher tutorials, trained evaluators who were blinded to the randomised group assessed the students' performance. Each evaluator completed a 15-item standardised checklist in an Objective Structured Clinical Examination (OSCE) station for intravenous cannulation. We performed a descriptive analysis of the data and a one-way analysis of variance. Additionally, we investigated the influence of previous intravenous cannulation experience on the total OSCE score.

RESULTS AND DISCUSSION

On analysing the 309 students' results, we did not find differences in the total rating of the performance (in percentage) between the three groups at the OSCE station (mental imagery group: 72.0%±17.9%; part-task trainer group: 74.4%±15.6%; written instructions group: 69.9%±16.6%, p=0.158). Multiple linear regression showed a small but statistically significant effect of students' previous intravenous cannulation experience on OSCE performance. With the same outcome, written instructions and mental imagery had a better return on effort, compared with resource-intensive hands-on training with part-task trainers.

CONCLUSION

A single, short refresher seems to have a limited effect on intravenous-cannulation skills in first-year medical students. Less resource-intensive interventions, such as written instructions or mental imagery, are effective compared with hands-on part-task trainer simulation for refreshing this simple but important skill.

TRIAL REGISTRATION NUMBER

AEARCTR-0008043.

Establishing the influence of case complexity on the order of cataract lists: a cross-sectional survey

OBJECTIVE

Order of the theatre list and complexity of the cases are important considerations which are known to influence surgical outcomes. This survey aimed to establish their influence on cataract surgery.

METHODS AND ANALYSIS

Cataract surgeons ordered five cataract cases according to their surgical preference, first using case notes and second using composite ORs (CORs) for posterior capsule rupture. Descriptive and non-parametric statistics were used to analyse the data.

RESULTS

Between 11 June and 14 July 2020, 192 cataract surgeons from 14 countries completed the online survey. Majority of the surgeons (142 vs 50) preferred to choose the order of their list (p<0.01) and to review the case notes prior to the day of surgery (89 vs 53; p=0.04). 39.86% preferred to start with the less risky case and 32.43% reserved the last position on the list for the riskiest case. There was a significant trend to order the list in an ascending level of risk, independent of whether case notes or CORs were used. Additionally, 44.79% of the respondents indicated they would be happy to have their list order planned by an automated program based on their preferred risk score.

CONCLUSION

This survey demonstrates that cataract surgeons prefer to choose the order of their theatre list and that the order is dependent on the complexity of cases. There is support among surgeons for automated list ordering based on an objective score for risk stratification, such as a COR.

Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE.

METHODS

This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard.

RESULTS

Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed.

CONCLUSION

Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts.

LEVEL OF EVIDENCE

Diagnostic test, no or poor gold standard, level V.

Development and Validation of a Virtual Reality Haptic Femoral Nailing Simulator

OBJECTIVE

To create a virtual reality (VR) femoral nailing simulator combining haptics and image intensifier functionality and then carry out validation studies to assess its educational value.

DESIGN

The simulator consisted of a 3D virtual environment, a haptic device and 3D printed drill handle and a VR headset. The environment was created using a video game development engine, interfaced with plugins to allow haptic feedback and image intensifier functionality. Two tasks were created within the simulator as part of an antegrade femoral intramedullary (IM) nail procedure: proximal guidewire entry and distal locking.For the validation study, participants performed the above tasks on the simulator. Metrics were collected including time taken, number of X-rays and tool distance travelled and used to assess construct validity. A questionnaire was then completed to assess authenticity and content validity.

SETTING

Simulator development in centre for simulation and engagement science laboratory. Validation study in a teaching hospital environment.

PARTICIPANTS

Orthopedic specialist trainees and consultants.

RESULTS

Surgeon experience (number of IM nails performed/postgraduate year) correlated with significantly improved task performance. More experienced surgeons took less time, used fewer X-rays and had greater economy of movement than less experienced surgeons. Authenticity and content validity were well rated, with criticisms primarily due to hardware limitations.

CONCLUSIONS

To our knowledge this is the first orthopedic simulator to combine immersive VR with haptics and full image intensifier functionality. By combining multiple aspects of surgical practice within a single device, we aimed to improve participant immersion and educational value. Our work so far has focused on technical skills, demonstrating good authenticity, content and construct validity, however our findings show promise in other applications such as nontechnical skill development and assessment.

