Cost and logistics of implementing a tissue-based American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for general surgery residents of all clinical years

Current status of resident simulation training curricula: pearls and pitfalls

BACKGROUND

Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation.

MATERIALS AND METHODS

Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected.

RESULTS

Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding.

CONCLUSIONS

While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

GlobalSurgBox: A Portable Surgical Simulator for Surgical Trainees Worldwide

OBJECTIVES

Identify barriers to surgical simulation in multiple countries across the income spectrum. Evaluate whether a novel, portable surgical simulator (GlobalSurgBox) would be valuable to surgical trainees and overcome these barriers.

DESIGN

Trainees from high-, middle-, and low-income countries were instructed on how to perform surgical skills using the GlobalSurgBox. Participants were sent an anonymized survey after 1 week to evaluate practicality and helpfulness of the trainer.

SETTING

Academic medical centers in 3 countries: USA, Kenya, and Rwanda.

PARTICIPANTS

48 medical students, 48 surgery residents, 3 medical officers, and 3 cardiothoracic surgery fellows.

RESULTS

99.0% of respondents agreed surgical simulation was an important aspect of surgical education. Despite 60.8% having access to simulation resources, only 3 of 40 (7.5%) US trainees, 2 of 12 (16.7%) of Kenyan trainees, and 1 of 10 (10.0%) Rwandan trainees used these resources routinely. 38 (95.0%) US trainees, 9 (75.0%) Kenyan trainees, and 8 (80.0%) Rwandan trainees with access to simulation resources stated there were barriers to using them. The frequently cited barriers included lack of convenient access and lack of time. After using the GlobalSurgBox, 5 (7.8%) US participants, 0 (0%) Kenyan participants, and 5 (38.5%) Rwandan participants reported lack of convenient access as a continued barrier to simulation. 52 (81.3%) US trainees, 24 (96.0%) Kenyan trainees, and 12 (92.3%) Rwandan trainees stated the GlobalSurgBox was a good facsimile of the operating room. 59 (92.2%) US trainees, 24 (96.0%) Kenyan trainees, and 13 (100%) Rwandan trainees stated the GlobalSurgBox better prepared them for clinical settings.

CONCLUSIONS

A majority of trainees across all 3 countries reported multiple barriers to simulation in their current surgical training. The GlobalSurgBox eliminates many of these barriers by providing a portable, affordable, and realistic way to practice skills needed in the operating room.

International Learner Perceptions, Educational Value, and Cost Associated With the Use of Start-to-Finish Surgical Simulation Compared With Cadaveric Models

BACKGROUND

Graduate surgical education is highly variable across regions and institutions regarding case volume and degree of trainee participation in each case. Dedicated educational curriculum using cadaveric tissue has been shown to enhance graduate surgical training, however with associated financial and utility burden to the institution.

OBJECTIVE

To investigate the utility of educational and cost applications of a novel method of combining mixed organic hydrogel polymers and 3-dimensional printed anatomic structures to create a complete "start-to-finish" simulation for resident education in spinal anatomy, instrumentation, and surgical techniques.

METHODS

This qualitative pilot study investigated 14 international participants on achievement of objective and personal learning goals in a standardized curriculum using biomimetic simulation compared with cadaveric tissue. A questionnaire was developed to examine trainee evaluation of individual anatomic components of the biomimetic simulators compared with previous experience with cadaveric tissue.

RESULTS

A total of 210 responses were acquired from 14 participants. Six participants originated from US residency education programs and 8 from transcontinental residency programs. Survey results for the simulation session revealed high user satisfaction. Score averages for each portion of the simulation session indicated learner validation of anatomic features for the simulation compared with previous cadaveric experience. Cost analysis resulted in an estimated savings of $10 833.00 for this single simulation session compared with previous cadaveric tissue sessions.

CONCLUSION

The results of this study indicate a strong potential of establishing biomimetic simulation as a cost-effective and high-quality alternative to cadaveric tissue for the instruction of fundamental spine surgical techniques.

