Acquiring surgical skills

Effect of surgical simulator training on student and live animal outcomes in a feline ovariohysterectomy teaching laboratory

OBJECTIVE

To evaluate the effect of training with a high-fidelity surgical simulator on outcomes of live animals and students participating in a feline ovariohysterectomy teaching laboratory.

STUDY DESIGN

Nonrandomized controlled trial.

SAMPLE POPULATION

Cats (n = 186) and students (n = 146).

METHODS

Live animals were paired with student surgeons. Outcomes for animals and students were evaluated over two consecutive years before (year 1: NO SIM) and after (year 2: SIM) the introduction of a graded student teaching laboratory conducted on a high fidelity surgical simulator. Live animal surgical times and postoperative pain scores using the Glasgow Composite Measure Pain Scale - Feline acute pain scale as well as self-declared student confidence were assessed and the scores of the two groups were compared.

RESULTS

The duration of the live animal surgical procedure was on average 6 min shorter in the SIM group (p = .04). A pain score triggering intervention (> = 5/20) occurred less frequently in the SIM group (n = 1/82) than in the NO-SIM (n = 16/104) group (p < .01). Similarly, rescue analgesia was administered less frequently (4/82 vs 16/104, p = .03) in the SIM group. Student confidence prior to the live animal procedure was higher (median = 7/10 [IQR = 6-8]) in the SIM group than in the NO-SIM group (median = 6/10 [IQR = 4-7]) (p < .01).

CONCLUSION

Surgical simulator training prior to live animal procedures improves live animal outcomes and student confidence.

CLINICAL SIGNIFICANCE

Surgical simulator competency should be considered a prerequisite to participation in live animal teaching laboratories. This would improve both animal welfare and the student experience.

Sensorimotor Challenges in Minimally Invasive Surgery: A Theoretically-Oriented Review

OBJECTIVE

This review surveys the literature on sensorimotor challenges impacting performance in laparoscopic minimally invasive surgery (MIS).

BACKGROUND

Despite its well-known benefits for patients, achieving proficiency in MIS can be challenging for surgeons due to many factors including altered visual perspectives and fulcrum effects in instrument handling. Research on these and other sensorimotor challenges has been hindered by imprecise terminology and the lack of a unified theoretical framework to guide research questions in the field.

METHOD

We conducted a systematic survey of the MIS literature, focusing on studies investigating sensorimotor challenges affecting laparoscopic performance. To provide a common foundation for cross-study comparisons, we propose a standardized taxonomy that distinguishes between different experimental paradigms used in the literature. We then show how the computational motor learning perspective provides a unifying theoretical framework for the field that can facilitate progress and motivate future research along clearer, hypothesis-driven lines.

RESULTS

The survey identified diverse sensorimotor perturbations in MIS, which can be effectively categorized according to our proposed taxonomy. Studies investigating monitor-, camera-, and tool-based perturbations were systematically analyzed, elucidating their impact on surgical performance. We also show how the computational motor learning perspective provides deeper insights and potential strategies to mitigate challenges.

CONCLUSION

Sensorimotor challenges significantly impact MIS, necessitating a systematic, empirically informed approach. Our proposed taxonomy and theoretical framework shed light on the complexities involved, paving the way for more structured research and targeted training approaches to enhance surgical proficiency.

APPLICATION

Understanding the sensorimotor challenges inherent to MIS can guide the design of improved training curricula and inform the configuration of setups in the operating room to enhance surgeon performance and ultimately patient outcomes. This review offers key insights for surgeons, educators, and researchers in surgical performance and technology development.

Preceptorship in robotic colorectal surgery: experience from the Australian private sector

This article describes a post-fellowship preceptorship training program to train sub-specialty colorectal surgeons in gaining proficiency in robotic colorectal surgery using a dual-surgeon model in the Australian private sector. The Australian colorectal surgeon faces challenges in gaining robotic colorectal surgery proficiency with limited exposure and experience in the public setting where the majority of general and colorectal surgery training is currently conducted. This training model uses graded exposure with a range of simulation training, wet lab training, and clinical operative cases to progress through both competency and proficiency in robotic colorectal surgery which is mutually beneficial to surgeons and patients alike. Ongoing audit of practice has shown no adverse impacts.

Thriving in foreign learning environments: The case of hands-on activities in early years of dental education

OBJECTIVES

Hands-on learning environments can challenge learners' wellbeing in dental education, given their unfamiliarity with students. As today's learners are more aware about their wellbeing needs, it is important to explore the depth and complexity of the challenges they experience and provide them with the necessary support strategies. This study aims to identify the challenges and sources of cognitive overload of early years' dental students across two time-points: 2012 and 2022. We also aim to describe the students' recommendations for future program revision considerations to support students' wellbeing.

