Development and validity evidence of an objective structured assessment of technical skills score for minimally invasive linear-stapled, hand-sewn intestinal anastomoses: the A-OSATS score

Extrapolative Validity Evidence of the Anastomosis Objective Structured Assessment of Technical Skill (A-OSATS) for Robotic Ileocolic Anastomosis

OBJECTIVE

To collect validity evidence for the use of the Anastomosis Objective Structured Assessment of Technical Skills (A-OSATS) instrument, which has been developed to evaluate performance of a minimally invasive side-to-side bowel anastomosis with hand-sewn common enterotomy.

DESIGN

Residents performed a robotic ileocolic anastomosis simulation on an ex vivo porcine model. Faculty scored each resident with the A-OSATS and performed a provocative leak test on the completed anastomoses. Residents were reassessed on the sewing sub-score 1 month later. Data were compared with parametric and nonparametric analysis.

SETTING

Single academic general surgery residency PARTICIPANTS: PGY-4 and -5 general surgery residents (n = 17) RESULTS: PGY-5s performed better than PGY-4s in repeat A-OSATS sewing sub-score (mean 55/55 ± 0 vs 43 ± 4.9, p < 0.001) and time to complete (minutes, mean 14.5 ± 4.9 vs 21.2 ± 3.9, p = 0.01). There was a strong correlation between A-OSATS score and time (r = -0.67, p = 0.005). For the initial assessment, there was no significant difference in mean A-OSATS score between anastomoses that leaked and those that did not leak (137.3 ± 14.5 vs 150.1 ± 11.2, p = 0.098), but on repeat assessment, intact anastomoses had a higher mean A-OSATS sewing sub-score than those that leaked (52.2 ± 4.7 vs 39 ± 3.5, p = 0.007). There was no significant difference between initial A-OSATS score and repeat score (p = 0.14).

CONCLUSIONS

We provide extrapolative validity evidence for the A-OSATS instrument by comparing A-OSATS score to time to sew, provocative leak test, and discrimination between PGY-4s and PGY-5s. Generalizability validity evidence is provided by test-retest reliability. Further refinement is needed for the A-OSATS tool to be used for high-stakes entrustment decisions in resident-performed robotic ileocolic anastomoses.

Expanded Access to Video-Based Laparoscopic Skills Assessments: Ease, Reliability, and Accuracy

OBJECTIVE

Video-based performance assessments provide essential feedback to surgical residents, but in-person and remote video-based assessment by trained proctors incurs significant cost. We aimed to determine the reliability, accuracy, and difficulty of untrained attending staff surgeon raters completing video-based assessments of a basic laparoscopic skill. Secondarily, we aimed to compare reliability and accuracy between 2 different types of assessment tools.

DESIGN

An anonymous survey was distributed electronically to surgical attendings via a national organizational listserv. Survey items included demographics, rating of video-based assessment experience (1 = have never completed video-based assessments, 5 = often complete video-based assessments), and rating of favorability toward video-based and in-person assessments (0 = not favorable, 100 = favorable). Participants watched 2 laparoscopic peg transfer performances, then rated each performance using an Objective Structured Assessment of Technical Skill (OSATS) form and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS). Participants then rated assessment completion ease (1 = Very Easy, 5 = Very Difficult).

SETTING

National survey of practicing surgeons.

PARTICIPANTS

Sixty-one surgery attendings with experience in laparoscopic surgery from 10 institutions participated as untrained raters. Six experienced laparoscopic skills proctors participated as expert raters.

RESULTS

Inter-rater reliability was substantial for both OSATS (k = 0.75) and MISTELS (k = 0.85). MISTELS accuracy was significantly higher than that of OSATS (κ: MISTELS = 0.18, 95%CI = [0.06,0.29]; OSATS = 0.02, 95%CI = [-0.01,0.04]). While participants were inexperienced with completing video-based assessments (median = 1/5), they perceived video-based assessments favorably (mean = 73.4) and felt assessment completion was "Easy" on average.

CONCLUSIONS

We demonstrate that faculty raters untrained in simulation-based assessments can successfully complete video-based assessments of basic laparoscopic skills with substantial inter-rater reliability without marked difficulty. These findings suggest an opportunity to increase access to feedback for trainees using video-based assessment of fundamental skills in laparoscopic surgery.

European Robotic Surgery Consensus (ERSC): Protocol for the development of a consensus in robotic training for gastrointestinal surgery trainees

BACKGROUND

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process.

METHODS AND ANALYSIS

In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document.

REGISTRATION DETAILS

The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review

BACKGROUND

There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula.

METHODS

A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.

RESULTS

Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.