3D Printing of Customizable Phantoms to Replace Cadaveric Models in Upper Extremity Surgical Residency Training

Medical phantoms are commonly used for training and skill demonstration of surgical procedures without exposing a patient to unnecessary risk. The discrimination of these tissues is critical to the ability of young orthopedic surgical trainees to identify patient injuries and properly manipulate surrounding tissues into healing-compliant positions. Most commercial phantoms lack anatomical specificity and use materials that inadequately attempt to mimic human tissue characteristics. This paper covers the manufacturing methods used to create novel, higher fidelity surgical training phantoms. We utilize medical scans and 3D printing techniques to create upper extremity phantoms that replicate both osseous and synovial geometries. These phantoms are undergoing validation through OSATS training of surgical residents under the guidance of attendings and chief residents. Twenty upper extremity phantoms with distal radius fracture were placed into traction and reduced by first- and second-year surgical residency students as part of their upper extremity triage training. Trainees reported uniform support for the training, enjoying the active learning exercise and expressing willingness for participation in future trials. Trainees successfully completed the reduction procedure utilizing tactile stimuli and prior lecture knowledge, showing the viability of synthetic phantoms to be used in lieu of traditional cadaveric models.

Training model in abdominal wall endoscopic surgery for ventral hernias. Extended totally extra-peritoneal approach (e-tep)

Purpose:

To develop a reproducible training program model covering the steps of the extended totally extraperitoneal approach (e-tep) technique for correction of ventral or incisional hernia repair.

Methods:

Training sessions with surgeons in the laboratory using both porcine specimens and a new ethylene vinyl acetate (EVA) model simulating the operative steps of the e-tep technique. Students were interviewed and asked to answer a questionnaire pre and post the sessions to assess their performance and evaluated the course and model.

Results:

A total of 25 trained abdominal wall surgeons was evaluated at the end of the course. It was obtained a 100% satisfaction score of the training, as well as increased confidence levels up to 9 and 10 in all technical aspects of the surgery, having 96% of the surgeons performed a surgery under supervision of the proctors after the course.

Conclusions:

This training model is simple, effective, low cost, and replicable in guidance on the beginning of e-tep technique adoption, and performance. As a result, surgeons can get more confident and more able to perform surgeries employing this technique.

Forensic Implications of Anatomical Education and Surgical Training With Cadavers

Anatomical education and surgical training with cadavers are usually considered an appropriate method of teaching, above all for all surgeons at various levels. Indeed, in such a way they put into practice and exercise a procedure before performing it live, reducing the learning curve in a safe environment and the risks for the patients. Really, up to now it is not clear if the nonuse of the cadavers for anatomical education and surgical training can have also forensic implications. A substantial literature research was used for this review, based on PubMed and Web of Science database. From this review, it is clear that the cadaveric training could be considered mandatory, both for surgeons and for medical students, leading to a series of questions with forensic implications. Indeed, there are many evidences that a cadaver lab can improve the learning curve of a surgeon, above all in the first part of the curve, in which frequent and severe complications are possible. Consequently, a medical responsibility for residents and surgeons which perform a procedure without adequate training could be advised, but also for hospital, that has to guarantee a sufficient training for its surgeons and other specialists through cadaver labs. Surely, this type of training could help to improve the practical skills of surgeons working in small hospitals, where some procedures are rare. Cadaver studies can permit a better evaluation of safety and efficacy of new surgical devices by surgeons, avoiding using patients as ≪guinea pigs≫. Indeed, a legal responsibility for a surgeon and other specialists could exist in the use of a new device without an apparent regulatory oversight. For a good medical practice, the surgeons should communicate to the patient the unsure procedural risks, making sure the patients' full understanding about the novelty of the procedure and that they have used this technique on few, if any, patients before. Cadaver training could represent a shortcut in the standard training process, increasing both the surgeon learning curve and patient confidence. Forensic clinical anatomy can supervise and support all these aspects of the formation and of the use of cadaver training.

