Training, assessment and competency in gynaecologic surgery

Midwifery students' opinions about episiotomy training and using virtual reality: A qualitative study

BACKGROUND

The use of simulations and digital technologies in education in the health field is common. Virtual reality technologies, which offer three-dimensional (immersive) simulation environments, have become easily accessible and cost-effective in recent years and this has this has increased this use of this technology in educating students who will work in the health field.

OBJECTIVES

The aim of the study was to investigate the views of midwifery undergraduate students about the current episiotomy education they received and their expectations when related education is given with virtual reality technology.

PARTICIPANTS

Students in their third or fourth year of undergraduate midwifery who have taken prior episiotomy education.

DESIGN

The research was carried out as a phenomenological design for qualitative research. Data were collected between December 2022 and January 2023 at a public university in Türkiye, with institutional ethical approval.

METHODS

Participants were asked open-ended questions to collect qualitative data. Data were analysed using content analysis by MaxQDA.

RESULTS

Data were analysed, and four main themes were determined. These main themes consisted of 16 sub-themes, and included midwifery department students' positive and negative opinions about the current episiotomy education and their expectations in cases where the education is carried out using virtual education environments.

CONCLUSIONS

Although the current episiotomy education has positive aspects, such as suturing ability, it does not give a sense of reality, is not repetitive, and has many negative aspects, such as cost. It was determined that in virtual reality episiotomy education environments, students' expectations are similar to the real birth environment, and they have expectations of simulating risky situations because they think it will be more useful.

Development of a 3D Printed Lung Model Made of Synthetic Materials for Simulation

BACKGROUND

 Considering the complexity of lung structures and the difficulty of thoracoscopic surgery, simulation-based training is of paramount importance for junior surgeons. Here, we aim to design a high-fidelity lung model through utilizing the three-dimensional (3D) printing technology combined with synthetic materials to mimic the real human lung.

METHODS

 The 3D printed lung model was manufactured based on the computed tomography images of a randomly selected male patient. Synthetic materials were used for the construction of lung parenchyma, blood vessels, and bronchi. Then, the model was assessed in terms of its visual, tactile, and operational features by participants (the senior surgeons, junior surgeons, and medical students), who were asked to complete the specially designed survey-questionnaires.

RESULTS

 A 3D printed model of the right lung made of synthetic materials was successfully fabricated. Thirty subjects participated in our study (10 senior surgeons, 10 junior surgeons, and 10 medical students). The average visual evaluation scores for senior surgeons, junior surgeons, and medical students were 3.97 ± 0.61, 4.56 ± 0.58, 4.76 ± 0.49, respectively. The average tactile evaluation scores were 3.40 ± 0.50, 4.13 ± 0.68, 4.00 ± 0.64, respectively. The average operation evaluation scores were 3.33 ± 0.83, 3.93 ± 0.66, 4.03 ± 0.66, respectively. Significant lower scores were obtained in the group of the senior surgeons compared with the other two groups.

CONCLUSION

 A high level of fidelity was exhibited in our 3D printed lung model and it could be applied as a promising simulator for the surgical training in the future.

The effectiveness of problem-based learning in gynecology and obstetrics education in China: A meta-analysis of randomized controlled trials

BACKGROUND

A meta-analysis was conducted to assess the effectiveness of problem-based learning (PBL) in gynecology and obstetrics education in China.

METHODS

English and Chinese databases were systematically searched for eligible studies that compared the effects of PBL and traditional teaching methods measuring theoretical knowledge, student satisfaction, clinical operations, and clinical practice scores in gynecology and obstetrics education in China. The authors restricted included studies to randomized controlled trials and performed a meta-analysis. Standardized mean difference (SMD) and risk ratio with 95% confidence interval (CI) were estimated.

RESULTS

A total of 38 randomized controlled trials with 3005 participants were included. Compared with traditional teaching group, the PBL group significantly increased theoretical knowledge scores (SMD: 3.17, 95% CI: 2.28, 4.07), student satisfaction (risk ratio: 1.29, 95% CI: 1.16, 1.43), clinical operations (SMD: 1.15, 95% CI: 0.93, 1.37) and clinical practice (SMD: 2.17, 95% CI: 3.63, 2.71).

CONCLUSION

The current research shows that PBL in gynecology and obstetrics education in China is more effective than the traditional teaching in enhancing theoretical knowledge, student satisfaction, clinical operations, and clinical practice scores. However, more delicate-designed studies on this topic are needed in the future to validate these results.

