Neurosurgical Skills Assessment: Measuring Technical Proficiency in Neurosurgery Residents Through Intraoperative Video Evaluations

Simulation-Based Bypass Training and Learning Curves-Resident Experience

Introduction  Bypass surgery is a challenging operative procedure that requires surgical excellence. Achieving the skills required for vascular surgery is difficult to master in the operating room without intensive microsurgical training. Various models have been developed to provide training to young neurosurgeons and increase dexterity and patient safety. Bypass surgery requires complex microsurgical techniques. Methods  Microanastomosis training was performed on plastic tubes and chicken wings for 2 months. Each microanastomosis was evaluated by a senior author. Results  An improvement in the quality and patency of microanastomosis was observed. Conclusion  Microsurgical simulation training can contribute to the improvement of surgical skills and dexterity.

Computer-vision based analysis of the neurosurgical scene - A systematic review

Introduction

With increasing use of robotic surgical adjuncts, artificial intelligence and augmented reality in neurosurgery, the automated analysis of digital images and videos acquired over various procedures becomes a subject of increased interest. While several computer vision (CV) methods have been developed and implemented for analyzing surgical scenes, few studies have been dedicated to neurosurgery.

Research question

In this work, we present a systematic literature review focusing on CV methodologies specifically applied to the analysis of neurosurgical procedures based on intra-operative images and videos. Additionally, we provide recommendations for the future developments of CV models in neurosurgery.

Material and methods

We conducted a systematic literature search in multiple databases until January 17, 2023, including Web of Science, PubMed, IEEE Xplore, Embase, and SpringerLink.

Results

We identified 17 studies employing CV algorithms on neurosurgical videos/images. The most common applications of CV were tool and neuroanatomical structure detection or characterization, and to a lesser extent, surgical workflow analysis. Convolutional neural networks (CNN) were the most frequently utilized architecture for CV models (65%), demonstrating superior performances in tool detection and segmentation. In particular, mask recurrent-CNN manifested most robust performance outcomes across different modalities.

Discussion and conclusion

Our systematic review demonstrates that CV models have been reported that can effectively detect and differentiate tools, surgical phases, neuroanatomical structures, as well as critical events in complex neurosurgical scenes with accuracies above 95%. Automated tool recognition contributes to objective characterization and assessment of surgical performance, with potential applications in neurosurgical training and intra-operative safety management.

A high-definition, low cost endoscope to video record head and neck surgery- our experience

Head and neck surgery is a challenging speciality to video-record due to its open, small and sometimes deep operative field. Consequently current commercial technologies yield a high financial cost. This study explores how a low-cost, commercially available endoscope, called a borescope, may be used to overcome these challenges. It was hypothesised that due to its size, versatility and low-cost, it may be an accessible tool to circumnavigate the pitfalls of previously trialled recording devices. We report two cases in which a borescope was used intra-operatively. We found that the borescope can capture images suitable for teaching and training purposes but not when mounted as a headcam. As such the borescope is unable to provide a surgeons point of view.

Feasibility of Conducting a Virtual Exit Exam in Neurosurgery During the SARS-COV19 Pandemic

Background

Skills assessment forms an integral part of the exit examination in neurosurgical training programs. The established method of evaluating trainees for their clinical knowledge and surgical proficiency in the operating room is not feasible in the current time of SARS-COV19 pandemic.

Objective

The feasibility of conducting such an assessment using case modules on an online meeting platform is discussed.

Methods

Six candidates were evaluated on two consecutive days with two internal examiners located at the examination site and two external examiners situated at their own institutions elsewhere in the country. Clinical details, including images and videos of patients managed at our institute were recorded and provided to the candidates as case modules. Four sessions were conducted in the form of long and short cases, operative neurosurgery, neuroradiology, and neuropathology and a general viva-voce using "Zoom" (Zoom-Video-Communications, Inc. USA) platform. Feedback from the examinee and the examiners were obtained for any modification in the current format.

Result

The online platform worked well without any interruption except for slight lag in the audio-visual system and occasional difficulty in using microphone and screen simultaneously. Trainees were able to interpret the clinical details and rated this format close to actual clinical evaluation. The examiners uniformly agreed that the online format for assessment was satisfactory and made some suggestions for improvement.