High-Fidelity Wrist Fracture Phantom as a Training Tool to Develop Competency in Orthopaedic Surgical Trainees

BACKGROUND

This article will describe the development of a low-cost 3D-printed medical phantom of the arm with a distal radius fracture (DRF) to facilitate training of reduction and splinting techniques. The phantom incorporates tactile responses and visual stimuli from fluoroscopy to assist skill acquisition in a clinical setting. This provides feedback to trainees to help them develop competency and knowledge before providing care to patients.

METHODS

Phantoms were developed through advice and feedback from fellowship-trained hand surgeons and orthopaedic senior and junior residents. Phantoms were then pilot tested during a surgical skills examination, with residents having minimal previous exposure to distal radial reduction techniques. Residents were evaluated on procedure speed and accuracy by attending surgeons using the objective structured assessment of technical skills. Residents then completed a written knowledge examination about relevant requirements of DRF management and feedback on their opinion of the exercise using the Likert scale.

RESULTS

Residents who passed the hands-on examination also scored higher on the written examination. All residents reported that the phantom was beneficial and motivating as part of their overall training.

DISCUSSION

Real-time feedback using a phantom limb and fluoroscopic imaging, in conjunction with guidance from surgeons, allows residents to learn and practice DRF reduction and splinting techniques. These educational exercises are relatively low-cost and remove the risk of potential harm to patients during early skill acquisition. This training method may be a predictor of surgical performance in addition to providing assessment of background knowledge. Additional training sessions will be required to determine the effect of repeat exposure to residents' proficiency and comprehension.

Template for a program tailored ACS/APDS phase 1 curriculum: From needs assessment to implementation

BACKGROUND

The Phase 1 ACS/APDS skills curriculum standardizes intern training. Despite this, institutional implementation varies and is nationally low. We aimed to use Kern's six-steps to tailor this to our program, providing a framework to improve implementation.

METHODS

Problem identification and general needs assessment were performed. Targeted needs assessment (TNA) of incoming interns ('interns'), current residents, and attendings determined perceived importance of skills and intern's previous experience and confidence. Educational strategies were developed. Learner knowledge was assessed before and after modules, deficiencies identified enabled employment of active learning strategies. Modular and curricular evaluations were completed.

RESULTS

TNA determined all interns had been taught knot tying and suturing, and were most confident with suturing, knot tying, and urethral catheterization. Educational strategies included simulation and lectures. Evaluations demonstrated improvement in test scores (pre-v post-) and skills confidence on curricula completion.

CONCLUSION

Our framework utilizes institutional resources and expertise while focusing on determining existing knowledge, skill, and technical deficiencies of learners. This approach demonstrated improvement in knowledge and confidence, and could improve implementation rates of the Phase 1 curriculum.

Institution-specific utilization of the American College of Surgeons/Association of Program Directors operative skills curriculum: From needs assessment to implementation

BACKGROUND

The American College of Surgeons/Association of Program Directors in Surgery operative skills curriculum standardizes training. However, simulation resources are variable with curriculum implementation institution dependent. Our aim was to use Kern's six steps of curricular development to demonstrate how to tailor the American College of Surgeons/Association of Program Directors in Surgery Phase 2 curriculum to program specific needs.

METHODS

Problem identification and general needs assessment was performed. Targeted needs assessment of general surgery residents and attendings was conducted to determine perceived importance of operative skills and residents' confidence with these skills and attendings perceptions of deficiencies in technical skills using the Objective Structured Assessment of Technical Skills criteria. Educational strategies were developed dependent on program resources. The program was piloted between 2018 to 2019 and implemented in the 2019 to 2020 academic year. Assessment of resident technical skills and resident or faculty teaching skills was performed for each session. Resident confidence with procedures was assessed using the Zwisch scale before and after modules. Curricular evaluations were completed by residents after each module.

RESULTS

The previous curriculum did not comprehensively cover Phase 2 modules and was not tailored to the needs of residents. Targeted needs assessment revealed differences in prioritization of learning for techniques by seniority (most important operation for faculty: laparoscopic cholecystectomy, postgraduate year 4 and 5: laparoscopic partial colectomy, interns: open inguinal/femoral hernia repair). Faculty identified technical skills on which to focus (ie, interns' knowledge of a specific procedure, postgraduate year 4 and 5 flow of the operation and forward planning). Educational strategies employed included wet and dry lab simulations and online materials. Residents reported increased procedural confidence after curriculum completion.