An Educational Network for Surgical Education Supported by Gamification Elements: Protocol for a Randomized Controlled Trial

Background

Traditionally, medical students have learned surgical skills by observing a resident physician or surgeon who is performing the technique. Due to inconsistent practice opportunities in the clinical setting, a disparity of skill levels among students has been observed. In addition, the poor availability of faculty professors is a limiting factor in teaching and adequately preparing medical students for their clerkship years. With the ongoing COVID-19 pandemic, medical students do not have access to traditional suturing learning opportunities. Didactic courses are available on videoconferencing platforms; however, these courses do not include technical training.

Objective

Our overarching goal is to evaluate the efficacy and usability of web-based peer-learning for advanced suturing techniques (ie, running subcuticular sutures). We will use the Gamified Educational Network (GEN), a newly developed web-based learning tool. We will assess students’ ability to identify and perform the correct technique. We will also assess the students’ satisfaction with regard to GEN.

Methods

We will conduct a prospective randomized controlled trial with blinding of expert examiners. First-year medical students in the Faculty of Medicine of Université de Montréal will be randomized into four groups: (1) control, (2) self-learning, (3) peer-learning, and (4) peer-learning with expert feedback. Each arm will have 15 participants who will learn how to perform running subcuticular sutures through videos on GEN. For our primary outcome, the students’ ability to identify the correct technique will be evaluated before and after the intervention on GEN. The students will view eight videos and rate the surgical techniques using the Objective Structured Assessment of Technical Skills Global Rating Scale and the Subcuticular Suture Checklist as evaluation criteria. For our secondary outcomes, students will anonymously record themselves performing a running subcuticular suture and will be evaluated using the same scales. Then, a survey will be sent to assess the students’ acceptance of the intervention.

Results

The study will be conducted in accordance with the Declaration of Helsinki and has been approved by our institutional review board (CERSES 20-068-D). No participants have been recruited yet.

Conclusions

Peer learning through GEN has the potential to overcome significant limitations related to the COVID-19 pandemic and the lack of availability of faculty professors. Further, a decrease of the anxiety related to traditional suturing classes can be expected. We aim to create an innovative and sustainable method of teaching surgical skills to improve the efficiency and quality of surgical training in medical faculties. In the context of the COVID-19 pandemic, the need for such tools is imperative.

Trial Registration

ClinicalTrials.gov NCT04425499; https://clinicaltrials.gov/ct2/show/NCT04425499

International Registered Report Identifier (IRRID)

PRR1-10.2196/21273

Skill Acquisition, Assessment, and Simulation in Minimal Access Surgery: An Evolution of Technical Training in Surgery

Diminishing resources and expanding technologies, such as minimal access surgery, have complicated the acquisition and assessment of technical skills in surgical training programs. However, these challenges have been met with both innovation and an evolution in our understanding of how learners develop technical competence and how to better measure it. As these skills continue to grow in breadth and complexity, so too must the surgical education systems’ ability. This literature review examines and describes the pressures placed on surgical education programs and the development of methods to ameliorate them with a focus on surgical simulation.

A model to teach concomitant patient communication during psychomotor skill development

Many health professionals use psychomotor or task-based skills in clinical practice that require concomitant communication with a conscious patient. Verbally engaging with the patient requires highly developed verbal communication skills, enabling the delivery of patient-centred care. Historically, priority has been given to learning the psychomotor skills essential to clinical practice. However, there has been a shift towards also ensuring competent communication with the patient during skill performance. While there is literature outlining the steps to teach and learn verbal communication skills, little is known about the most appropriate instructional approach to teach how to verbally engage with the patient when also learning to perform a task. A literature review was performed and it identified that there was no model or proven approach which could be used to integrate the learning of both psychomotor and communication skills. This paper reviews the steps to teach a communication skill and provides a suggested model to guide the acquisition and development of the concomitant -communication skills required with a patient at the time a psychomotor skill is performed.

Teaching psychomotor skills in the twenty-first century: Revisiting and reviewing instructional approaches through the lens of contemporary literature

A diverse range of health professionals use psychomotor skills as part of their professional practice roles. Most health disciplines use large or complex psychomotor skills. These skills are first taught by the educator then acquired, performed, and lastly learned. Psychomotor skills may be taught using a variety of widely-accepted and published teaching models. The number of teaching steps used in these models varies from two to seven. However, the utility of these models to teach skill acquisition and skill retention are disputable when teaching complex skills, in contrast to simple skills. Contemporary motor learning and cognition literature frames instructional practices which may assist the teaching and learning of complex task-based skills. This paper reports 11 steps to be considered when teaching psychomotor skills.

