Introduction, availability and role of simulation in surgical education and training: Review of current evidence and recommendations from the Association of Surgeons in Training

A systematic review of simulation training for lower extremity bypass procedures

OBJECTIVES

Simulation is used across surgical specialties for skill enhancement. The choice and assessment method of a simulator varies across literature. In the age of endovascular approach, trainees have limited exposure to open lower limb bypass procedures which needs attention. This review aims to assess the utility of simulation training in lower limb bypass surgery using Kirkpatrick's model.

METHODS

Using PRISMA statement, we included all the studies done on simulators in lower limb bypass surgical procedures for this systematic review. The primary outcome was to assess the effectiveness of different types of simulation used for lower limb bypass surgery using the Kirkpatrick's model for training evaluation.

RESULTS

An initial search identified 295 articles out of which 7 articles were found to be eligible for this systematic review. A variety of simulators were used including cadavers and synthetic models. Most studies (n=5) found the use of simulation as an effective tool in achieving technical competence. All the five studies we found at level 2 on Kirpatrick's model evaluation.

CONCLUSION

Most of the existing studies are at level 2 of Kirkpatrick's model which reflects learning changes in trainees after simulation. Feedback mechanism needs to be evolved where the improvement after simulation training can be gauged by its replication in clinical practice and improved patient care practices corresponding to the highest level of Kirkpatrick's model.

Innovating medical education: Development of an affordable, 3-D printed knot-tying simulator

BACKGROUND

Three-dimensional (3-D) printing offers an innovative option to produce clinical simulators because of its low production costs and widespread availability. We aimed to develop a low-cost, 3-D printed knot-tying simulator that overcomes the barriers students face in self-directed skills development.

APPROACH

Medical students completing a procedural residency preparation course (PRPC) completed a pre-survey with Likert scales and multiple choice questions to assess their perceptions of and barriers to self-directed knot-tying practice. Subsequently, a 3-D printed knot-tying simulator, which contains a progression of knot-tying challenges and a designated video curriculum, was designed. After utilising the simulator in a 1-hour, faculty-guided knot-tying session, PRPC students assessed the educational utility and usability of the simulator via a post-survey.

EVALUATION

The primary barriers students faced in engaging in self-directed knot-tying practice included limited accessibility to simulators and insufficient knowledge of knot-tying techniques. Many students (91.3%, n = 21) agreed that practicing with the simulator improved their knot-tying motor skills and was easy to use (100%, n = 23). Twenty-two (95.7%) students agreed that they would continue to use the simulator beyond the knot-tying session and PRPC.

IMPLICATIONS

We demonstrate the educational utility and usability of a novel 3-D printed knot-tying simulator for medical education. Enabling students to engage in self-directed technical skills development is critical in developing surgical skills that can translate to clinical environments. Our simulator highlights the benefits of 3-D printers as an innovative, inexpensive option to improve the availability and accessibility to medical education tools.

Development and validation of a simulation-based assessment of operative competence for higher specialist trainees in general surgery

BACKGROUND

Simulation is increasingly being explored as an assessment modality. This study sought to develop and collate validity evidence for a novel simulation-based assessment of operative competence. We describe the approach to assessment design, development, pilot testing, and validity investigation.

METHODS

Eight procedural stations were generated using both virtual reality and bio-hybrid models. Content was identified from a previously conducted Delphi consensus study of trainers. Trainee performance was scored using an equally weighted Objective Structured Assessment of Technical Skills (OSATS) tool and a modified Procedure-Based Assessment (PBA) tool. Validity evidence was analyzed in accordance with Messick's validity framework. Both 'junior' (ST2-ST4) and 'senior' trainees (ST 5-ST8) were included to allow for comparative analysis.

RESULTS

Thirteen trainees were assessed by ten assessors across eight stations. Inter-station reliability was high (α = 0.81), and inter-rater reliability was acceptable (inter-class correlation coefficient 0.77). A significant difference in mean station score was observed between junior and senior trainees (44.82 vs 58.18, p = .004), while overall mean scores were moderately correlated with increasing training year (rs = .74, p = .004, Kendall's tau-b .57, p = 0.009). A pass-fail score generated using borderline regression methodology resulted in all 'senior' trainees passing and 4/6 of junior trainees failing the assessment.

CONCLUSION

This study reports validity evidence for a novel simulation-based assessment, designed to assess the operative competence of higher specialist trainees in general surgery.

[Learn playfully, operate seriously : The new era of surgical training]

BACKGROUND

Traditional surgical training and further education has historically involved long working hours and hands-on experience within the framework of a teacher-apprentice relationship; however, changes in regulatory policy in the USA and subsequently in Switzerland and the European Union from 2003, led to restrictions in the working hours of medical residents. As a result the traditional method of surgical training "see one, do one, teach one" has come under scrutiny, prompting a search for alternative training methods beyond the confines of the operating theater.

OBJECTIVE

This publication highlights the possibilities and limitations associated with the use of virtual reality (VR) and gamification in surgical training and further education. It examines the ability of these technological resources to enhance the effectiveness and engagement of medical residents and the feasibility of incorporating them into the surgical training curriculum.

MATERIAL AND METHODS

The study was based on a literature search for current developments in surgical training, VR and gamification. Furthermore, various studies and projects that investigated the use of VR and gamification in medical training and further education were analyzed.

RESULTS AND DISCUSSION

In this investigation it could be shown that the use of VR reduces the perioperative risks and improves the training environment and learning. The use of gamification also increases the motivation and engagement of the medical residents. As a result the quality of medical education can be improved by the fusion of VR and gamification.

A novel latex patch model enables cost-effective hands-on teaching in vascular surgery

Objectives

We developed a new simulator for hands-on teaching of vascular surgical skills, the Leipzig Latex Patch Model (LPM). This study aimed to quantify the effectiveness and acceptance of the LPM evaluated by students, as well as evaluation of the results by experienced vascular surgeons.

Methods

A prospective, single-center, single-blinded, randomized study was conducted. Fifty 5th-year medical students were randomized into two groups, first performing a patch suture on the LPM (study group) or established synthetic tissue model (control), then on porcine aorta. The second suture was videotaped and scored by two surgeons using a modified Objective Structured Assessment of Technical Skill (OSATS) score. We measured the time required for suturing; the participants completed questionnaires.

Results

Participants required significantly less time for the second suture than the first (median: LPM 30 min vs. control 28.5 min, p = 0.0026). There was no significant difference in suture time between the groups (median: 28 min vs. 30 min, p = 0.2958). There was an increase in confidence from 28 % of participants before to 58 % after the course (p < 0.0001). The cost of materials per participant was 1.05€ (LPM) vs. 8.68€ (control). The OSATS-scores of the LPM group did not differ significantly from those of the control (median: 20.5 points vs. 23.0 points, p = 0.2041).