The Effect of an Interval Training on Skill Retention of High-Complex Low-Volume Minimal Invasive Pediatric Surgery Skills: A Pilot Study

Background: Current training programs for complex pediatric minimal invasive surgery (MIS) are usually bulk training, consisting of 1- or 2-day courses. The aim of this study was to examine the effects of bulk training versus interval training on the preservation of high-complex, low-volume MIS skills. Materials and Methods: Medical students, without prior surgical experience, were randomly assigned to either a bulk or interval training program for complex MIS (congenital diaphragmatic hernia [CDH] and esophageal atresia [EA] repair). Both groups trained for 5 hours; the bulk group twice within 3 days and the interval groups five times in 3 weeks. Skills retention was assessed at 2 weeks, 6 weeks, and 6 months posttraining, using a composite score (0%-100%) based on the objective parameters tracked by SurgTrac. Results: Seventeen students completed the training sessions (bulk n = 9, interval n = 8) and were assessed accordingly. Retention of the skills for EA repair was significantly better for the interval training group than for the bulk group at 6 weeks (P = .004). However, at 6 months, both groups scored significantly worse than after the training sessions for EA repair (bulk 60 versus 67, P = .176; interval 63 versus 74, P = .028) and CDH repair (bulk 32 versus 67, P = .018; interval 47 versus 62, P = .176). Conclusion: This pilot study suggests superior retention of complex pediatric MIS skills after interval training, during a longer period of time, than bulk training. However, after 6 months, both groups scored significantly worse than after their training, indicating the need for continuous training.

Surgical ergonomics for urologists: a practical guide

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

Effect of successive endoscopic procedures in polyp and adenoma detection rates: Too early is not always too good

BACKGROUND AND AIMS: There is conflicting evidence regarding the impact of hypothetical cumulative fatigue after performing too many endoscopic procedures on both polyp and adenoma detection rates (PDR, and ADR, respectively). The aim of this study is to evaluate the effect of successive endoscopic procedures on PDR and ADR.

METHODS

A retrospective cross-sectional study was undertaken among consecutive patients on whom colonoscopy and/or esophagogastroduodenoscopy were performed between January 2012 and August 2014. Data regarding polyp and adenoma detection, cecal intubation, and bowel cleansing quality as well as demographical data of subjects were extracted. Endoscopic procedures were classified according to the time slots of the procedures throughout the endoscopy session in three groups: from the 1st to 4th endoscopy study (round 1), from the 5th to the 8th study (round 2), above the 9th study (round 3). We compared PDR and ADR among rounds.

RESULTS

Overall, 3388 patients were enrolled. Median age was 50 years (range 18-95) and 52.39% were female. There was a significant difference in terms of PDR among rounds (36.83%, 41.24%, and 43.38%, respectively, p = 0.007) and a non-significant numerical difference when ADR was compared (23.2%, 25.71%, and 26.78%, p = 0.07). On multivariate analysis, ADR was significantly associated with age (odds ratio [OR] 1.02 [1.01-1.03]), and male sex (OR 1.64 [1.38-1.94]).

CONCLUSION

Theoretical endoscopist's fatigue due to cumulative performance of endoscopies does not diminish colonoscopy quality. Both PDR and ADR seem to improve after endoscopist's cumulative rounds of performed endoscopies. This could be due to a "warm-up" effect.

Benefits of an oocyte pickup simulation training program using a high-fidelity simulator (PickUpSimTM) for obstetrics and gynaecology residents: an observational survey study