Conclusion

Clinical and surgical skill evaluation is feasible using case modules and online meeting platforms. Use of original patient's data, images, videos demonstrating clinical signs, and operative procedures makes this assessment more objective.

A Novel Low-Cost Exoscopy Station for Training Neurosurgeons and Neurosurgery Trainees

BACKGROUND

The loss of stereopsis and the need for markedly enhanced hand-eye coordination are obstacles to overcome when performing exoscopic procedures, but both should improve with training. Our objectives were to describe an exoscopy training station and to compare time and performance of a given microsurgical technique among neurosurgery residents and junior neurosurgeons.

METHODS

We designed a low-cost exoscopy training station featuring a notebook computer, a webcam, and a light-emitting diode source. Surgeons and surgical trainees with no experience in exoscopy were enrolled and divided into 2 groups (trainees and controls). Performance and time in suture placement were evaluated by a skilled observer in both groups at baseline and 3 days later. Between evaluations, trainees completed an exoscopy training module.

RESULTS

There were 22 participants divided equally into 2 groups. At baseline, trainees had a greater percentage of proper sutures than controls (58% vs. 35%), but they were also slower (32 minutes vs. 25 minutes). On final evaluation, not only were trainees approximately 14 minutes faster than at baseline (P = 0,03), but also their successful suture rate had increased by 18% (final rate 76%, P = 0.02). Moreover, controls were faster compared with baseline by 6 minutes (P = 0.003), but their percentage of successful sutures did not increase (final rate 38%, P = 0.49). The change from baseline to final evaluation favored trainees for both outcomes (P = 0.03 and P = 0.02).

CONCLUSIONS

Using the exoscopy training station, the trainees were able to improve their time and performance of exoscopy compared with the controls.

Comparison of Conventional Microscopic and Exoscopic Experimental Bypass Anastomosis: A Technical Analysis

BACKGROUND

Recently, the use of digital exoscopes has been increasingly promoted as an alternative to microscopes. The aim of this study is to compare experimental bypass quality in both visualization methods.

METHODS

This study used two hundred 1-mm chicken wing vessels, which were used for either exoscopic or microscopic (100 samples each) bypass procedures. All procedures were recorded between July 2018 and September 2018. The bypass quality was evaluated according to our published practical scale (time, stitch distribution, intima-intima attachment, and orifice size).

RESULTS

Both methods are effective in doing bypass suturing (practical scale score was good, 86% vs. 85%; P = 0.84). There were no significant differences regarding intima-intima attachment (P = 0.26) and orifice size (P = 0.25). However, suturing time (P < 0.001) was less using the microscope, whereas stitch distribution (P = 0.001) was better using the exoscope. Different suturing techniques (interrupted vs. continuous) had overall comparable results (P = 0.55).

CONCLUSIONS

Both methods produced equally satisfactory results in experimental bypass procedures. The exoscope has the potential for better 3-dimensional visualization and sharing the surgeon's view with others for teaching purposes.

Clinical Improvement Interventions for Residents and Practicing Physicians: A Scoping Review of Coaching and Mentoring for Practice Improvement

BACKGROUND

Graduate medical education (GME) bodies are beginning to mandate coaching as an integral part of the learning process, in addition to current requirements for mentorship. Once an emergency medicine physician transitions beyond graduate training, there is no requirement and little focus on coaching as a method of improving or maintaining clinical practice. Our objective was to understand and describe the current state of the published literature with regard to the use of coaching and mentorship for both GME and practicing physicians.

METHODS

We conducted a structured review of the literature through PubMed and Google Scholar and included all articles applying coaching or mentorship modalities to GME trainees or practicing physicians. A Google Form was used for standardized data abstraction. Data were collected pertaining to the settings of intervention, the nature of the intervention, its effect, and its resource requirements.

RESULTS

A total of 3,546 papers were isolated during the literature review. After exclusion, 186 underwent full-text review by the authors of which 126 articles were included in the final data analysis. Eighty-two articles (65%) pertained to mentorship and 14 (11%) to coaching; the remainder of the articles discussed a combination or variation of these two concepts. Fifty-three (42%) articles were descriptive studies and 35 (28%) were narrative reviews or commentaries. Forty-seven (37%) articles originated from within surgical specialties and coaching was most commonly applied to procedural or manual skills with 22 (17%) instances among all studies.