Conclusions

This pilot study demonstrated an increase in technical skills and confidence through simulator-based teaching. Our data suggests comparable results of the LPM compared to the conventional model, as assessed by the OSATS-score. This low-cost, low-threshold training model for vascular suturing skills should make hands-on training more accessible to students and surgical residents.

Key message

We developed and validated a low-cost, low-threshold training model for vascular suturing skills. This should make hands-on training more accessible to medical students and surgical residents in the future.

A force sensor improves trainee technique for rigid endoscopy

OBJECTIVE

Developing skills in rigid endoscopy poses challenges to the surgical trainee. This study investigates whether a modified manikin can improve the technical skill of junior operators by providing direct quantitative feedback.

METHODS

A force-sensing pad was incorporated into the oral cavity of a life support manikin. Junior trainees and senior otolaryngologists were invited to perform rigid endoscopy and received real-time feedback from the force sensor during the procedure.

RESULTS

There was a significant inverse correlation between operator seniority and the weight applied to the oral cavity (p < 0.0001). All junior trainee operators applied less weight after five attempts (346 ± 90.95 g) compared to their first attempt (464 ± 85.79 g). This gave a statistically significant decrease of 118 g (standard deviation = 107.27 g, p = 0.007) when quantitative feedback was provided to learning operators.

CONCLUSION

This low-cost, simple model allows trainees to rehearse a high-risk procedure in a safe environment and adjust their operative technique.

Multi-institutional beta testing of a novel cervical esophagogastric anastomosis simulator

Objective

A novel simulator developed to offer hands-on practice for the stapled side-to-side cervical esophagogastric anastomosis was tested previously in a single-center study that supported its value in surgical education. This multi-institutional trial was undertaken to evaluate validity evidence from 6 independent thoracic surgery residency programs.

Methods

After a virtual session for simulation leaders, learners viewed a narrated video of the procedure and then alternated as surgeon or first assistant. Using an online survey, perceived value was measured across fidelity domains: physical attributes, realism of materials, realism of experience, value, and relevance. Objective assessment included time, number of sutures tearing, bubble test, and direct inspection. Comparison across programs was performed using the Kruskal-Wallis test.

Results

Surveys were completed by 63 participants as surgeons (17 junior and 20 senior residents, 18 fellows, and 8 faculty). For 3 of 5 tasks, mean ratings of 4.35 to 4.44 correlated with "somewhat easy" to "very easy" to perform. The interrupted outer layer of the anastomosis rated lowest, suggesting this task was the most difficult. The simulator was rated as a highly valuable training tool. For the objective measurements of performance, "direct inspection" rated highest followed by "time." A total of 90.5% of participants rated the simulator as ready for use with only minor improvements.

Conclusions

Results from this multi-institutional study suggest the cervical esophagogastric anastomosis simulator is a useful adjunct for training and assessment. Further research is needed to determine its value in assessing competence for independent operating and associations between improved measured performance and clinical outcomes.

A review of minimal access surgery provision and training within the United Kingdom

When combined with healthcare pressures, the exponential growth of robotic-assisted surgery (RAS) has impacted UK-based training outcomes, including the learning curve to competency. Aim: To ascertain the current provision of RAS and investigate differences in access to minimal access surgical (MAS) facilities and training across the UK. A two-armed electronic survey was conducted. The first arm questioned clinical leads regarding robotic practice and future training provisions. The second investigated trainee and trainers' perceptions of MAS training and facilities. 64% (52/81) of responding trusts utilise a robotic system. The majority (68% [55/81]) have plans to expand or acquire a system within 3 years. 171 responses from 112 UK and Republic of Ireland hospitals were collected for Arm 2. Laparoscopic categories queried whether trainees had access to a formal curriculum, training days and sim-boxes. Most consultants (51.9%) and trainees (51.6%) reported that there was no formal local training curriculum for robotic surgery. Combined responses demonstrated 42.1% (n = 195/463) said "yes", 39.5% (n = 183) "no" and 18.4% (n = 85) "don't know". For combined robotic categories (simulation, training days and operative lists) 28.3% (n = 134/473) responded "yes", 51.6% (n = 244) said "no" and 20.1% (n = 95) said "don't know". This study provides insight into the current provision of robotic-assisted surgery at UK trusts and highlights the need to facilitate regular clinical training and equitable access to MAS simulation within a formal curriculum. This may aid regulation of training in parallel with the expansion of robotic practice and avoid a significant skill acquisition gap and risks to patient safety.

Evaluation of a novel home-based laparoscopic and core surgical skills programme (Monash Online Surgical Training)

INTRODUCTION

Limitations to surgical education access were exacerbated during the COVID-19 Pandemic. In response, we created a national home-based comprehensive surgical skills course: Monash Online Surgical Training (MOST). Our aim was to evaluate the educational impact of this approach.

METHODS

A remote, 6-week course was designed with learning objectives aligned to the national surgical training. Participants received a personal laparoscopic bench trainer, instrument tracking software, live webinars, access to an online theoretical learning platform, and individualised feedback by system-generated or expert surgeons' assessments. Mixed method analysis of instrument tracking metrics, pre- and post-course questionnaires (11 core surgical domains) and participant comments was utilised. Data were analysed using the Mann-Whitney U test, and a p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 54 participants with varied levels of experience (1 to > 6 years post-graduate level) completed MOST. All 11 learning-outcome domains demonstrated statistically significant improvement including core laparoscopic skills (1.4/5 vs 2.8/5, p < 0.0001) and handling laparoscopic instruments (1.5/5 vs 2.8/5, p < 0.0001). A total of 3460 tasks were completed reflecting 158.2 h (9492 min) of practice, 394 were submitted for formal feedback. Participants rated the course (mean 8.5/10, SD 1.6), live webinars (mean 8.9/10, SD 1.6) and instrument tracking software (mean 8.6, SD 1.7) highly. Qualitative analysis revealed a paradigm shift including the benefits of a safe learning environment and self-paced, self-directed learning.

CONCLUSION

The MOST course demonstrates the successful implementation of a fully remote laparoscopic simulation course which participants found to be an effective tool to acquire core surgical skills.