The aim of this study was to evaluate an oocyte pick-up (OPU) simulation training program for residents using the high fidelity PickUpSim^TM (Accurate, Cesena, Italy) simulator. The authors carried out an observational study during an OPU simulation workshop. A successful scenario was defined as an oocyte retrieval rate ≥70% without any complications. Forty-six residents affiliated to 23 different French university hospitals were included, and 37/46 (80.4%) of them successfully completed the scenario with a mean time of 3.4 ± 1.1 minutes. The oocyte retrieval rate was 442/561 (78.8%). All residents found training beneficial and 41/46 (87%) were in favour of having simulation-based training programs for OPU in their reproductive medicine departments. All residents who had previous experience with OPU (11/11) recommended the use of a simulator before performing OPU. This study confirms that high-fidelity OPU simulation is a simple and efficient method for training residents.Impact statementWhat is already known on this subject? Simulator-based training has been shown to be effective and useful for oocyte pick-up (OPU) training.What the results of this study add? All residents found the simulation program beneficial and formative, with 80% successfully completing their scenarios in a mean time of 3.4 ± 1.1 minutes. All residents who had previous experience with OPU recommended the use of a simulator before performing OPU.What the implications are of these findings for clinical practice and/or further research? Prospective studies are needed to confirm the short- and long-term positive clinical impact of OPU simulation training programs.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Use of a Low-Cost Portable 3D Virtual Reality Gesture-Mediated Simulator for Training and Learning Basic Psychomotor Skills in Minimally Invasive Surgery: Development and Content Validity Study

Background

Simulation in virtual environments has become a new paradigm for surgeon training in minimally invasive surgery (MIS). However, this technology is expensive and difficult to access.

Objective

This study aims first to describe the development of a new gesture-based simulator for learning skills in MIS and, second, to establish its fidelity to the criterion and sources of content-related validity evidence.

Methods

For the development of the gesture-mediated simulator for MIS using virtual reality (SIMISGEST-VR), a design-based research (DBR) paradigm was adopted. For the second objective, 30 participants completed a questionnaire, with responses scored on a 5-point Likert scale. A literature review on the validity of the MIS training-VR (MIST-VR) was conducted. The study of fidelity to the criterion was rated using a 10-item questionnaire, while the sources of content-related validity evidence were assessed using 10 questions about the simulator training capacity and 6 questions about MIS tasks, and an iterative process of instrument pilot testing was performed.

Results

A good enough prototype of a gesture-based simulator was developed with metrics and feedback for learning psychomotor skills in MIS. As per the survey conducted to assess the fidelity to the criterion, all 30 participants felt that most aspects of the simulator were adequately realistic and that it could be used as a tool for teaching basic psychomotor skills in laparoscopic surgery (Likert score: 4.07-4.73). The sources of content-related validity evidence showed that this study’s simulator is a reliable training tool and that the exercises enable learning of the basic psychomotor skills required in MIS (Likert score: 4.28-4.67).

Conclusions

The development of gesture-based 3D virtual environments for training and learning basic psychomotor skills in MIS opens up a new approach to low-cost, portable simulation that allows ubiquitous learning and preoperative warm-up. Fidelity to the criterion was duly evaluated, which allowed a good enough prototype to be achieved. Content-related validity evidence for SIMISGEST-VR was also obtained.

Impact of surgical case order on epiretinal membrane peeling surgery

OBJECTIVE

To determine whether surgical warm-up affects epiretinal membrane (ERM) peeling complication rates and surgical case times.

SETTING

Jewish General Hospital, Montreal, QC, Canada.

DESIGN

Retrospective case-control study.

METHODS

We assessed consecutive patients who underwent pars plana vitrectomy for ERM peel (macular pucker) by one surgeon at the Jewish General Hospital from January 2006 until March 2016. Cases evaluated were sequential ERM peels performed as the first 2 surgeries of the day. The first case of the day was considered the "warm-up" and the second case was the "post-warm-up." Baseline demographics, pre-operative characteristics, perioperative and postoperative best-corrected visual acuity (BCVA) at 2 months and 6 months, as well as postoperative complications are described. Results were analyzed using the χ² test, t test, and Fischer's exact test. Regression models were used to identify any predictors of postoperative BCVA.

RESULTS

The study reviewed 108 patients. The warm-up group was compared with the post-warm-up group, and there was no significant difference between the mean pre-operative BCVA and the post-operative BCVA at 2 and 6 months. ERM peeling surgery complication rates were not statistically different between the warm-up cases and the post-warm-up cases. There was a tendency for performing complex surgeries that needed phaco procedures in post-warm-up cases (13% vs 2%, p = 0.03). Analysis of simple ERM peeling procedures (with no concomitant phaco procedures) showed no statistically significant tendencies for any of the groups to go beyond the 60 minutes allocated for the surgery (25.4% vs 20.0%, p = 0.27).

CONCLUSION

Warming-up does not influence the rate of postoperative complications or the postoperative BCVA in patients undergoing ERM peels. The strongest predictor of post-operative BCVA was pre-operative BCVA.