CONCLUSIONS

Most literature on coaching and mentorship is descriptive or narrative, and few papers are in the specialty of emergency medicine. Most interventions are limited to single instances of coaching or mentorship without longitudinal application of the intervention. There is an important need to study and publish further evidence on coaching interventions.

A Comparison of Visual Rating Scales and Simulated Virtual Reality Metrics in Neurosurgical Training: A Generalizability Theory Study

BACKGROUND

Adequate assessment and feedback remains a cornerstone of psychomotor skills acquisition, particularly within neurosurgery where the consequence of adverse operative events is significant. However, a critical appraisal of the reliability of visual rating scales in neurosurgery is lacking. Therefore, we sought to design a study to compare visual rating scales with simulated metrics in a neurosurgical virtual reality task.

METHODS

Neurosurgical faculty rated anonymized participant video recordings of the removal of simulated brain tumors using a visual rating scale made up of seven composite elements. Scale reliability was evaluated using generalizability theory, and scale subcomponents were compared with simulated metrics using Pearson correlation analysis.

RESULTS

Four staff neurosurgeons evaluated 16 medical student neurosurgery applicants. Overall scale reliability and internal consistency were 0.73 and 0.90, respectively. Reliability of 0.71 was achieved with two raters. Individual participants, raters, and scale items accounted for 27%, 11%, and 0.6% of the data variability. The hemostasis scale component related to the greatest number of simulated metrics, whereas respect for no-go zones and tissue was correlated with none. Metrics relating to instrument force and patient safety (brain volume removed and blood loss) were captured by the fewest number of rating scale components.

CONCLUSIONS

To our knowledge, this is the first study comparing participant's ratings with simulated performance. Given rating scales capture less well instrument force, quantity of brain volume removed, and blood loss, we suggest adopting a hybrid educational approach using visual rating scales in an operative environment, supplemented by simulated sessions to uncover potentially problematic surgical technique.

Advancement of thyroid surgery video recording: A comparison between two full HD head mounted video cameras

BACKGROUND

The aim of this study was to test two different video cameras and recording systems used in thyroid surgery in our Department. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer aware of the difference with the naked eye vision.

MATERIALS AND METHODS

In this retrospective study, we recorded and compared twenty thyroidectomies performed using loupes magnification and microsurgical technique: ten were recorded with GoPro^® 4 Session action cam (commercially available) and ten with our new prototype of head mounted video camera.

RESULTS

Settings were selected before surgery for both cameras. The recording time is about from 1 to 2 h for GoPro^® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro^® and 7-8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro^® to highlight the surgical details.

CONCLUSION

the present study showed that our prototype of video camera, compared with GoPro^® 4 Session, guarantees best results in terms of surgical video recording quality, provides to the viewer the exact perspective of the microsurgeon and shows accurately his magnified view through the loupes in thyroid surgery. These recordings are surgical aids for teaching and education and might be a method of self-analysis of surgical technique.

Simple training tricks for mastering and taming bypass procedures in neurosurgery

Background:

Neurosurgeons devoted to bypass neurosurgery or revascularization neurosurgery are becoming scarcer. From a practical point of view, “bypass neurosurgeons” are anastomosis makers, vessels technicians, and time-racing repairers of vessel walls. This requires understanding the key features and hidden tricks of bypass surgery. The goal of this paper is to provide simple and inexpensive tricks for taming the art of bypass neurosurgery. Most of these tricks and materials described can be borrowed, donated, or purchased inexpensively.

Methods:

We performed a review of relevant training materials and recorded videos for training bypass procedures for 3 years between June 2014 and July 2017. In total, 1,300 training bypass procedures were performed, of which 200 procedures were chosen for this paper.

Results:

A training laboratory bypass procedures is required to enable a neurosurgeon to develop the necessary skills. The important skills for training bypass procedures gained through meticulous practice to be as reflexes are coordination, speed, agility, flexibility, and reaction time. Bypassing requires synchronization between the surgeon's gross movements, fine motoric skills, and mental strength. The suturing rhythm must be timed in a brain–body–hand fashion.

Conclusion:

Bypass-training is a critical part of neurosurgical training and not for a selected few. Diligent and meticulous training can enable every neurosurgeon to tame the art of bypass neurosurgery. This requires understanding the key features and hidden tricks of bypass surgery, as well as uncountable hours of training. In bypass neurosurgery, quality and time goes hand in hand.