Neurosurgical simulation models developed in Latin America and the Caribbean: a scoping review

Simulation training is an educational tool that provides technical and cognitive proficiency in a risk-free environment. Several models have recently been presented in Latin America and the Caribbean (LAC). However, many of them were presented in non-indexed literature and not included in international reviews. This scoping review aims to describe the simulation models developed in LAC for neurosurgery training. Specifically, it focuses on assessing the models developed in LAC, the simulated neurosurgical procedures, the model's manufacturing costs, and the translational outcomes. Simulation models developed in LAC were considered, with no language or time restriction. Cadaveric, ex vivo, animal, synthetic, and virtual/augmented reality models were included for cranial and spinal procedures. We conducted a review according to the PRISMA-ScR, including international and regional reports from indexed and non-indexed literature. Two independent reviewers screened articles. Conflicts were resolved by a third reviewer using Covidence software. We collected data regarding the country of origin, recreated procedure, type of model, model validity, and manufacturing costs. Upon screening 917 studies, 69 models were developed in LAC. Most of them were developed in Brazil (49.28%). The most common procedures were related to general neurosurgery (20.29%), spine (17.39%), and ventricular neuroendoscopy and cerebrovascular (15.94% both). Synthetic models were the most frequent ones (38.98%). The manufacturing cost ranged from 4.00 to 2005.00 US Dollars. To our knowledge, this is the first scoping review about simulation models in LAC, setting the basis for future research studies. It depicts an increasing number of simulation models in the region, allowing a wide range of neurosurgical training in a resource-limited setting.

Nodo-Tie: an innovative, 3-D printed simulator for surgical knot-tying skills development

Introduction

Clinical simulators are an important resource for medical students seeking to improve their fundamental surgical skills. Three-dimensional (3-D) printing offers an innovative method to create simulators due to its low production costs and reliable printing fidelity. We aimed to validate a 3-D printed knot-tying simulator named Nodo-Tie.

Methods

We designed a 3-D printed knot-tying simulator integrated with a series of knot-tying challenges and a designated video curriculum made accessible via a quick-response (QR) code. The Nodo-Tie, which costs less than $1 to print and assemble, was distributed to second-year medical students starting their surgical clerkship. Participants were asked to complete a survey gauging the simulator's usability and educational utility. The time between simulator distribution and survey completion was eight weeks.

Results

Students perceived the Nodo-Tie as easy-to-use (4.6 ± 0.8) and agreed it increased both their motor skills (4.5 ± 0.9) and confidence (4.5 ± 0.8) for tying surgical knots in the clinical setting. Many students agreed the Nodo-Tie provided a stable, durable surface for knot-tying practice (83.7%, n = 41) and that they would continue to use it beyond their participation in the study period (91.7%, n = 44).

Discussion

Medical students found this interactive, 3-D printed knot-tying simulator to be an effective tool to use for self-directed development of their knot-tying skills. Given the Nodo-Tie's low cost, students were able to keep the Nodo-Tie for use beyond the study period. This increases the opportunity for students to engage in the longitudinal practice necessary to master knot-tying as they progress through their medical education.

Key messages

Clinical simulators provide proactive learners with reliable, stress-free environments to engage in self-directed surgical skills development. The Nodo-Tie, a 3-D printed simulator, serves as a cost-effective, interactive tool for medical students to develop their knot-tying abilities beyond the clinical setting.

Simulating A Subcondylar Mandibular Fracture With Intraoral Open Reduction and Internal Fixation: A Novel Education Tool for Residents

Study Design

Face and content validation of a surgical simulation model.

Objective

Open reduction and internal fixation in displaced subcondylar mandibular fractures is standard care. This requires an extraoral (eg: retromandibular, transparotideal) or intraoral approach. An intraoral approach requires further training since specialized instrumentation such as the 90° screwdriver system and endoscopes might be needed. Currently, no simulation models are available for training residents in intraoral reduction and fixation of subcondylar mandibular fractures. Therefore, we present a validated simulation model for intraoral treatment of subcondylar mandibular fractures.

Methods

Based on a computer tomography data set, we designed and printed a 3D model of a mandible with a unilateral subcondylar fracture. To simulate intraoral work depth, it was positioned inside a dental phantom. We tested the model by a group of experts (n = 8), simulating intraoral reduction and fixation of a unilateral subcondylar fracture, using a 90° screwdriver system, a 1.0 subcondylar plate (lambda), and 5-6 mm screws.We assessed Face and Content validity by survey.

Results

We provided an open-source printable fracture model. Printing costs were approximately US $10. Experts "Agreed" the model resembling the real scenario and its use for training intraoral reduction and fixation of subcondylar mandibular fractures.

Conclusions

We developed a low cost, reproducible, open-source simulator for subcondylar mandibular fractures. Face and Content validity was achieved through evaluation by a group of experts.

High-fidelity virtual reality simulation training in enhancing competency assessment in orthopaedic training

Surgical competence is the ability to successfully apply academic knowledge, clinical skills and professional behaviour to inpatient care. Along with ensuring patient safety, the ability to communicate effectively, collaborative teamwork and probity, and achieving satisfactory competencies form the fundamental principles of good medical practice. Current strategies to develop surgical competencies include a range of formative and summative assessments. The cancellation of traditional face-to-face meetings and training opportunities during the COVID-19 pandemic had a profound impact on the delivery of medical education and opportunities to achieve surgical competencies. Simulation learning has been used since before the pandemic to deliver surgical training across all grades and specialities, including orthopaedic surgery. Simulation-based training provides a safe, controlled environment to develop skill acquisition. Simulated surgery using virtual reality has evolved following developments in software and hardware. This article explores the role of high-fidelity virtual reality simulation to assess competencies in orthopaedic training in the post-COVID-19 era, and examines whether simulation could be used within the curriculum to augment and improve training.

Self-made transvaginal ultrasound simulator: new training equipment in ultrasound evaluation of controlled ovarian stimulation and oocyte retrieval

Aim

We sought to create and describe a self-made simulator designed and created for teaching purposes: a high-fidelity ultrasound phantom for demonstrating antral follicle count, ultrasound supervision of controlled of ovarian stimulation, and ultrasound-guided oocyte retrieval.

Materials and methods

The uterus and ovaries of the ultrasound phantom were made from beef tongue, a male condom, latex gloves, cotton suture threads, bi-distilled water, and ultrasound gel. The components were placed in a pelvis created using three-dimensional (3D) printing. The phantom was presented to and evaluated by a group of 14 physicians pursuing a postgraduate course in reproductive medicine. Two training stations were structured: one to simulate antral follicle count and controlled ovarian stimulation and the other to simulate ultrasound-guided oocyte retrieval. Future specialists were requested to complete a feedback questionnaire evaluating the self-made simulator and the two practice stations.

Results

The transvaginal ultrasound phantom was successfully created, making it possible to simulate antral follicle count, ultrasound control of ovarian hyperstimulation, and oocyte retrieval, and to capture ultrasound images. A review of the answers provided in the feedback questionnaire showed that the phantom had a good appearance and design, was realistic, helped to improve motor coordination, and could be a useful tool in the training of specialists in assisted reproduction.