A comprehensive review on learning curve associated problems in endoscopic vein harvesting and the requirement for a standardised training programme

Endoscopic vein harvesting is becoming one of the most favourable vein harvesting techniques in multiple bypass coronary surgery, due to its short term post-operative benefits with high patient satisfaction. However, long-term graft patency has been both supported and questioned in the literature. Graft failure can be affected by harvesting methods and operator's experience. Endoscopic vein harvesting is associated with a learning curve period, during which the incidence of vein trauma is high due to unfamiliarity with the surgical technique. There is a paucity of structured learning tools for novice practitioners, meaning that training differs significantly between hospital centres. Inconsistent training methods can lead to poor surgical technique, which can have a significant impact on vein quality and stress level of the practitioner. In turn, this can lead to increased postoperative complications and longer surgical duration. The main aim of this literature review is to understand the impact of the learning curve on the vein conduit and whether there is a requirement for a standardised training programme for the novice practitioners.

Assessment tool for total laparoscopic hysterectomy: a Delphi consensus survey among international experts

OBJECTIVE

 To achieve consensus among experts on the essentials steps to include in an assessment tool for total laparoscopic hysterectomy. 

METHODS

 Using a Delphi consensus process, an initial survey was created based on the current literature and local expertise in laparoscopic surgery and sent to international experts in laparoscopic gynaecology. Experts were selected according to specific criteria. A second survey was formulated based on the answers and comments from the first round and sent to all experts who participated in the first round. Consensus was defined as a Cronbach alpha ≥ 0.80. A rate of agreement ≥ 0.70 was used to define which substeps to keep in the final tool.

RESULTS

 From the 85 experts invited to participate, 53 (62%) agreed to participate, and 51 of these participated in both rounds. The final instrument to assess total laparoscopic hysterectomy was created using the items with a high level of agreement after two rounds. This final tool showed good internal consistency among the experts, with a Cronbach alpha of 0.90.

CONCLUSION

 Using a Delphi methodology, we achieved international consensus among experts in laparoscopic gynaecology within a short time frame and with minimal costs. The resulting evaluation tool for total laparoscopic hysterectomy may serve in the assessment of surgical skills in the future, and would be a valuable adjunct to postgraduate training and continuing medical education programs. This tool will now undergo a validation process, comparing the rating scores of novices and experts surgeons.

Trends in reported resident surgical experience in hysterectomy

STUDY OBJECTIVE

To compare differences in trends in reported surgical experience of residents in obstetrics and gynecology in the United States insofar as abdominal, vaginal, and laparoscopic hysterectomy.

DESIGN

Retrospective analysis of the national case log reports from the Accreditation Council for Graduate Medical Education (ACGME) for obstetrics and gynecology cases logged as "surgeon" from 2002 to 2012 (Canadian Task Force classification III).

SETTING

AGCME-accredited residency programs in obstetrics and gynecology.

PARTICIPANTS

Eleven thousand five hundred and eight graduating residents in obstetrics and gynecology (n = 11 508).

MEASUREMENTS AND MAIN RESULTS

Since 2008, when the ACGME began reporting the 4-year cumulative hysterectomy case load statistics for graduating residents in obstetrics and gynecology, there has been no significant change in the mean (SD) number of hysterectomies performed by residents from 118.1 (38.0) cases in 2008-2009 to 116.1 (31.0) cases in 2011-2012 (p = .16; 95% confidence interval [CI], -0.78 to 4.78). During the past decade, however, the total number of reported abdominal hysterectomies consistently decreased from 89.1 (34.2) cases in 2002-2003 to 59.1 (21.0) cases in 2011-2012 (28% decrease; p <.001; 95% CI, 27.7-32.3). The number of vaginal hysterectomies also trended down from 34.9 (19.2) cases to 19.4 (9.0) cases (40% decrease; p <.001; 95% CI, 14.3-16.7). The ACGME did not report the number of laparoscopic hysterectomies performed by residents until 2008-2009, when residents reported performing 23.4 (17.0) cases. From 2008 to 2012, this number increased to 38.5 (20.0) cases (72% increase; p <.001; 95% CI, 13.6-16.6). The proportion of reported laparoscopic hysterectomies performed with robotic assistance was not separately reported.