CONCLUSION

This comprehensive implementation of the American College of Surgeons/Association of Program Directors in Surgery Phase 2 skills curriculum effectively used resources and expertise of an institution and focused on the knowledge and technical deficiencies of the target learners. Improvement in learner confidence was demonstrated by this approach.

The impact of intensive laparoscopic training course with structured assessment and immediate feedback on residents' operative performance in animal lab

INTRODUCTION

The objective of this study was to examine the impact of an intensive laparoscopic training course incorporating structured assessment and immediate feedback on residents' operative performance in animal lab.

METHODS

Surgical residents participated in a 2-day intensive laparoscopic training course. They performed the same procedures on two consecutive days on live pigs. Junior residents (PGY1-2) performed laparoscopic cholecystectomy and incisional hernia repair and the senior residents (PGY3-5) performed laparoscopic Nissen fundoplication, splenectomy, and low anterior colon resection. Assessment tools with proven validity evidence (global and procedure-specific rating tools for operative assessment of laparoscopic skills) were used to assess their operative performance. Faculty assessment and self-assessments were completed immediately after each procedure on both days. The Wilcoxon rank test was used to examine the effect of training on resident performance after one repetition.

RESULTS

Forty surgical residents (20 junior and 20 senior residents) participated. There was a significant improvement in general laparoscopic skills during incisional hernia repair and Nissen fundoplication using global rating scales (p < 0.05). Moreover, there was an improvement in their performance during cholecystectomy, incisional hernia repair, and low anterior colectomy when procedure-specific skills assessments were used (p < 0.05). There was a positive correlation between residents' self-reported confidences and their operative performance CONCLUSION: Trainees showed significant improvements in performance in general and procedure-specific laparoscopic skills in a wide range of procedures after an intensive training course. This study demonstrates the benefit of a structured training curriculum in improving operative performance in basic and advanced laparoscopic skills in a simulated environment. Future studies are needed to examine the duration of training required to achieve skill retention and competency.

Needs-driven skill training for surgical residents: our first experience in a low-/middle-income country

Traditional Halstead teaching, which is time- and opportunity-dependent, has often been replaced by 'boot' camps which involve expensive modules and are usually a grand one-time event. This does not suit the complex teaching and learning needs of low- and middle-income countries (LMICs). We studied the impact of a needs-driven surgical training course implemented instead. The course was taken by 17 first-year residents of surgery, and included a pre-course knowledge assessment test, pre-test skills assessment, as well as post-test assessment and feedback impressions.Mean post-test scores improved significantly (P < 0.05) in all eight skills areas, though only 7 (44.11%) scored ≥80% in tests after the course, but all 17 in theoretical and clinical skills. There was strong agreement over all six points that the needs-driven course was of benefit. Our short and intensive needs-driven skills video training course for surgical residents fills the gap in skills development for general surgery residents.

Operating room preparation by general surgery residents: A qualitative analysis

BACKGROUND

Surgical education is changing, with residents having less time to learn more procedures. We aim to explore how residents prepare for the operating room and what factors impact their preparation.

METHODS

A qualitative study was conducted using conventional content analysis. General surgery residents at one institution were invited to participate in semi-structured interviews. Each interview was recorded, transcribed verbatim, and then inductively examined to generate themes.

RESULTS

Fourteen residents elected to participate. Six themes were identified: (1) All participants similarly defined preparation, (2) Residents learned through trial and error and co-residents, (3) Factors impacting preparation were time, attendings, autonomy, case complexity, and difficulty finding resources, (4) Resource use varied, (5) PGY level impacted preparation and, (6) Optimal resources were high yield.

CONCLUSION

Although surgical residents similarly defined operating room preparation, they use a variety of different resources to achieve this, which is often difficult and time consuming.