A Pilot Study on Oocyte Retrieval Simulator: A New Tool for Training?

This prospective study was aimed at assessing the usefulness of a box simulator in oocyte pick-up and at establishing whether it could be an appropriate training tool for egg retrieval. Forty-four clinicians, divided in two groups on the grounds of the previous experience (Novices and Experts), participated to two training sessions with a pick-up simulator. Data concerning the mean number of follicles correctly aspired (%OK med), the average time needed to correctly aspirate one follicle (t foll med) and the ratio between the two afore-mentioned parameters (%OK med/t foll med) were collected. At the end of the two sessions all participants completed a questionnaire aimed at assessing the performance of the simulator in terms of realism and acceptability for use. A significant improvement in efficiency (mean number of follicles correctly aspired, 82% versus 75%), speed (mean time needed to aspirate one follicle, 21 versus 28 s) and accuracy (mean percentage of follicles correctly aspirated in one minute, 2.53% versus 1.86%) was noted in the total sample. The performance accuracy was significantly increased in both groups (2.34% versus 1.83% for Novices and 2.50% versus 2.06%, for Experts). Speed was significantly improved in the Novices' group. Simulator-based training has been shown to be effective and useful and it should be considered in training programs.

Construct, content and face validity of the eoSim laparoscopic simulator on advanced suturing tasks

Background

The purpose of this study was to validate the eoSim, an affordable and mobile inanimate laparoscopic simulator with instrument tracking capabilities, regarding face, content and construct validity on complex suturing tasks.

Methods

Participants recruited for this study were novices (no laparoscopic experience), target group for this training (surgical/gynaecologic/urologic residents, > 10 basic and < 20 advanced laparoscopic procedures) and experts (> 20 advanced laparoscopic procedures). Each participant performed the intracorporeal suturing exercise (Task 1), an upside down needle transfer (Task 2, developed for this study) and an anastomosis needle transfer (Task 3). Following, the participants completed a questionnaire regarding their demographics and opinion on the eoSim in terms of realism, didactic value and usability. Measured outcome parameters were time, distance, percentage of instrument tip off-screen, working area, speed, acceleration and smoothness.

Results

In total, 104 participants completed the study, of which 60 novices, 31 residents and 13 experts. Face and content validity results showed a mean positive opinion on realism (3.9 Task 1, 3.6 Task 2 and 3.7 Task 3), didactic value (4.0, 3.4 and 3.7, respectively) and usability (4.2. 3.7 and 4.0, respectively). There were no significant differences in these outcomes between the specified expertise groups. Construct validity results showed significant differences between experts, target group or novices for Task 1 in terms of time (means 339, 607 and 1224 s, respectively, p < 0.001) and distance (means 8.1, 15.6 and 21.7 m, respectively, p < 0.001). Task 2 showed significant differences between groups regarding time (p < 0.001), distance (p 0.003), off-screen (p < 0.001) and working area (p < 0.001). Task 3 showed significant differences between groups, after subanalyses, on total number of stitches (p < 0.001), time per stitch (p < 0.001) and distance per stitch (p < 0.001).

Conclusions

The results of this study indicate that the eoSim is a potential meaningful and valuable simulator in the training of suturing tasks.

Operating list composition and surgical performance

BACKGROUND

Recent reviews suggest that the way in which surgeons prepare for a procedure (warm up) can affect performance. Operating lists present a natural experiment to explore this phenomenon. The aim was to use a routinely collected large data set on surgical procedures to understand the relationship between case list order and operative performance.

METHOD

Theatre lists involving the 35 procedures performed most frequently by senior surgeons across 38 private hospitals in the UK over 26 months were examined. A linear mixed-effects model and matched analysis were used to estimate the impact of list order and the cost of switching between procedures on a list while controlling for key prognosticators. The influence of procedure method (open versus minimally invasive) and complexity was also explored.

RESULTS

The linear mixed-effects model included 255 757 procedures, and the matched analysis 48 632 pairs of procedures. Repeating the same procedure in a list resulted in an overall time saving of 0·98 per cent for each increase in list position. Switching between procedures increased the duration by an average of 6·48 per cent. The overall reduction in operating time from completing the second procedure straight after the first was 6·18 per cent. This pattern of results was consistent across procedure method and complexity.