CONCLUSIONS

Although the overall number of hysterectomies reported by residents has remained stable since 2008, the predominant modes of hysterectomy during the past decade have changed substantially, with laparoscopic hysterectomy comprising an increasingly large proportion of resident experience. As laparoscopic hysterectomy has become more common, reported cases of abdominal and vaginal hysterectomies have decreased. Additional statistics on the percentage of laparoscopic hysterectomies performed using robotic assistance would be valuable to additionally analyze the effect of this new technology on resident training.

Teaching elliptical excision skills to novice medical students: a randomized controlled study comparing low- and high-fidelity bench models

BACKGROUND

The search for alternative and effective forms of training simulation is needed due to ethical and medico-legal aspects involved in training surgical skills on living patients, human cadavers and living animals.

AIMS

To evaluate if the bench model fidelity interferes in the acquisition of elliptical excision skills by novice medical students.

MATERIALS AND METHODS

Forty novice medical students were randomly assigned to 5 practice conditions with instructor-directed elliptical excision skills' training (n = 8): didactic materials (control); organic bench model (low-fidelity); ethylene-vinyl acetate bench model (low-fidelity); chicken legs' skin bench model (high-fidelity); or pig foot skin bench model (high-fidelity). Pre- and post-tests were applied. Global rating scale, effect size, and self-perceived confidence based on Likert scale were used to evaluate all elliptical excision performances.

RESULTS

The analysis showed that after training, the students practicing on bench models had better performance based on Global rating scale (all P < 0.0000) and felt more confident to perform elliptical excision skills (all P < 0.0000) when compared to the control. There was no significant difference (all P > 0.05) between the groups that trained on bench models. The magnitude of the effect (basic cutaneous surgery skills' training) was considered large (>0.80) in all measurements.

CONCLUSION

The acquisition of elliptical excision skills after instructor-directed training on low-fidelity bench models was similar to the training on high-fidelity bench models; and there was a more substantial increase in elliptical excision performances of students that trained on all simulators compared to the learning on didactic materials.

Low-fidelity bench models for basic surgical skills training during undergraduate medical education

It is remarkable the reduction in the number of medical students choosing general surgery as a career. In this context, new possibilities in the field of surgical education should be developed to combat this lack of interest. In this study, a program of surgical training based on learning with models of low-fidelity bench is designed as a complementary alternative to the various methodologies in the teaching of basic surgical skills during medical education, and to develop personal interests in career choice.

Simulation-based cutaneous surgical-skill training on a chicken-skin bench model in a medical undergraduate program

BACKGROUND

Because of ethical and medico-legal aspects involved in the training of cutaneous surgical skills on living patients, human cadavers and living animals, it is necessary the search for alternative and effective forms of training simulation.

AIMS

To propose and describe an alternative methodology for teaching and learning the principles of cutaneous surgery in a medical undergraduate program by using a chicken-skin bench model.

MATERIALS AND METHODS

One instructor for every four students, teaching materials on cutaneous surgical skills, chicken trunks, wings, or thighs, a rigid platform support, needled threads, needle holders, surgical blades with scalpel handles, rat-tooth tweezers, scissors, and marking pens were necessary for training simulation.

RESULTS

A proposal for simulation-based training on incision, suture, biopsy, and on reconstruction techniques using a chicken-skin bench model distributed in several sessions and with increasing levels of difficultywas structured. Both feedback and objective evaluations always directed to individual students were also outlined.

CONCLUSION

The teaching of a methodology for the principles of cutaneous surgery using a chicken-skin bench model versatile, portable, easy to assemble, and inexpensive is an alternative and complementary option to the armamentarium of methods based on other bench models described.

Standards for gynecologic surgery

There are significant problems to consider when we reflect on "Standards for Gynecologic Surgery." Surely most professional standards are already in place, or are they? Are standards already available, locally, nationally, or internationally? Where those standards are not already available will it be possible set new standards for the multiplicity of operative interventions, performed by an array of trainees, specialists, and colleagues many of whom are outside of our remit and spread over the continents? If we do set standards how do we audit outcomes to gynecologic surgery and insure that the standards are being complied with? How do we tutor our trainees effectively and also insure that established specialists retain their skill base, are up-to-date, and compliant with continuing medical education? It is important to realize that the success or failure of a modern surgical investigation or procedure will now be judged not on the pure surgical outcome alone, but will also need to reflect patient focus through excellence in the areas of communication, patient information, informed consent and confidentiality. The accessibility to services, appropriate environment, and processes being offered by trained and competent staff members-who are supervised when required-should all be included in audits of outcomes set against agreed auditable standards.