Conclusion

This phantom was designed to enable instruction and practice in the evaluation of ovarian follicles and ultrasound-guided oocyte retrieval in a supervised training environment. This self-made simulator is proposed as a training tool that could be included in the curricular structure of residency and postgraduate programs in reproductive medicine.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Feasibility of Sheep Auricular Cartilage as a Teaching Tool for Training in Slicing Techniques for Cartilage Tympanoplasty

There are temporal bone dissection workshops organised all-over the world, however, there is no dedicated teaching program to train in slicing techniques for cartilage tympanoplasty. The aim of the study is to train the otologists in slicing techniques in cartilage tympanoplasty using sheep auricular cartilage as a teaching model and to evaluate the impact of the training on the participants. A total of 98 otologists have been trained in slicing techniques using cartilage slicer during 7 workshops organised at our centre from January 2016 to January 2020 for a total of 6 days for each trainee. Each trainee performed slicing techniques in cartilage tympanoplasty using 5 sheep pinna. Evaluation of the impact of the training was done in terms of assessment of improvement in performance. The feedback forms evaluated the training technique with sheep cartilage, its feasibility and usability as a model for teaching. The impact of the training on the overall performance of the trainee was assessed in terms of confidence, ability and speed in performing tasks related to slicing and cartilage tympanoplasty. The simulation in slicing techniques using sheep auricular cartilage has a teaching potential to improve the surgical outcomes of tympanoplasty as assessed by the performance of the participants. Level of evidence: 4.

Creation of a Proof-of-Concept 3D-Printed Spinal Lateral Access Simulator

Background

Minimally invasive lateral lumbar interbody fusion (LLIF) offers advantages over traditional approaches, providing indirect decompression of neural elements and deformity correction while avoiding many challenges and risks of anterior and posterior approaches. Mastering this technique requires a specialized team, advanced equipment, and sufficient case exposure. Current training is limited to the classic educational model, and alternative training methods such as cadaver labs can be inconvenient, inaccessible, expensive, and incompatible with intraoperative neuromonitoring (IONM) systems.

Objective

The aim of this study was to create a proof-of-concept, low-cost, fully synthetic lateral lumbar surgical simulator and to increase awareness of the lack of current training alternatives.

Methods

Standard engineering design and expert interviews of attending neurosurgeons, nurses, engineers, and medical device representatives (n=20) were utilized to determine key elements for the simulator, physical characteristics of the components, and translational strategy. Physical and radiographic testing was performed on multiple thermoplastics to determine appropriateness for inclusion in the simulator. For evaluation of the concept, a descriptive slide deck and questionnaire were sent to 15 U.S. and 15 international surgeons who perform LLIF.

Results

The lateral access training model (LATM) features the following three components: torso casing, spine module, and IONM feature. This model utilizes operable ABS (acrylonitrile butadiene styrene) 3D-printed lumbar vertebrae, verified for anatomical accuracy and compatibility with fluoroscopy. Additionally, a novel neuromonitoring simulation algorithm was developed to train junior residents on neurological complications. To further highlight the need for lateral training models, 30/30 polled surgeons felt that this simulator has value for the field, 29/30 noted that they would have used the LATM if they had access during training, and 30/30 responded that they would encourage trainees to practice on the LATM.

Conclusion

The LATM is a first step to provide reliable and inexpensive basic lateral lumbar spine training. While this model is lacking some anatomical features, our simulator offers novel training elements for lateral lumbar transpsoas approaches, which lay the foundation for future models to be built. The need for this training exists, and current gaps in the approach to learning these complex techniques need to be filled due to the inconvenience, cost, and impracticability of standard cadaveric models.

Surgical simulation training for escharotomy: a novel course, improving candidate’s confidence in a time critical procedure

BACKGROUND

Circumferential deep burns on the limb lead to a constrictive, tourniquet-like effect causing critical limb ischaemia. The treatment, escharotomy, is a time-critical procedure that sometimes is required before the patient arrives at a burn centre. At present, no practical method of teaching this procedure is incorporated into formal educational courses.

METHODS

The feasibility of a comprehensive education package to teach upper limb escharotomy was assessed in a group of plastic and general surgery trainees in Wales. Small group workshops focused on the clinical presentation of patients requiring escharotomy. Participants then executed this on a custom-made high-fidelity simulation upper limb model. The articulated limb has subcutaneous silicone fat which bulges upon decompression and a finger-tip which turns pink indicating satisfactory reperfusion. A before and after five-point Likert scale was used to evaluate changes in participants' self-assessed confidence in the surgical management of escharotomy. Statistical significance between scores was assessed using the Wilcoxon signed-rank test.

RESULTS

A total of 34 participants took part. Following completion of the course, general surgery trainees' confidence in executing the procedure increased from a median score of 1.00 "not confident at all" (IQR 1.00-2.00) to 4.00 "fairly confident" (IQR 4.00-5.00, p < 0.01). Plastic surgery trainees' confidence increased from a median score of was 3.00 "somewhat confident" (IQR 1.75-4.00) to 4.00 "fairly confident" (IQR 3.00-4.25, p < 0.01).

DISCUSSION

We developed a comprehensive simulator course that has been demonstrated to improve candidate's confidence in performing escharotomy. The next stage in the course development is to confirm the results in a larger cohort. By developing this simulator course we aim to improve emergency burn care education in the UK and globally.

Associating Surgeon Feedback With Material Physical Properties in the Development Process of a Resective Epilepsy Surgery Simulator

BACKGROUND

Hands-on neurosurgical simulations, specifically techniques involving white matter disconnection, are underdeveloped owing to the paucity of low indentation materials that can adequately mimic brain dissection.

OBJECTIVE

To describe the discovery phase of developing a resective epilepsy surgery simulator by quantifying the physical properties of 6 materials and correlating the scores with surgeon feedback data.

METHODS

Six materials, silicone, TissueMatrix, gel support, Synaptive hydrogel, dry SUP706, and moist SUP706 of equal dimension, were evaluated for hardness by measuring their resistance to indentation. Temporal lobe prototypes, 1 for each material, were dissected by 2 neurosurgeons and ordinal ranking assigned. Two null hypotheses were tested: one is that no differences in the indentation properties of the 6 materials analyzed would be elicited and the other is that there would be no correlation between indentation and surgeon feedback scores. Statistical comparison of the means of the different materials was performed using one-way analysis of variance. Surgeon feedback data and indentation score associations were analyzed using the Kendall rank correlation coefficient.