CONCLUSIONS

Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

Assessment of robotic telesurgery system among surgeons: a single-center study

The field of robotic-assisted surgery is expanding rapidly; therefore, future robotic surgeons will need to be trained in an organized manner. Here, we aimed to examine surgeon performance on the Sinaflex Robotic Telesurgery System for correlation with training hours spent in training program. This is a prospective study of a single-center experience at the Hasan Sadikin Hospital, Bandung City of West Java, Indonesia. We included 43 surgeons from 11 departments, all invited to train using the Sinaflex Robotic Telesurgery system at the Hasan Sadikin Hospital. All study cohorts have never performed a robotic surgery procedure beforehand and have had at least five years of field experience. The surgeons were free to choose their training duration and simulation. After finishing the training session, they were asked to perform several tasks with increasing difficulty levels. There were nine training tasks in total with increasing levels of difficulty. A total of 43 surgeons from 11 different department were included in this prospective study. Our study was separated into 3 different batches and most surgeons failed to pass the examination (n = 12, 8, and 9, for batches 1, 2, and 3, respectively). The "failed" surgeon, additionally, tended to be older than the "passed" cohort (49.3 ± 7.4 vs 42.1 ± 7.3 years old, p = 0.005). In terms of duration of hours spent training on the robot, there was little difference training hours between the cohort that passed and the cohort that failed cohort (10.0 [8.4-10.1] vs 10.0 [8.0-10.0], respectively) with a p value of 0.265. We found no correlation between the total hours spent in the training program and surgeon performance on the Sinaflex robotic telesurgery system. Structured robot surgical training courses must be incorporated into the training programs.

Assessment of laparoscopic intracorporeal intestinal anastomosis training using simulation-based 3D printed models: exploring surgical performance and learning curves

BACKGROUND AND AIMS

Intestinal anastomosis is a clinical procedure widely used to reconstruct the digestive tract, but authentic laparoscopic intracorporeal intestinal anastomosis (LIIA) models are lacking. However, three-dimensional (3D) printing can enable authentic and reusable models. In this paper, a novel cost-effective 3D-printing training model of LIIA is designed and the authenticity and validity of the model are tested.

METHODS

A fused deposition modeling 3D printing and an assembled lab model were built to test LIIA. Fifteen surgeons were required to perform LIIA, and their operation score and time were recorded and analyzed. Five experts were invited to assess the face and content validity of the models. A study was also performed to further evaluate and validate the learning curve of surgeons.

RESULTS

The difference in modified anastomosis objective structured assessment of technical skills (MAOSATS) scores between the expert, intermediate, and novice groups were significant (64.1±1.8: 48.5±1.7: 29.5±3.1, P <0.001). In addition, the operation time of the procedure was statistically different for all three groups (21.5±1.9: 30.6±2.8:70.7±4.0, P<0.001 ). The five experts rated the face and content validity of the model very highly, with the median being four out of five. Surgeons who underwent repeated training programs showed improved surgical performance. After eight training sessions, the novices' performance was similar to that of the average level of untrained intermediates, while the operation scores of the intermediates were close to that of the average level of experts.

CONCLUSIONS

In this study, it is found that the LIIA model exhibits excellent face, content, and construct validity. Repeated simulation training of the LIIA training program improved the surgeon's operative performance, so the model is considered one of the most effective methods for LIIA training and assessment of surgical quality in the future and for reducing healthcare costs.

Robotic-assisted versus laparoscopic bowel anastomoses: randomized crossover in vivo experimental study

BACKGROUND

Initial learning curves are potentially shorter in robotic-assisted surgery (RAS) than in conventional laparoscopic surgery (LS). There is little evidence to support this claim. Furthermore, there is limited evidence how skills from LS transfer to RAS.

METHODS

A randomized controlled, assessor blinded crossover study to compare how RAS naïve surgeons (n = 40) performed linear-stapled side-to-side bowel anastomoses in an in vivo porcine model with LS and RAS. Technique was rated using the validated anastomosis objective structured assessment of skills (A-OSATS) score and the conventional OSATS score. Skill transfer from LS to RAS was measured by comparing the RAS performance of LS novices and LS experienced surgeons. Mental and physical workload was measured with the NASA-task load index (NASA-Tlx) and the Borg-scale.