Teaching and assessing endoscopic sinus surgery skills on a validated low-cost task trainer

OBJECTIVES/HYPOTHESIS

To evaluate a previously validated low-cost sinus surgery task trainer as a means of acquiring basic endoscopic sinus surgery skills and as an objective structured assessment of technical skills (OSATS) to determine procedural competency.

STUDY DESIGN

Prospective blinded study.

METHODS

Medical students (N = 52) with no sinus surgery experience learned to perform nasal endoscopy and five specific sinus surgery tasks using the validated task trainer. Training included regimented expert instruction, peer instruction/observation, and experienced-based learning. Pre- and post-training video recordings of nasal endoscopy and five sinus surgery skills were obtained. Two blinded expert otolaryngologists compared pre- and post-training performance using a checklist and global rating scale.

RESULTS

Medical student post-training performance was significantly better than pre-training performance for each checklist item and global rating scale as calculated by paired t test (P < .001). Interrater reliability and internal consistency were confirmed by Kendall's coefficient of concordance and Cronbach's α calculations, respectively.

CONCLUSIONS

The sinus surgery task trainer provides an effective means of teaching and evaluating nasal endoscopy and basic sinus surgery skills for novice surgeons. With repeated practice, there was significant improvement in performance. An OSATS using the sinus surgery task trainer suggests that we can effectively measure endoscopic sinus surgery ability with the potential to reliably determine competency outside the operating room.

Basic Plastic Surgery Skills Training Program on Inanimate Bench Models during Medical Graduation

Due to ethical and medical-legal drawbacks, high costs, and difficulties of accessibility that are inherent to the practice of basic surgical skills on living patients, fresh human cadaver, and live animals, the search for alternative forms of training is needed. In this study, the teaching and learning process of basic surgical skills pertinent to plastic surgery during medical education on different inanimate bench models as a form of alternative and complementary training to the teaching programs already established is proposed.

Dermatosurgery: total quality management in a dermatology department

BACKGROUND

Dermatosurgery (DS) is a growing sector in dermatology. Performance measurement is organized worldwide to improve the quality of health care. Clinical audit relies on self-assessment, comparison with guidelines, frames of references and implementation of improvement actions.

OBJECTIVE

To assess the efficiency of our DS department.

METHODS

A clinical audit focusing on the organization of the DS unit, patient routing, continuing medical education and training for students was conducted by two external auditors. After an initial evaluation, improvements were implemented and reassessed 1 year later by the same auditors.

RESULTS

The audit resulted in the implementation of preoperative consultation, improved pre- and postoperative information leaflets for patients, standardizing of surgery reports, earmarking of funds for materials, and patient satisfaction survey. The training of residents was organized.

CONCLUSION

This audit was a driving force for communication among the medical and paramedical teams and helped improve patient care and training of residents in DS. It also highlighted areas needing further improvement.

Educational value of an intensive and structured interval practice laparoscopic training course for residents in obstetrics and gynecology: a four-year prospective, multi-institutional recruitment study

OBJECTIVE

To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents.

DESIGN

Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate.

SETTING

International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France.

PARTICIPANTS

191 PGY2 or PGY3 residents from different institutions.

RESULTS

Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p < 0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p < 0.0001).

CONCLUSIONS

Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Teaching and training in laparoscopic surgery: experience of Catholic Laparoscopy Advanced Surgery School in the basic gynecological surgery

PURPOSE

To evaluate the effectiveness of our training method for basic "hands-on" laparoscopic courses.

METHODS

A prospective observational study between September 2008 and December 2010 at Catholic Laparoscopy Advanced Surgery School of the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Sacred Heart-Rome, was conducted. Each course lasted for 3 days, divided into theoretical and practical parts, ending with a live surgery. Gynecologists who attended our 'hands-on' laparoscopic courses had no or minimum experience with laparoscopic technique. The teachers were expert laparoscopists of our Division, and every single group of participants had the same tutor for the entire course. Trainees completed self-assessment anonymous questionnaire of laparoscopic knowledge, before and immediately after the course.