RESULTS

A statistically significant effect (P value <.0001; α 0.05) was measured. Gel support and Synaptive hydrogel had the lowest indentation scores and similar physical properties. Moist support material scored lower than dry support (P = .0067). A strong positive correlation (Kendall tau = 0.9333, P < .0001) was ascertained between the surgeon feedback ranking and indentation scores.

CONCLUSION

Reasonable material options for developing a resective epilepsy surgery are proposed and ranked in this article. Early involvement of surgeons is useful in the discovery phase of simulator invention.

Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The 'learning curve' in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.

[Use of surgical simulators in further education-A nationwide analysis in Germany]

BACKGROUND

In addition to learning theoretical knowledge, the medical specialist training in surgery necessitates the acquisition of practical surgical competences. Simulation-based teaching concepts represent an alternative to education and advanced training on patients. The aim of this study was to analyze the distribution and implementation of surgical simulators in German hospitals.

METHODS

The data analysis was carried out based on an individual on-line questionnaire with a total of 19 standardized questions. This was sent to the senior surgeons in hospitals and clinics via the email distributors of specialist societies for surgery in Germany.

RESULTS

A total of 267 complete datasets were analyzed (response rate 12%). Of the participants 84% reported that they were active in a teaching hospital. At the time of the investigation 143 surgical simulators were in use at 35% of the hospitals and clinics included in the evaluation. There were clear regional differences between the individual federal states. Of the participants, 21.1% did not have a simulator at the hospital but the acquisition of one was planned. Simulation training was most frequently used by students (41.1%) and physicians during further education (32.5%). Simulators were not integrated into advanced surgical training in 81.8%. Of the participating hospitals, 94% showed an interest in integration into surgical specialist training in the future.

CONCLUSION

The results of this survey confirmed the special importance of simulation-based training for surgical education in German hospitals; however, at the same time there were clear deficits in information concerning user behavior and a deficiency in the perceived integration of simulation training in advanced training for surgery.

Application of 3D Printing Support Material for Neurosurgical Simulation

Brain dissection, an intricate neurosurgical skill, is central to life-saving procedures such as intrinsic brain tumor excision and resective epilepsy surgery. The aims of this manuscript are to outline the selection process of a suitable material for the development of a dissectible brain simulator and to present the use of support material, SUP 706, manufactured by Stratasys Ltd. as a non-waste alternative for sustainably engineering solutions for surgical education. A feasibility study was conducted through qualitative function deployment (QFD) followed by a material selection process. End-user requirements and manufacturing product characteristics were incorporated into the workflow. Three materials, silicone, TissueMatrix™ and support material each formed the primary component of the first two prototypes. Expert feedback, manufacturing cost, safety profiling, functional fidelity and post-processing time data were collected and analyzed. The unique break-away feature of moist support material was found to be more suitable than using silicone or TissueMatrix™ for demonstrating brain dissection techniques. In addition, support material displayed higher functional fidelity by mimicking surgical tissues such as pia mater, gray and white matter, and blood vessels. The cost of the support material prototype was 39% less that of TissueMatrix™ and roughly the same as the silicone model. It took twice as long to post-process the support material prototype than it did the TissueMatrix™ design. Support material lost its ideal dissection properties and began to disintegrate after 30 - 45 minutes. In conclusion 3D printer support material is a low-cost material for a dissectible brain simulator.Clinical Relevance- The use of support material as the primary material in developing a dissectible brain simulator is a promising way of advancing neurosurgical education.

A qualitative study of seven simulation models for tendon repairs

Seven models for tendon repair simulation (urinary catheter, liquorice, fishing lure, dental rolls, drinking straw, silicone sealant and the authors' modification of silicone sealant with Micropore™ tape) were assessed for their performance in a number of domains. The silicone sealant and surgical tape model scored highest overall and for each individual domain. This was significantly higher than all other models with the exception of the silicone sealant alone. The lowest scoring model was the drinking straw model.

Three-Dimensionally Printed Surgical Simulation Tool for Brain Mapping Training and Preoperative Planning

BACKGROUND

Brain mapping is the most reliable intraoperative tool for identifying surrounding functional cortical and subcortical brain parenchyma. Brain mapping procedures are nuanced and require a multidisciplinary team and a well-trained neurosurgeon. Current training methodology involves real-time observation and operation, without widely available surgical simulation.

OBJECTIVE

To develop a patient-specific, anatomically accurate, and electrically responsive biomimetic 3D-printed model for simulating brain mapping.

METHODS

Imaging data were converted into a 2-piece inverse 3D-rendered polyvinyl acetate shell forming an anatomically accurate brain mold. Functional and diffusion tensor imaging data were used to guide wire placement to approximate the projection fibers from the arm and leg areas in the motor homunculus. Electrical parameters were generated, and data were collected and processed to differentiate between the 2 tracts. For validation, the relationship between the electrical signal and the distance between the probe and the tract was quantified. Neurosurgeons and trainees were interviewed to assess the validity of the model.

RESULTS

Material testing of the brain component showed an elasticity modulus of 55 kPa (compared to 140 kPa of cadaveric brain), closely resembling the tactile feedback a live brain. The simulator's electrical properties approximated that of a live brain with a voltage-to-distance correlation coefficient of r2 = 0.86. Following 32 neurosurgeon interviews, ∼96% considered the model to be useful for training.

CONCLUSION

The realistic neural properties of the simulator greatly improve representation of a live surgical environment. This proof-of-concept model can be further developed to contain more complicated tractography, blood and cerebrospinal fluid circulation, and more in-depth feedback mechanisms.

Urology Residents Simulation Training Improves Clinical Outcomes in Laparoscopic Partial Nephrectomy

BACKGROUND

Partial nephrectomy (PN) is the preferred modality of treatment for small renal masses. Laparoscopic partial nephrectomy (LPN) has been adopted worldwide and a fundamental role is played by surgical skills. The need for skill instruction outside the operating room is well recognized in the modern models of surgery residency training. We aim to investigate the impact of residents' laparoscopic surgical skills training on the successful implementation of LPN in a reference public teaching hospital in southern Brazil.

METHODS

We accessed all patients undergoing LPN by senior's urology residents at Hospital de Clínicas de Porto Alegre. Patients were stratified in 2 periods of time named 'LPN eras' 1 and 2, to report the training impact on the outcome. LPN era 1 was from October 2012 to February 2017 and LPN era 2 from March 2017 to June 2019. All the senior residents of LPN era 2 followed a simulation training divided into 4 years with a total training time of 244 hours before performing the LPN. Residents from LPN era 1 did not have simulation training.