Fresh frozen cadaver workshops for general surgical training

BACKGROUND

The technical proficiency of a surgeon is intricately linked to training and experience. Reduction in working hours, decreased operating time and ethical imperatives to protect patients have all resulted in a decrease in hands-on experience. The introduction of laparoscopic procedures has also decreased trainees' exposure to open operative procedures not routinely performed in the current era.

METHODS

The Clinical Training and Evaluation Centre at The University of Western Australia introduced the Core Skills Workshop for general surgical trainees in 2007. The workshop provides cadaveric dissection time for a range of open procedures. We describe in this article the logistics of setting up and running a cadaveric workshop, the performance and report our trainees' evaluation of the workshop.

RESULTS

The Clinical Training and Evaluation Centre has hosted 26 General Surgery Core Skills Workshops since 2007. There were 227 participants with 196 evaluations returned (response rate 86%). Feedback was strongly positive for the course meeting the participants' expectations as well as its contribution to their skillset. Participants value the use of cadavers and high instructor:student ratios along with performance of a large number of open procedures in the setting of a stress-free workshop and looked forward to more similar courses in the future.

CONCLUSIONS

Fresh frozen cadaver workshops are of value in the face of current surgical training challenges in providing an efficient, effective and safe environment.

Validation of the Omni: A Novel, Multimodality, and Longitudinal Surgical Skills Assessment

OBJECTIVE

The breadth of technical skills included in general surgery training continues to expand. The current competency-based training model requires assessment tools to measure acquisition, learning, and mastery of technical skill longitudinally in a reliable and valid manner. This study describes a novel skills assessment tool, the Omni, which evaluates performance in a broad range of skills over time.

DESIGN

The 5 Omni tasks, consisting of open bowel anastomosis, knot tying, laparoscopic clover pattern cut, robotic needle drive, and endoscopic bubble pop, were developed by general surgery faculty. Component performance metrics assessed speed, accuracy, and quality, which were scaled into an overall score ranging from 0 to 10 for each task. For each task, ANOVAs with Scheffé's post hoc comparisons and Pearson's chi-squared tests compared performance between 6 resident cohorts (clinical years (CY1-5) and research fellows (RF)). Paired samples t-tests evaluated changes in performance across academic years. Cronbach's alpha coefficient determined the internal consistency of the Omni as an overall assessment.

SETTING

The Omni was developed by the Department of Surgery at Duke University. Annual assessment and this research study took place in the Surgical Education and Activities Lab.

PARTICIPANTS

All active general surgery residents in 2 consecutive academic years spanning 2015 to 2017.

RESULTS

A total of 62 general surgery residents completed the Omni and 39 (67.2%) of those residents completed the assessment in 2 consecutive years. Based on data from all residents' first assessment, statistically significant differences (p < 0.05) were observed among CY cohorts for bowel anastomosis, robotic, and laparoscopic task metrics. By pair-wise comparisons, mean bowel anastomosis scores distinguished CY1 from CY3-5 and CY2 from CY5. Mean robotic scores distinguished CY1 from RF, and mean laparoscopic scores distinguished CY1 from RF, CY3, and CY5 in addition to CY2 from CY3. Mean scores in performance on the knot tying and endoscopic tasks were not significantly different. Statistically significant improvement in mean scores was observed for all tasks from year 1 to year 2 (all p < 0.02). The internal consistency analysis revealed an alpha coefficient of 0.656.

CONCLUSIONS

The Omni is a novel composite assessment tool for surgical technical skill that utilizes objective measures and scoring algorithms to evaluate performance. In this pilot study, 3 tasks demonstrated discriminative ability of performance by CY, and all 5 tasks demonstrated construct validity by showing longitudinal improvement in performance. Additionally, the Omni has adequate internal consistency for a formative assessment. These results suggest the Omni holds promise for the evaluation of resident technical skill and early identification of outliers requiring intervention.

The Science of Selection: Using Best Practices From Industry to Improve Success in Surgery Training

BACKGROUND

The selection of high-quality applicants is critical to the future of surgery. However, it is unclear if current practices meet industry criteria of a successful selection system, as measured by administrative efficiency and performance and attrition of those selected.

