Effect of structural training on surgical outcomes of residents' first operative laparoscopy: a randomized controlled trial

Objective assessment tools in laparoscopic or robotic-assisted gynecological surgery: A systematic review

INTRODUCTION

There is a growing emphasis on proficiency-based progression within surgical training. To enable this, clearly defined metrics for those newly acquired surgical skills are needed. These can be formulated in objective assessment tools. The aim of the present study was to systematically review the literature reporting on available tools for objective assessment of minimally invasive gynecological surgery (simulated) performance and evaluate their reliability and validity.

MATERIAL AND METHODS

A systematic search (1989-2022) was conducted in MEDLINE, Embase, PubMed, Web of Science in accordance with PRISMA. The trial was registered with the Prospective Register of Systematic Reviews (PROSPERO) ID: CRD42022376552. Randomized controlled trials, prospective comparative studies, prospective single-group (with pre- and post-training assessment) or consensus studies that reported on the development, validation or usage of assessment tools of surgical performance in minimally invasive gynecological surgery, were included. Three independent assessors assessed study setting and validity evidence according to a contemporary framework of validity, which was adapted from Messick's validity framework. Methodological quality of included studies was assessed using the modified medical education research study quality instrument (MERSQI) checklist. Heterogeneity in data reporting on types of tools, data collection, study design, definition of expertise (novice vs. experts) and statistical values prevented a meaningful meta-analysis.

RESULTS

A total of 19 746 titles and abstracts were screened of which 72 articles met the inclusion criteria. A total of 37 different assessment tools were identified of which 13 represented manual global assessment tools, 13 manual procedure-specific assessment tools and 11 automated performance metrices. Only two tools showed substantive evidence of validity. Reliability and validity per tool were provided. No assessment tools showed direct correlation between tool scores and patient related outcomes.

CONCLUSIONS

Existing objective assessment tools lack evidence on predicting patient outcomes and suffer from limitations in transferability outside of the research environment, particularly for automated performance metrics. Future research should prioritize filling these gaps while integrating advanced technologies like kinematic data and AI for robust, objective surgical skill assessment within gynecological advanced surgical training programs.

What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework

OBJECTIVE

To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes.

BACKGROUND

Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies.

METHODS

A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents.

RESULTS

Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored.

CONCLUSION

The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.

A novel step-by-step training program for transanal endoscopic surgery

BACKGROUND

The objective of our study is to develop an effective training platform for transanal endoscopic surgery and to validate a step-by-step training program for learning the basic skills necessary for this approach.

METHODS

We have designed a two-part study: an experimental study (with the aim to design the training platform and the training exercises - on synthetic and biological material) and a prospective analytical study, in order to validate the training program by enrolling as participants general surgery residents and specialists, without previous experience in transanal endoscopic interventions. The performance of the participants was assessed based on the time of completion, as well as the quality of the execution.

RESULTS

We have developed three different diameter platforms (5 cm, 7.5 and 10 cm), that can be used with both the TEO and TAMIS platforms; specific exercises were developed to train different surgical skills like manipulation of tissue, cutting, dissection and suturing. Forty participants were enrolled for the validation of the proposed training program (12 young residents, 16 senior residents and 12 specialist surgeons). A statistically significant improvement of the performance time, from round to round, was observed for all participants in all exercises. The time of completion for the exercises, considering the correct technical execution, was the shortest for more experienced surgeons: specialist surgeons, followed by senior residents and young residents. The biological material exercises, that closely recreate intraoperative conditions and had more strict technical requirements, were difficult to be performed by young residents; better completion rates were seen in senior residents, while all the participants in the specialist surgeons group have completed these exercises.

CONCLUSIONS

Our training program is an effective simulation based educational model for recreating intraoperative conditions particular to transanal endoscopic surgery. The proposed step-by-step training program has demonstrated to be useful in developing the important basic skills needed for transanal endoscopic surgery and assured the progress of all the participants, regardless of their surgical experience.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries.

DATA SOURCES

PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included.

METHODS

Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals.

RESULTS

Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures.

CONCLUSION

Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Learning a MIPO technique for distal radius fractures: Mentoring versus simple experience versus deliberate practice

BACKGROUND

Performance skills of a surgeon for a specific surgical technique range from 1 (novice) to 5 (expert). Mentoring can bring the surgeon to level 3. Simple experience rarely allows achievement of level 5, in contrast to deliberate practice, in which performance skills are improved by setting learning goals based on feedback about the trainee's previous performance.

HYPOTHESIS

When learning a technique for the internal fixation of distal radius fractures, the level of performance skills achieved is higher with deliberate practice than with mentoring or simple experience.