RESULTS

124 patients underwent LPN during the study period, 53 (42.7%) of those were performed in LPN era 1 and 71 (57.3%) in LPN era 2. Baseline characteristics of the patients in the two groups were similar. The training performed by LPN era 2 residents was able to significantly reduce estimated blood loss, ischemia time and LOS with p value respectively 0.007, 0.001 and 0.001. LPN era 2 group also reached Trifecta in 77.5% of patients, being significantly more than in the LPN era 1 (p = 0.007).

CONCLUSIONS

Simulation in residents surgical training was able to improve clinical outcomes in LPN. These data reinforce the fundamental importance of adequate residents training before performing surgery on a patient.

Deliberate Practice in Simulation-Based Surgical Skills Training: A Scoping Review

BACKGROUND

In recent years there has been a shift from traditional Halstedian methods toward more simulation-based medical education (SBME) for developing surgical skills. Questions remain about the role and value of SBME, although feedback and engagement in repetitive practice have been associated with positive learning outcomes. Regardless of approach, the principles of deliberate practice align with both the Halstedian traditions and ways of implementing SBME. Whilst deliberate practice is well described in the wider literature, the extent to which it is an effective instructional approach in surgical training remains unknown.

OBJECTIVE

To explore the effectiveness of deliberate practice as an instructional design for developing surgical skills through SBME interventions, as assessed by improvements in trainee performance and/or patient outcomes.

METHODS

A combined search was conducted in PUBMED, CINAHL, EMBASE, MEDLINE, PSYCHINFO, and Google Scholar. Three hundred one articles were screened and 17 met the inclusion criteria for analysis.

RESULTS

There was heterogeneity of study methods with 6 randomized control trials, 7 pretest/post-test design, 2 nonrandomized comparisons and 2 observational studies. All articles demonstrated positive learner outcomes following SBME with deliberate practice, although there was no direct comparison to another instructional method. Two studies demonstrated skill transfer to the clinical environment and 1 demonstrated improved patient outcomes.

CONCLUSION

Deliberate practice informed SBME interventions appeared effective for developing surgical skills among trainee surgeons, however the reliability of these conclusions was limited by the modest quality of the research studies and the design elements of deliberate practice were inconsistently applied. There was little evidence that deliberate practice led to skills retention beyond 30 days, although participant numbers were low and the quality of studies was modest.

Perceptions and experiences of simulation-based assessment of technical skill in surgery: A scoping review

INTRODUCTION

The introduction of simulation-based assessment raises questions as to its role in trainee selection, progression, certification and credentialing. This study sought to review and critique the available research regarding the perceptions and experiences of residents and their trainers towards simulation-based assessment of technical skills in surgery.

METHODS

A comprehensive literature review of the Medline (PubMed), Embase, Cochrane and Web of Science databases was performed in accordance with the Joanna Briggs Institute 2020 protocol for scoping reviews in July 2020, for all original research articles, abstracts and conference proceedings assessing the attitudes, perceptions, opinions and experiences of residents and surgical trainers toward simulation-based assessment of technical or operative skill.

RESULTS

A total of 1869 studies were identified on database searching. Quantitative, qualitative and mixed-methodology publications reporting the attitudes and experiences of surgical trainers and residents were identified, with 21 articles ultimately meeting the inclusion criteria for (qualitative) thematic analysis. Results were charted and categorized into broad themes: 1) Perceptions of simulation-based assessment in principle, 2) Entrustment, 3) Credentialing and certification, and 4) Resident selection and recruitment, identifying both positive perceptions and key areas of concern from residents and trainers alike regarding the current and future application of simulation-based assessment.

CONCLUSION

There is broadly positive agreement amongst residents and surgical trainers in the published literature regarding the validity of simulation-based assessment. Perceptions of the broader application and implications of simulation-based skill assessment has been identified as a gap in the literature. Future studies should aim to record comprehensive data from key stakeholders prior to implementation of a simulation-based assessment curriculum to ensure acceptability.

A systematic review of low-cost simulators in ENT surgery

BACKGROUND

Simulation training has become a key part of the surgical curriculum over recent years. Current trainees face significantly reduced operating time as a result of the coronavirus disease 2019 pandemic, alongside increased costs to surgical training, thus creating a need for low-cost simulation models.

METHODS

A systematic review of the literature was performed using multiple databases. Each model included was assessed for the ease and expense of its construction, as well as its validity and educational value.

RESULTS

A total of 18 low-cost simulation models were identified, relating to otology, head and neck surgery, laryngeal surgery, rhinology, and tonsil surgery. In only four of these models (22.2 per cent) was an attempt made to demonstrate the educational impact of the model. Validation was rarely formally assessed.

CONCLUSION

More efforts are required to standardise validation methods and demonstrate the educational value of the available low-cost simulation models in otorhinolaryngology.

Simulation design and students' satisfaction with home-based simulation learning in oral health therapy

OBJECTIVES

The COVID-19 pandemic presents a challenging situation for dental education, with school closures worldwide. While practical sessions are important for the acquisition of clinical skills, few studies have examined the role of home-based simulation learning (HBSL). This study aims to identify key aspects of simulation design and factors associated with students' satisfaction with HBSL.

METHODS

During a "circuit-breaker" period in Singapore, the Nanyang Polytechnic School of Health & Social Sciences (Oral Health Therapy) distributed portable manikins and instruments to students and staff for use at home. Synchronous teaching sessions with real-time feedback were carried out over the Zoom teleconferencing platform. A cross-sectional survey of students was conducted after 3 weeks of the HBSL program. Multiple linear regression analyses were carried out to assess the association between satisfaction with domains of simulation design and overall satisfaction with HBSL.

RESULTS

The top three factors of importance to students in HBSL were feedback and guided reflection, support, and objectives and information. Final-year students expressed higher levels of overall satisfaction and self-confidence following HBSL than first-year students. Satisfaction with the objectives (β = 0.42, 95% CI 0.26-0.57), support (β = 0.27, 95% CI 0.11-0.42), and problem-solving (β = 0.28, 95% CI 0.10-0.46) domains in the Simulation Design Scale were positively associated with overall student satisfaction and self-confidence in learning.

CONCLUSION

The findings can aid educators in the design of future HBSL programs, with a focus on areas of simulation design that are of importance to students.

The Impact of Coronavirus Disease 2019 on Maxillofacial Surgery Training in Portugal: The Resident’s Perspective

Introduction

Methods

Results

Discussion

Conclusion

Assessing the efficacy of tablet-based simulations for learning pseudo-surgical instrumentation

Nurses and surgeons must identify and handle specialized instruments with high temporal and spatial precision. It is crucial that they are trained effectively. Traditional training methods include supervised practices and text-based study, which may expose patients to undue risk during practice procedures and lack motor/haptic training respectively. Tablet-based simulations have been proposed to mediate some of these limitations. We implemented a learning task that simulates surgical instrumentation nomenclature encountered by novice perioperative nurses. Learning was assessed following training in three distinct conditions: tablet-based simulations, text-based study, and real-world practice. Immediately following a 30-minute training period, instrument identification was performed with comparable accuracy and response times following tablet-based versus text-based training, with both being inferior to real-world practice. Following a week without practice, response times were equivalent between real-world and tablet-based practice. While tablet-based training does not achieve equivalent results in instrument identification accuracy as real-world practice, more practice repetitions in simulated environments may help reduce performance decline. This project has established a technological framework to assess how we can implement simulated educational environments in a maximally beneficial manner.