METHODS

We performed a modified systematic review process to gain an understanding of current selection processes, remediation practices, and attrition rates in surgery residency training programs in the United States. We also conducted semistructured interviews with local residency program directors and coordinators to obtain a specific snapshot of the amount of time and resources dedicated to these activities in various sized programs. The associated financial costs of these activities are also presented.

RESULTS

The administrative costs for current residency selection processes are substantial, ranging from $45,000 to $148,000 for each program per year. Approximately 30% of residents require at least 1 remediation intervention, costing programs $3400 to $5300 per episode, and typically involve concerns around nontechnical skills. Attrition rates range from 20% to 40%.

CONCLUSIONS

This review suggests that additional methodologies may allow surgery residency programs to identify best-fit candidates more efficiently and effectively, while also decreasing remediation and attrition rates. Possible solutions include incorporation of structured interviews, personality inventories, and situational judgment tests. Resources dedicated to current interview practices, remediation efforts, and attrition management can be redirected to support these methodologies. By applying the science of selection and assessment to the recruitment process, programs may be able to make more data-driven decisions to identify candidates who will be successful at their institution.

Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies

BACKGROUND

Preparatory courses for senior medical students aim to ease the transition from medical school to residency. We designed a novel adjunct curriculum to enhance students' readiness for surgical internship. This study addresses the feasibility and outcomes of this course.

MATERIALS AND METHODS

A curriculum was designed based on ACGME surgical milestones. Students participated in 8 (3h) sessions held over 4 weeks as an adjunct to a well-established intern preparatory course. Course activities involved interactive simulation cases to emphasize care of surgical patients, and skills sessions focused on knot tying and suturing, which were reinforced with home video assignments. Students rated confidence on 14 management skills using a 5-point Likert scale (5 = high confidence). Faculty graded students' technical performance using a global scale (0-10) for 5 suturing exercises. Comparisons between precourse and postcourse data collected for all measures were made using t-tests (α = 0.05).

RESULTS

A total of 11 students entering 4 different surgical fields participated. Overall confidence in patient management improved from 2.41 to 3.89 (standard deviation = 0.49, 0.35; p < 0.05). Students' scores on all 5 suturing tasks increased (p < 0.05).

CONCLUSIONS

We developed a surgery-specific component to the existing preparatory course at our institution. Students demonstrated increased confidence in ward management skills and increased technical scores in all exercises. Although only 3 sessions were dedicated to technical skills, improvements may highlight the benefit of home video assignments. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum highlights skills specific for surgical residency, while maximizing resources.

High acceptability of a newly developed urological practical skills training program

Background

Benefits of simulation training are widely recognized, but its structural implementation into urological curricula remains challenging. This study aims to gain insight into current and ideal urological practical skills training and presents the outline of a newly developed skills training program, including an assessment of the design characteristics that may increase its acceptability.

Methods

A questionnaire was sent to the urology residents (n = 87) and program directors (n = 45) of all Dutch teaching hospitals. Open- and close-ended questions were used to determine the views on current and ideal skills training and the newly developed skills training program. Eight semi-structured interviews were conducted with 39 residents and 15 program directors. All interviews were audiotaped, fully transcribed, and thereafter analyzed.

Results

Response was 87.4 % for residents and 86.7 % for program directors. Residents appeared to be still predominantly trained ‘by doing’. Structured practical skills training in local hospitals takes place according to 12 % of the residents versus 44 % of the program directors (p < 0.001). Ideally, residents prefer to practice certain procedures on simulation models first, especially in endourology. The majority of residents (92 %) and program directors (87 %) approved of implementing the newly developed skills training program (p = 0.51). ‘Structured scheduling’, ‘use of peer teaching’ and ‘high fidelity models’ were indicated as design characteristics that increase its acceptability.

Conclusions

Current urological residency training consists of patient-related ‘learning by doing’, although more practice on simulation models is desired. The acceptability of implementing the presented skills-training program is high. Design characteristics that increase its acceptability are structured scheduling, the use of peer teaching and high fidelity models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-015-0084-8) contains supplementary material, which is available to authorized users.