RESULTS

During the study period, we performed 20 basic courses, enrolling 120 consecutive gynecologists. Among them, 114 (95%) decided to participate. Average age was 41 years (range 35-60 years) and 108 (94.7%) trainees were Italian. The subjective assessment showed an immediate improvement of motor skills.

CONCLUSIONS

Laparoscopic training course can improve both theoretical knowledge and motor skills. Such courses result in a short-term subjective improvement.

Value of an objective assessment tool in the operating room

BACKGROUND

Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intraoperative use.

METHODS

Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience.

RESULTS

Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p=0.008, 95% confidence interval 0.44-1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors.

CONCLUSION

Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.

Are minimally invasive procedures harder to acquire than conventional surgical procedures?

BACKGROUND

It is frequently suggested that minimally invasive surgery (MIS) is harder to acquire than conventional surgery. To test this hypothesis, residents' learning curves of both surgical skills are compared.

METHODS

Residents had to be assessed using a general global rating scale of the OSATS (Objective Structured Assessment of Technical Skills) for every procedure they performed as primary surgeon during a 3-month clinical rotation in gynecological surgery.

RESULTS

Nine postgraduate-year-4 residents collected a total of 319 OSATS during the 2 years and 3 months investigation period. These assessments concerned 129 MIS (laparoscopic and hysteroscopic) and 190 conventional (open abdominal and vaginal) procedures. Learning curves (in this study defined as OSATS score plotted against procedure-specific caseload) for MIS and conventional surgery were compared using a linear mixed model. The MIS curve revealed to be steeper than the conventional curve (1.77 vs. 0.75 OSATS points per assessed procedure; 95% CI 1.19-2.35 vs. 0.15-1.35, p < 0.01).

CONCLUSIONS

Basic MIS procedures do not seem harder to acquire during residency than conventional surgical procedures. This may have resulted from the incorporation of structured MIS training programs in residency. Hopefully, this will lead to a more successful implementation of the advanced MIS procedures.

Meaningful assessment method for laparoscopic suturing training in augmented reality

BACKGROUND

To be an effective training tool, a laparoscopic simulator has to provide metrics that are meaningful and informative to the trainee. Time, path length and smoothness are often used parameters, but are not very informative on the quality of the performance. This study aims to validate a newly developed assessment method for laparoscopic suturing on the ProMIS augmented reality simulator, and compares it with scores of objective observers.

METHODS

Twenty-four participants practised their suturing skills on the augmented reality suturing module: experienced participants (n = 10), >50 clinical laparoscopic suturing experience; and novice participants (n = 14), without laparoscopic experience. The performances were recorded and assessed by two unrelated observers and compared with the assessment scores. The assessment score was a calculation of time spent in the correct area and quality (strength) of the knot. To test the accuracy of the individual assessment parameters, we compared these with each other.

RESULTS

The experienced participants had significantly higher performance scores than the novice participants in the beginner-level mode (mean 95.73 vs. 60.89, standard deviation 2.63 vs. 17.09, p < 0.001, independent t-test). The performance scores of the assessment method (n = 43) correlated significantly with the scorings of the objective observers (Spearman's rho 0.672; p < 0.001). The parameter time spent in correct area had a calculated significant correlation with the strength of the knot (n = 229, Spearman's rho 0.257, p < 0.001), but this was clinically irrelevant.

CONCLUSION

This assessment method is a valid tool for objectively assessing laparoscopic suturing skills. Although assessment parameters can correlate, to provide informative feedback it is important to combine meaningful measurements in the assessment of suturing skills.

Intraoperative monitoring of laparoscopic skill development based on quantitative measures

BACKGROUND

Methods for evaluating standard skills in the operating room typically are based on direct observation and checklists, but such evaluations are time consuming and can be subject to bias. It often is possible to acquire more objective measurements using surgical simulators. However, motor performance in simulators can differ significantly from that in the operating room. Intraoperative assessment is particularly challenging because of the significant variability between procedures related to differences in the patients, the surgical setup, and the team. This study aimed to evaluate the feasibility of using a new framework for interpreting quantitative measures acquired in the operating room to distinguish between levels of laparoscopic skill development.