A Systematic Review of Trauma Crew Resource Management Training: What Can the United States and the United Kingdom Learn From Each Other?

OBJECTIVE

Crew Resource Management (CRM) training incorporates methods such as simulation, debrief, and teamwork training to emphasize human factors skills. This systematic review aimed to assess differences in CRM between UK and USA trauma personnel.

DESIGN

A structured search of the databases MEDLINE and Embase in addition to unstructured reference review and Google Scholar search was undertaken without time restraint to identify articles describing CRM training courses of trauma personnel. Predetermined criteria for inclusion included comprehensive reports of CRM training in trauma personnel with participant assessment. Articles were analyzed for course details and descriptions, Kirkpatrick domains and levels utilized, and measure items and outcomes.

RESULTS

Twenty-nine full-text articles (24 USA, 5 UK) met predetermined criteria. UK-based CRM had a heavy emphasis on doctors while USA-based CRM reached a range of multidisciplinary civilian and military professionals. UK-based CRM focused on skills outcomes using pre- and post-training questionnaires, whereas USA-based training focused on behavior and nontechnical skills utilizing validated standardized measures. CRM-based training, and particularly courses incorporating simulation and multidisciplinary methods, resulted in significantly improved preparedness for trauma, emergency skills, and clinical behavioral change.

CONCLUSIONS

CRM training has the potential to give significant benefits to participant learning, teamwork behaviors, and clinical care outcomes. The USA appears to utilize a focused multidisciplinary and human factors approach to trauma training, which could be adopted by UK institutions to improve cohesive team performance and patient care.

Trainee Experience in Simulation-Based Education of Open Vascular Surgery

BACKGROUND

Simulation continues to be an important adjunct to vascular surgery training, yet the optimal implementation of simulation to complement conventional surgical training continues to evolve. This study aims to find areas for improvement in current simulation-based training of open vascular skills by characterizing the experience of vascular trainees attending a national simulation-based course.

METHOD

This was a survey study conducted at the simulation course of the Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What's New in Vascular and Endovascular Surgery, a national vascular surgery meeting. The survey consisted of 17 questions and was administered on paper or electronically via the Audience Response System, before the start of the course. The survey assessed the participants' experience in formal training, simulation training, and comfort with open surgical procedures.

RESULTS

Between 2013 and 2018, the survey was completed by 150 participants of which 65% were vascular fellows. Only 48% of the participants had formal training in suturing and surgical instruments. Most participants had formal training in basic vascular techniques and advanced vascular operations. In 71%, simulation was incorporated into basic technique training and 60% in open surgical training. Simulation training was most commonly utilized in learning anastomotic techniques and open abdominal aortic aneurysm repair. Simulation skills were deemed translatable to the operating room by 59% of participants. Most participants were comfortable performing open vascular procedures. However, 68% of participants were uncomfortable performing an abdominal aortic aneurysm repair.

CONCLUSIONS

There continues to be a significant portion of trainees who do not undergo a simulation-based education. Current simulation training is being targeted to meet trainee needs in open vascular surgery, specifically open aneurysm repair. Nonetheless, trainees continue to have doubts regarding applicability of simulation-based skills to the operating theater. Further studies investigating access to simulation education as well as its translatability are needed.

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

Simulation with 3D Neuronavigation for Learning Cortical Bone Trajectory Screw Placement

BACKGROUND AND OBJECTIVE

 Learning a new technique in neurosurgery is a big challenge especially for trainees. In recent years, simulations and simulators got into the focus as a teaching tool. Our objective is to propose a simulator for placement of cortical bone trajectory (CBT) screws to improve results and reduce complications.

METHODS

 We have created a platform consisting of a sawbone navigated with a 3D fluoroscope to familiarize our trainees and consultants with CBT technique and later implement it in our department. Objective Structured Assessment of Technical Skills (OSATS) and Physician Performance Diagnostic Inventory Scale (PPDI) were obtained before and after the use of the simulator by the five participants in the study. Patients who were operated on after the implementation of the technique were retrospectively reviewed.

RESULTS

 During the simulation, there were 4 cases of pedicle breach out of 24 screws inserted (16.6%). After having completed simulation, participants demonstrated an improvement in OSATS and PPDI (p = 0.039 and 0.042, respectively). Analyzing the answers to the different items of the tests, participants mainly improved in the knowledge (p = 0.038), the performance (p = 0.041), and understanding of the procedure (p = 0.034). In our retrospective series, eight patients with L4-L5 instability were operated on using CBT, improving their Oswestry Disability Index (ODI) score (preoperative ODI 58.5 [SD 16.7] vs. postoperative ODI 31 [SD 13.4]; p = 0.028). One intraoperative complication due to a dural tear was observed. In the follow-up, we found a case of pseudoarthrosis and a facet joint violation, but no other complications related to misplacement, pedicle fracture, or hardware failure.

CONCLUSION

 The simulation we have created is useful for the implementation of CBT. In our study, consultants and trainees have valued very positively the learning obtained using the system. Moreover, simulation facilitated the learning of the technique and the understanding of surgical anatomy. We hope that simulation helps reducing complications in the future.

Simulation training for lobectomy: a review of current literature and future directions†

With growing work-time restrictions and public expectations, the Halstedian educational model of 'see one, do one, teach one' is unfit for the modern training of thoracic residents. With the cardiothoracic surgical workforce set to decline by 50% over the next 10 years, new models are desperately needed to help trainees bypass the early error-prone phase of the lobectomy learning curve. In this review, we detail the development and validation of numerous simulators designed to teach trainees an array of skills ranging from basic technical skills to more complex non-technical skills. Given the recent increases in minimally invasive lobectomies, we critique both open and thoracoscopic simulators. We elucidate that whilst there are a growing number of thoracic simulators of varying fidelity available, fundamentally, there is currently a significant lack of well-designed trials validating various simulators for teaching lobectomy despite an awareness of their potential to improve surgical education. Furthermore, there is a void in the simulation training of non-technical skills within thoracic surgery. Encouragingly, there is a definite awareness of the ability of simulation to aid with the training of future thoracic surgical trainees.