OUTCOMES

In the overall cohort, there were no differences between RAS and LS for surgical performance (A-OSATS, time, OSATS). Surgeons that were naïve in both LS and RAS had significantly higher A-OSATS scores in RAS (Mean (Standard deviation (SD)): LS: 48.0 ± 12.1; RAS: 52.0 ± 7.5); p = 0.044) mainly deriving from better bowel positioning (LS: 8.7 ± 1.4; RAS: 9.3 ± 1.0; p = 0.045) and closure of enterotomy (LS: 12.8 ± 5.5; RAS: 15.6 ± 4.7; p = 0.010). There was no statistically significant difference in how LS novices and LS experienced surgeons performed in RAS [Mean (SD): novices: 48.9 ± 9.0; experienced surgeons: 55.9 ± 11.0; p = 0.540]. Mental and physical demand was significantly higher after LS.

CONCLUSION

The initial performance was improved for RAS versus LS for linear stapled bowel anastomosis, whereas workload was higher for LS. There was limited transfer of skills from LS to RAS.

Development of biotissue training models for anastomotic suturing in pancreatic surgery

BACKGROUND

Anastomotic suturing is the Achilles heel of pancreatic surgery. Especially in laparoscopic and robotically assisted surgery, the pancreatic anastomosis should first be trained outside the operating room. Realistic training models are therefore needed.

METHODS

Models of the pancreas, small bowel, stomach, bile duct, and a realistic training torso were developed for training of anastomoses in pancreatic surgery. Pancreas models with soft and hard textures, small and large ducts were incrementally developed and evaluated. Experienced pancreatic surgeons (n = 44) evaluated haptic realism, rigidity, fragility of tissues, and realism of suturing and knot tying.

RESULTS

In the iterative development process the pancreas models showed high haptic realism and highest realism in suturing (4.6 ± 0.7 and 4.9 ± 0.5 on 1-5 Likert scale, soft pancreas). The small bowel model showed highest haptic realism (4.8 ± 0.4) and optimal wall thickness (0.1 ± 0.4 on -2 to +2 Likert scale) and suturing behavior (0.1 ± 0.4). The bile duct models showed optimal wall thickness (0.3 ± 0.8 and 0.4 ± 0.8 on -2 to +2 Likert scale) and optimal tissue fragility (0 ± 0.9 and 0.3 ± 0.7).

CONCLUSION

The biotissue training models showed high haptic realism and realistic suturing behavior. They are suitable for realistic training of anastomoses in pancreatic surgery which may improve patient outcomes.

What are clinically relevant performance metrics in robotic surgery? A systematic review of the literature

A crucial element of any surgical training program is the ability to provide procedure-specific, objective, and reliable measures of performance. During robotic surgery, objective clinically relevant performance metrics (CRPMs) can provide tailored contextual feedback and correlate with clinical outcomes. This review aims to define CRPMs, assess their validity in robotic surgical training and compare CRPMs to existing measures of robotic performance. A systematic search of Medline and Embase databases was conducted in May 2022 following the PRISMA guidelines. The search terms included Clinically Relevant Performance Metrics (CRPMs) OR Clinically Relevant Outcome Measures (CROMs) AND robotic surgery. The study settings, speciality, operative context, study design, metric details, and validation status were extracted and analysed. The initial search yielded 116 citations, of which 6 were included. Citation searching identified 3 additional studies, resulting in 9 studies included in this review. Metrics were defined as CRPMs, CROMs, proficiency-based performance metrics and reference-procedure metrics which were developed using a modified Delphi methodology. All metrics underwent both contents and construct validation. Two studies found a strong correlation with GEARS but none correlated their metrics with patient outcome data. CRPMs are a validated and objective approach for assessing trainee proficiency. Evaluating CRPMs with other robotic-assessment tools will facilitate a multimodal metric evaluation approach to robotic surgery training. Further studies should assess the correlation with clinical outcomes. This review highlights there is significant scope for the development and validation of CRPMs to establish proficiency-based progression curricula that can be translated from a simulation setting into clinical practice.

Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial

Background: Distance learning is an interactive way of education when teachers and students are physically separated. Our purpose was to examine its effectivity in training of basic surgical techniques and to provide an alternative sustainable methodology for the training of medical professionals. Methods: Sixty students were involved in our single blinded randomized controlled study. Six homogenized groups were created then randomized into three groups of distance learning and three groups of in-person teaching. The groups completed the same curriculum using our own “SkillBox”. All students took the same pre- and post-course test evaluated blindly. The students filled out an online feedback form after the course. A financial analysis was also made. Results: There was no significant difference in the post-course exam results (distance 28.200 vs. in-person 25.200). We managed to achieve significantly better improvements in the distance learning of suturing (distance 19.967 vs. in-person 15.900, p = 0.043). According to 93% of the study group students, the quality of teaching did not decrease compared to the traditional classes. Conclusion: The results of the students improved similarly in distance learning and in-person education. The online form of teaching was received positively among the students; they found it an effective and good alternative.