CONCLUSION

There is a robust relationship between operating list composition and surgical performance (indexed by duration of operation). An evidence-based approach to structuring a theatre list could reduce the total operating time.

The role of simulation and warm-up in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills.

RECENT FINDINGS

Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes.

SUMMARY

Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Preoperative Practice Paired With Instructor Feedback May Not Improve Obstetrics-Gynecology Residents' Operative Performance

BACKGROUND

There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied.

OBJECTIVE

We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone.

METHODS

We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool.

RESULTS

A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15-36) compared to the PP group (14.5; range, 10-34) and the F group (21.25; range, 10.5-32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70-0.95) using the intraclass correlation coefficient.

CONCLUSIONS

This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Impact of Case Order on Laparoscopic Sacrocolpopexy: Do Surgeons Need a Warm-Up?

OBJECTIVES

Warm-up is defined as a preparatory activity or procedure. Using case order as a surrogate for surgeon warm-up, first cases were compared with second or later cases for intraoperative complications, operative time, and length of stay (LOS) among women undergoing laparoscopic sacrocolpopexy.

METHODS

This is a retrospective study of laparoscopic sacrocolpopexies performed from 2009 through 2014 at a large academic center. Any surgery preceding laparoscopic sacrocolpopexy was considered a surrogate for surgeon warm-up. Logistic and linear regression analyses were used to identify predictors of complications, operative time, and LOS.

RESULTS

Of 480 procedures, 192 (40%) were first cases and 288 (60%) were second or later. Baseline characteristics were similar between groups. Intraoperative complication rate was not different between groups (6.3% vs 3.1%, P = 0.50) even after controlling for risk factors. Operative times were comparable on initial analysis (231.2 ± 55.2 vs 225.9 ± 51.2 minutes, P = 0.28l), but a small difference was detected after adjusting for confounding factors (body mass index, menopausal status, surgeon experience, intraoperative complications, and concomitant hysterectomy or midurethral sling; adjusted β = 8.44 minutes, P = 0.037). Length of stay was longer for first case patients (1.44 ± 0.67 vs 1.24 ± 0.50 days, P < 0.001) even after adjusting for age, medical comorbidities, operative time, conversion to laparotomy, ileus/bowel obstruction, and postoperative urinary retention (adjusted β = 0.183 days, P = 0.001) as well as after accounting for delayed start time of second or later cases.

CONCLUSIONS

Laparoscopic sacrocolpopexy performed first case of the day without preoperative surgeon warm-up conferred no significant increase in intraoperative complications. Second or later cases were associated with small decreases in operative time and in LOS.

A systematic examination of preoperative surgery warm-up routines

BACKGROUND

Recent evidence indicates that a preoperative warm-up is a potentially useful tool in facilitating performance. But what factors drive such improvements and how should a warm-up be implemented?

METHODS

In order to address these issues, we adopted a two-pronged approach: (1) we conducted a systematic review of the literature to identify existing studies utilising preoperative simulation techniques; (2) we performed task analysis to identify the constituent parts of effective warm-ups. We identified five randomised control trials, four randomised cross-over trials and four case series. The majority of these studies reviewed surgical performance following preoperative simulation relative to performance without simulation.

RESULTS

Four studies reported outcome measures in real patients and the remainder reported simulated outcome measures. All but one of the studies found that preoperative simulation improves operative outcomes-but this improvement was not found across all measured parameters. While the reviewed studies had a number of methodological issues, the global data indicate that preoperative simulation has substantial potential to improve surgical performance. Analysis of the task characteristics of successful interventions indicated that the majority of these studies employed warm-ups that focused on the visual motor elements of surgery. However, there was no theoretical or empirical basis to inform the design of the intervention in any of these studies.

CONCLUSIONS

There is an urgent need for a more rigorous approach to the development of "warm-up" routines if the potential value of preoperative simulation is to be understood and realised. We propose that such interventions need to be grounded in theory and empirical evidence on human motor performance.

Effect of Preoperative Warm-up Exercise Before Laparoscopic Gynecological Surgery: A Randomized Trial

BACKGROUND

Laparoscopic surgical procedures require a high level of cognitive and psychomotoric skills. Thus, effective training methods to acquire an adequate level of expertise are crucial. The aim of this study was to investigate the effect of preoperative warm up training on surgeon׳s performance during gynecologic laparoscopic surgery.