Low-cost simulation models in Urology: a systematic review of the literature

INTRODUCTION

Simulation models have been found to be effective and valid for training in Urology. Due to increasing costs of surgical training, there is a need for low-cost simulation models to enable Urology trainees to improve their skills.

MATERIAL AND METHODS

A literature review was performed using the PubMed and Embase databases until March 2020. A total of 157 abstracts were identified using the search criteria, of which 20 articles were identified describing simulation models for Urology training. Articles reviewed described simulation models created from materials costing less than $150. Data was extracted from the relevant articles in order to critically assess each paper for validity, ease of construct and educational impact.

RESULTS

Models were found pertaining to suprapubic catheterization (6), cystoscopy (3), percutaneous nephrolithotomy (5), scrotal examination (1), circumcision (1), ureteroscopy (1), transurethral resection of the prostate and bladder (2), and open prostatectomy (1). 18/20 (90%) assessed for either face, content, or construct validity. None of the papers evaluated assessed for transferability of skills to performance in real patients.

CONCLUSIONS

A plethora of low-cost simulation models for urological procedures are described in the literature, many of which can be easily constructed from cheap and accessible materials. However there is a need for further efforts to validate or assess for transferability of skills to clinical practice.

Assessment of Technical Skills in Axillary Lymph Node Dissection

OBJECTIVE

A simulator to enable safe practice and assessment of ALND has been designed, and face, content and construct validity has been investigated.

SUMMARY AND BACKGROUND DATA

The reduction in the number of ALNDs conducted has led to decreased resident exposure and confidence.

METHODS

A cross-sectional multicenter observational study was carried out between July 2017 and August 2018. Following model development, 30 surgeons of varying experience (n = "experts,' n = 11 "senior residents,' and n = 10 "junior residents") were asked to perform a simulated ALND. Face and content validity questionnaires were administered immediately after ALND. All ALND procedures were retrospectively assessed by 2 attending breast surgeons, blinded to operator identity, using a video-based assessment tool, and an end product assessment tool.

RESULTS

Statistically significant differences between groups were observed across all operative subphases on the axillary clearance assessment tool (P < 0.001). Significant differences between groups were observed for overall procedure quality (P < 0.05) and total number of lymph nodes harvested (P < 0.001). However, operator grade could not be distinguished across other end product variables such as axillary vein damage (P = 0.864) and long thoracic nerve injury (P = 0.094). Overall, participants indicated that the simulator has good anatomical (median score >7) and procedural realism (median score >7).

CONCLUSIONS

Video-based analysis demonstrates construct validity for ALND assessment. Given reduced ALND exposure, this simulation is a useful adjunct for both technical skills training and formative Deanery or Faculty administered assessments.

Transfer of Automated Performance Feedback Models to Different Specimens in Virtual Reality Temporal Bone Surgery

Virtual reality has gained popularity as an effective training platform in many fields including surgery. However, it has been shown that the availability of a simulator alone is not sufficient to promote practice. Therefore, simulator-based surgical curricula need to be developed and integrated into existing surgical training programs. As practice variation is an important aspect of a surgical curriculum, surgical simulators should support practice on multiple specimens. Furthermore, to ensure that surgical skills are acquired, and to support self-guided learning, automated feedback on performance needs to be provided during practice. Automated feedback is typically provided by comparing real-time performance with expert models generated from pre-collected data. Since collecting data on multiple specimens for the purpose of developing feedback models is costly and time-consuming, methods of transferring feedback from one specimen to another should be investigated. In this paper, we discuss a simple method of feedback transfer between specimens in virtual reality temporal bone surgery and validate the accuracy and effectiveness of the transfer through a user study.

World Health Organization Surgical Safety Checklist with Addition of Infection Control Items: Intervention Study in Egypt

BACKGROUND

Surgical team is in command of the operating room (OR) and takes decisions regarding various patient care procedures. Educational programs directed to them, should be creative, provocative and tailored to their specific needs and the expected outcomes.

AIM

This study aims to design and conduct an educational program of patient safety and infection control for the OR team based on the WHO surgical safety checklist and to assess their post-intervention knowledge and practices.

METHODS

This interventional study was conducted at the ORs of Port-said general hospital. It passed through three stages; baseline assessment of knowledge and practice regarding patient safety and infection control among OR team (surgeons, anaesthetists and nurses), intervention stage in which an educational program based on the WHO surgical safety checklist with modifications and additions of more infection control items was conducted, then re-assessment of their post-intervention knowledge and practices.

RESULTS

All the studied participants showed improvement in both knowledge and practices of patient safety and infection control after the educational program based on the WHO surgical safety checklist with modifications and additions of more infection control items and including not only practices but also knowledge as well, than before.

CONCLUSION

The modification of the WHO surgical safety checklist to fit local knowledge and practices created a comprehensive tool that led to an improvement in both knowledge and practices of patient safety and infection control among the OR team.

Evidence in surgical training - a review

The first residency programs for surgical training were introduced in Germany in the late 1880s and adopted in 1889 by William Halsted in the United States [Cameron JL. William Stewart Halsted. Our surgical heritage. Ann Surg 1997;225:445-58.]. Since then, surgical education has evolved from a sheer volume of exposure to structured curricula, and at the moment, due to work time restrictions, surgical education is discussed on an international level. The reported effect of limited working hours on operative case volume has been variable [McKendy KM, Watanabe Y, Lee L, Bilgic E, Enani G, Feldman LS, et al. Perioperative feedback in surgical training: a systematic review. Am J Surg 2017;214:117-26.]. Experienced surgeons fear that residents do not have sufficient exposure to standard procedures. This may reduce the residents' responsibility for the treatment of the patient and even lead to a reduced autonomy at the end of the residency. Surgical education does not only require learning the technical skills but also human factors as well as interdisciplinary and interprofessional handling. When analyzing international surgical curricula, major differences even between countries of the European Union with more or less strict curricula can be found. Thus far, there is no study that analyzes the educational program of different countries, so there is no evidence which educational system is superior. There is also little evidence to distinguish the good from the average surgeon or the junior surgeons' progress during his residency training. Although some evaluation tools are already available, the lack of resources of most teaching hospitals often results in not using these tools as long it is not mandatory by a governmental program. Because of decreased working hours, increasing hospital costs, and increasing jurisdictional restrictions, teaching hospitals and teachers will have to change their sentiments and focus on their way of surgical education before governmental regulations will emerge leading to more regulation in surgical education. Some learning tools such as simulation, electronic learning, augmented reality, or virtual reality for a timely, sufficient and up to date surgical education. However, research and evidence for existing and novel learning tools will have to increase in the next years to allow surgical education for the future generation of surgeons around the world.