MATERIAL AND METHODS

Four surgeons each performed minimally invasive plate osteosynthesis (MIPO) of 15 distal radius fractures. The procedures were recorded by an HD camera. The first five fractures (step 1) were treated after mentoring, the next 5 fractures after reading an article and viewing a reference video (step 2), and the last 5 fractures after viewing and commenting 20 short videos highlighting possible errors (step 3). Each recording of the procedures performed by the surgeons was scored using the Objective Structured Assessment of Technical Skills (OSATS, 10 items on basic skills [B] and 10 on MIPO-specific skills [S]).

RESULTS

For the basic skills, the mean OSATS scores (on 50) were 31 for step 1, 31 for step 2, and 43 for step 3. For the specific skills, the mean OSATS scores (on 50) were 25 for step 1, 29 for step 2, and 48 for step 3. For overall skills (B+S), the mean OSATS score (on 100) was 56 for step 1, 60 for step 2, and 91 for step 3.

DISCUSSION

Our study confirms that the deliberate practice teaching method is more efficient in improving surgeon skills than simple experience. Deliberate practice consists of four essential steps: (i) setting a well-defined goal; (ii) being motivated to improve one's performance; (iii) receiving immediate feedback; and (iv) having multiple opportunities to repeat and gradually perfect one's performance. Our main hypothesis was verified, since the results of learning a MIPO technique, as assessed using the OSATS scale, were significantly better with a video-assisted deliberate practice technique than with mentoring or simple experience.

CONCLUSION

Video-assisted deliberate practice deserves to be widely used in order to optimise learning curves and to improve risk management in surgery.

LEVEL OF EVIDENCE

III.

Mentorship and formal robotic proficiency skills curriculum improve subsequent generations' learning curve for the robotic distal pancreatectomy

BACKGROUND

Minimally invasive distal pancreatectomy is the accepted standard of care. The robotic distal (RDP) learning curve is 20-40 surgeries with operating time (ORT) as the most significant factor. This study evaluates how formal mentorship and a robotic skills curriculum impact the learning curve for subsequent generation surgeons.

METHODS

Consecutive RDP from 2008 to 2017 were evaluated. First Generation was two surgeons who started program without training or mentorship. Second Generation was the two surgeons who joined the program with mentorship. Third Generation was fellows who benefited from both formal training and mentorship. Multivariable models (MVA) were performed for ORT, clinically relevant pancreatic fistula (CR-POPF), and major complications (Clavien≥3).

RESULTS

A total of 296 RDP were performed of which 187 did not include other procedures: First Generation (n = 71), Second Generation (n = 50), and Third Generation (n = 66). ORT decreased by generation (p < 0.001) without any differences in CR-POPF or Clavien≥3. On MVA, earlier generation (p = 0.019), pre-operative albumin (p = 0.001) and pancreatic adenocarcinoma (p = 0.019) were predictive of ORT. Increased BMI (p = 0.049) and neoadjuvant therapy (p = 0.046) were predictive of CR-POPF. Fellow participation at the console increased over time.

CONCLUSION

Formal mentorship and a skills curriculum decreased the learning curve and complications were largely dependent on patient factors.

Simulator training and residents' first laparoscopic hysterectomy: a randomized controlled trial

BACKGROUND

Hysterectomy rates are decreasing in many countries, and virtual reality simulators bring new opportunities into residents' surgical education. The objective of this study was to evaluate the effect of training in laparoscopic hysterectomy module with virtual reality simulator on surgical outcomes among residents performing their first laparoscopic hysterectomy.

METHODS

This randomized study was carried out at the Department of Obstetrics and Gynecology in Helsinki University Hospital and Hyvinkää Hospital. We recruited twenty residents and randomly signed half of them to train ten times with the laparoscopic hysterectomy module on a virtual reality simulator, while the rest represented the control group. Their first laparoscopic hysterectomy was video recorded and assessed later by using the Objective Structured Assessment of Technical Skills (OSATS) forms and Visual Analog Scale (VAS). The scores and surgical outcomes were compared between the groups.

RESULTS

The mean OSATS score for the Global Rating Scale (GRS) was 17.0 (SD 3.1) in the intervention group and 11.2 (SD 2.4) in the control group (p = 0.002). The mean procedure-specific OSATS score was 20.0 (SD 3.3) and 16.0 (SD 2.8) (p = 0.012), and the mean VAS score was 55.0 (SD 14.8) and 29.9 (SD 14.9) (p = 0.001). Operative time was 144 min in the intervention group and 165 min in the control group, but the difference did not reach statistical significance (p = 0.205). There were no differences between the groups in blood loss or direct complications.

CONCLUSION

Residents training with a virtual reality simulator prior to the first laparoscopic hysterectomy seem to perform better in the actual live operation. Thus, a virtual reality simulator hysterectomy module could be considered as a part of laparoscopic training curriculum.