MATERIALS AND METHODS

In this randomized controlled trial, surgeons performed a preoperative warm up training using a virtual reality simulator before laparoscopic unilateral salpingo-oophorectomy. Serving as their own controls, each subject performed 2 pairs of laparoscopic cases, each pair consisting of 1 case with and 1 without warm up before surgery. Surgeries were videotaped and psychomotoric skills were rated using objective structured assessment of technical skills (OSATS) and the generic error rating tool by a masked observer. Perioperative complications were assessed. Statistical analysis was performed using a mixed model, and mean OSATS scores were compared between both the groups.

RESULTS

In total, data of 10 surgeons and 17 surgeries were available for analysis. No differences between educational level and surgical experiences were observed between the groups. Mean standard error psychomotoric and task-specific OSATS scores of 19.8 (1.7) and 3.7 (0.2) were observed in the warm up group compared with 18.6 (1.7) and 3.8 (0.2) in the no warm up group, respectively (p = 0.51 and p = 0.29). Using generic error rating tool, the total number of errors was 8.75 (2.15) in the warm up group compared with 10.8 (2.18) in the no warm-up group (p = 0.53). Perioperative complications and operating time did not differ between both the groups.

DISCUSSION

The present study suggests that warm-up before laparoscopic salpingo-oophorectomy does not increase psychomotoric skills during surgery. Moreover, it does not influence operating time and complication rates. (Medical University of Vienna-IRB approval number, 1072/2011, ClinicalTrials.gov number, NCT01712607).

Effect of just-in-time simulation training on provider performance and patient outcomes for clinical procedures: a systematic review

Background

Providing simulation training directly before an actual clinical procedure—or ‘just-in-time’ (JiT)—is resource intensive, but could improve both provider performance and patient outcomes.

Objectives

To assess the effects of JiT simulation training versus no JiT training on provider performance and patient complications following clinical procedures on patients.

Study selection

We searched MEDLINE, Cochrane Library, CINAHL, PsycINFO, ERIC, ClinicalTrials.gov, simulation journals indexes and references of included studies during October 2014 for randomised trials, non-randomised trials and before-after studies comparing JiT simulation training versus no JiT training among providers performing clinical procedures. Findings were synthesised qualitatively.

Findings

Of 1805 records screened, 8 studies comprising 3540 procedures and 1969 providers were eligible. 5 involved surgical procedures; the other 3 included paediatric endotracheal intubations, central venous catheter dressing changes, or infant lumbar puncture. Methodological quality was high. Of the 8 studies evaluating provider performance, 5 favoured JiT simulation training with 18–48% relative improvement on validated clinical performance scales, 16–20% relative reduction in surgical time and 12% absolute reduction in corrective prompts during central venous catheter dressing changes; 3 studies were equivocal with no improvement in intubation success, lumbar puncture success or urological surgery clinical performance scores. 3 studies evaluated patient complications; 1 favoured JiT simulation training with 45% relative reduction in central line-associated blood stream infections; 2 studies found no differences following intubation or laparoscopic nephrectomy.

Conclusions

JiT simulation training improves provider performance, but currently available literature does not demonstrate a reduction in patient complications.

Does warming up improve surgical outcome in total hip arthroplasty?

PURPOSE

Warming up prior to surgery has been shown to enhance surgeons' performance during laparoscopic procedures. It is unknown whether or not warming up prior to total hip arthroplasty (THA) will have a similar effect on surgical outcome.

METHODS

We retrospectively evaluated the effect of warming up on the intraoperative outcome of 82 patients who underwent a primary THA with identical implants. The patients were divided equally into two groups. Group 1 (first case of the day) served as "warm-up procedure," while Group 2 (second case of the day) was the "post-warm-up procedure."

RESULTS

We found no statistically significant difference when we compared cup abduction and anteversion angles, femoral offset, postoperative LLD, stem alignment, hip center of rotation and femoral stem canal fill between the two groups (p > 0.05).

CONCLUSION

Warming up prior to performing surgery does not make a difference for primary THA when performed by an experienced surgeon. However, these results may not reflect its effect on procedures that require fine motor skills or done by an orthopedic trainee or less experienced surgeons.