Virtual operating room for team training in surgery

BACKGROUND

We proposed to develop a novel virtual reality (VR) team training system. The objective of this study was to determine the feasibility of creating a VR operating room to simulate a surgical crisis scenario and evaluate the simulator for construct and face validity.

METHODS

We modified ICE STORM (Integrated Clinical Environment; Systems, Training, Operations, Research, Methods), a VR-based system capable of modeling a variety of health care personnel and environments. ICE STORM was used to simulate a standardized surgical crisis scenario, whereby participants needed to correct 4 elements responsible for loss of laparoscopic visualization. The construct and face validity of the environment were measured.

RESULTS

Thirty-three participants completed the VR simulation. Attendings completed the simulation in less time than trainees (271 vs 201 seconds, P = .032). Participants felt the training environment was realistic and had a favorable impression of the simulation. All participants felt the workload of the simulation was low.

CONCLUSIONS

Creation of a VR-based operating room for team training in surgery is feasible and can afford a realistic team training environment.

Identifying Opportunities for Virtual Reality Simulation in Surgical Education: A Review of the Proceedings from the Innovation, Design, and Emerging Alliances in Surgery (IDEAS) Conference: VR Surgery

OBJECTIVES

To conduct a review of the state of virtual reality (VR) simulation technology, to identify areas of surgical education that have the greatest potential to benefit from it, and to identify challenges to implementation.

BACKGROUND DATA

Simulation is an increasingly important part of surgical training. VR is a developing platform for using simulation to teach technical skills, behavioral skills, and entire procedures to trainees and practicing surgeons worldwide. Questions exist regarding the science behind the technology and most effective usage of VR simulation. A symposium was held to address these issues.

METHODS

Engineers, educators, and surgeons held a conference in November 2013 both to review the background science behind simulation technology and to create guidelines for its use in teaching and credentialing trainees and surgeons in practice.

RESULTS

Several technologic challenges were identified that must be overcome in order for VR simulation to be useful in surgery. Specific areas of student, resident, and practicing surgeon training and testing that would likely benefit from VR were identified: technical skills, team training and decision-making skills, and patient safety, such as in use of electrosurgical equipment.

CONCLUSIONS

VR simulation has the potential to become an essential piece of surgical education curriculum but depends heavily on the establishment of an agreed upon set of goals. Researchers and clinicians must collaborate to allocate funding toward projects that help achieve these goals. The recommendations outlined here should guide further study and implementation of VR simulation.

Central venous catheterization using a perfused human cadaveric model: application to surgical education

OBJECTIVE

The purpose of this article is to present a unique training model using a perfused human cadaver for central line placement training with the ultimate goal of reducing central venous catheter mechanical complications.

DESIGN

The applicability of the fresh tissue cadaver model for central line placement was assessed using a 10-item questionnaire with a 5-point Likert-type scale. Respondents were asked to rate their opinions as strongly agree, agree, neutral, disagree, or strongly disagree.

SETTING

All participants received a didactic lecture followed by supervised practice on a commercially available simulator. The students were then relocated to the Fresh Tissue Dissection Laboratory where they practiced central vein catheterization on a fresh perfused human cadaver.

PARTICIPANTS

Course participants included 87 physicians from various medical specialties at different stages of training.

RESULTS

Results of the survey demonstrated that 91% of the participating physicians found the perfused cadaveric model to be a true simulation of conditions that exist in live patients, and 98% reported that the use of this model promoted acquisition of technical skills.

CONCLUSION

The integration of central line placement training on perfused cadavers into residency and fellowship training provides an unparalleled realistic simulation to participants. Further study is needed to assess whether realistic simulation translates into objective end points such as decreased mechanical complications.

Evaluation of Three Sources of Validity Evidence for a Synthetic Thoracoscopic Esophageal Atresia/Tracheoesophageal Fistula Repair Simulator

PURPOSE

Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator.

MATERIALS AND METHODS

Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha.

RESULTS

A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert.

CONCLUSIONS

We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.