METHODS

Two levels of surgical skill development were observed, namely, those of three fourth-year residents and three attending surgeons performing three laparoscopic cholecystectomies each. Electromagnetic position sensors were attached by the surgeons to a 5-mm curved dissector and a 5-mm atraumatic grasper. From the tools' position histories and video recordings, time, kinematics, and movement transition measures were extracted. Various measures such as the Kolmogorov-Smirnov statistic and the Jensen-Shanon Divergence were used to provide intuitive dimensionless difference measures ranging from 0 to 1. These scores were used to compare residents and expert surgeons executing two surgical tasks: exposure of Calot's triangle and dissection of the cystic duct and artery.

RESULTS

The two groups could be clearly differentiated in both tasks during monitoring for the dominant hand (analysis of variance [ANOVA] and Mann-Whitney; p < 0.05) but not for the nondominant hand.

CONCLUSIONS

It is practical to acquire time, kinematic, and movement transition measures intraoperatively using video and electromagnetic position-sensing technologies. Principal component analysis proved to be a useful technique for presenting differences between skill levels based on those measures. The authors conclude that objective assessment of intraoperative surgical motor behavior is feasible and likely practical.

[Surgery training of gynecologic residents: master and student in the operating room]

OBJECTIVES

Describe the surgical training of gynecologic residents in the operating room, by collecting the opinion of French gynecologists.

MATERIALS AND METHODS

A questionnaire investigating this subject was put on a web site. Every French gynecologist could answer the questionnaire from a duration of six months. The data of the inquiry were studied by comparing five groups: residents (group 1), fellows (group 2), seniors of public hospital (group 3), and seniors of private hospitals (group 4), or, groups 2, 3 and 4 together, as Group A.

RESULTS

Six hundred and fifty-seven gynecologists answered the inquiry. For the residents, lack of time and senior's weak educational motivation are the explanations most frequently retained in order to explain that residents do not operate. For group A, it is rather the residents' skills which is the most important fact to have residents operate. Residents more often practice surgery in general public hospital that in faculty hospital. For 31% of all the referees, heads of departments do not incite their teams to have residents operate. Nearly 25% of all the investigated believe that a man operates more than a woman in resident curriculum. Besides, by analyzing the answers of groups 1 and 2, we were able to correlate resident seniority at their first practice of 13 surgical operations. For 26% of the group A, residents operate less than they do during their own studies. Finally, all the investigated confirm the lack of surgical assessment in the resident curriculum.

DISCUSSION AND CONCLUSION

Decision to let the resident operate remains too dependent on senior personal appreciation and does not seem to join a strategy of training. Opinions of surgical training in the operating room is different between residents and seniors. Operating time increases when residents operate but there is no effect on quality of care. These results show again the necessity of a formal teaching and assessment, in a resident program with objectives, collecting every resident's surgery volume. These educational improvements will contribute certainly to the professionalization of residents.

The benefits of virtual reality simulator training for laparoscopic surgery

PURPOSE OF REVIEW

Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS

Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon's deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY

It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Risk management in gynaecology: principles and practice

The majority of gynaecology patients are fit women receiving relatively straightforward care. However, human error is inevitable. Furthermore, new treatments and technologies are constantly emerging, today's trainees are less experienced than their predecessors, and the need for team work is greater than ever. These and other factors pose threats to patient safety. Patient safety can be improved through risk management. This review describes risk management principles and tools applicable to gynaecology and highlights common sources of patient safety incidents in gynaecology clinics, wards and operating theatres. It provides an overview of communication, consent, staff training and supervision, and use of clinical practice guidance. Underlying theoretical principles are amply illustrated by practical examples.

Facilitating learning in the operating theatre and intensive care unit

Almost every aspect of anaesthetic and intensive care practice can be taught within the operating theatre and intensive care unit. This includes knowledge in the areas of medicine, anatomy, pharmacology, physiology, measurement and statistics, invaluable psychomotor and global skills and abilities, as well as the many important non-clinical aspects of anaesthesia and intensive care including effective communication, leadership, management, ethics and teaching. The operating theatre and intensive care unit offer many advantages and pose numerous challenges to education. This paper briefly discusses what can be taught in the operating theatre and intensive care unit, the educational challenges and benefits of teaching in these unique environments, implications for teaching and what consultants and trainees can do to positively influence the educational activity. The paper concludes with suggestions for facilitating learning in the operating theatre and intensive care unit including the Soldier's Five, practice vivas, skills training, endoscopic dexterity, interesting article exchange, in-service sessions, electronic resources and use out of hours.