METHODS

This study employs both qualitative and quantitative methods. Qualitatively, we utilized an Interpretive Description approach and conducted focus groups with first-year dental students in 2023. Quantitively, we utilized first-year dental students' responses to the Study Habits survey administered in 2012/2013.

RESULTS

Five main concerns and sources of cognitive load emerged from the focus groups and survey data: steepness of the learning curve, inconsistent feedback, stigma around asking for support, structural and organizational challenges, and lack of resources. Students also identified several suggestions to support their wellbeing, including time, instructor support, non-graded exercises, additional resources, and re-organizing the curriculum.

CONCLUSION

This study adopts a wellbeing lens to examine students' transition into hands-on learning activities. These findings were utilized to propose the TIPSS Support Framework (Time, Instructor Capacity Building, Peer Learning and Other Resources, Safe Learning Spaces, and Spiraling Curriculum). The proposed model can serve as a prototype for future studies to explore its applicability and effectiveness in other dental programs.

Learning Curve Analysis of Full-Length Costal Cartilage Harvesting by Plastic Surgery Residents: A Retrospective Study

ABSTRACT

Costal cartilage harvesting (CCH) is a fundamental skill for plastic surgery residents to master. Understanding the learning process is essential for optimizing training programs and ensuring patient safety. Previous research on learning curves has been limited. A retrospective study was conducted on patients who underwent CCH between January 2018 and December 2022. The learning process of 14 inexperienced residents was analyzed using the curve-fitting method, with operative time (OT) and complication rates as outcome measured. Data were compared with 4 attending surgeons who also performed CCH. Resident OTs decreased as experience grew, with the bi-exponential model fitting best. After 10 to 20 cases, the average OT decreased to around 40 minutes. By extrapolation, novice residents require ~50 cases to achieve a plateau of OT similar to the attending surgeons, around 27 minutes. Most complications of the resident group occurred within the first 10 to 20 cases, and the complication rate of attending surgeons was <1%. Harvesting on the left side and a higher body mass index resulted in longer OTs for residents. Harvesting the seventh rib required significantly more time for both residents and attending surgeons. The learning curve for CCH shows that 10 to 20 cases are necessary for residents to perform safely and efficiently. Training should progress gradually, starting with longer incisions and leaner patients, then moving to smaller incisions and more challenging cases.

LEVEL OF EVIDENCE

Level IV.

M1 transcranial direct current stimulation augments laparoscopic surgical skill acquisition

The acquisition of basic surgical skills is a key component of medical education and trainees in laparoscopic surgery typically begin developing their skills using simulation box trainers. However, despite the advantages of simulation surgical training, access can be difficult for many trainees. One technique that has shown promise to enhance the deliberate practice of motor skills is transcranial electric stimulation (tES). The purpose of this study was to assess the impact of transcranial direct current stimulation (tDCS) on training induced improvements and retention of traditional time and kinematic based laparoscopic surgical skill metrics. Forty-nine medical students were randomly allocated to a neurostimulation or sham group and completed 5 training sessions of a bead transfer and threading laparoscopic task. Participants in both the sham and stimulation groups significantly improved their time and kinematic performance on both tasks following training. Although we did find that participants who received M1 tDCS saw greater performance benefits in response to training on a bead transfer task compared to those receiving sham stimulation no effect of neurostimulation was found for the threading task. This finding raises new questions regarding the effect that motor task complexity has on the efficacy of neurostimulation to augment training induced improvement and contributes to a growing body of research investigating the effects of neurostimulation on the sensory-motor performance of laparoscopic surgical skill.

The effectiveness of problem-based learning compared with lecture-based learning in surgical education: a systematic review and meta-analysis

BACKGROUND

This meta-analysis was conducted to systematically evaluate the impact of problem-based learning (PBL) and lecture-based learning (LBL) teaching models on students' learning in surgical education.

METHODS

We systematically searched the publications related to the application of PBL and LBL in surgical courses in PubMed, Embase, Web of Science and Cochrane Library databases, the last retrieval time is September 20, 2022. After screening the literature according to the inclusion and exclusion criteria, extracting data and evaluating the methodological treatment of the included studies, Stata 17.0 software was used to perform meta-analysis.

RESULTS

Nine studies were included totally. The results showed that compared with LBL, PBL was superior in clinical competence (SMD = 0.81, 95% CI: 0.12 ~ 1.49, P = 0.020) and student satisfaction (SMD = 2.13, 95% CI: 1.11 ~ 3.15, P < 0.0001) with significant differences. But the comprehensive scores (SMD = 0.26, 95% CI: -0.37 ~ 0.89, P = 0.421) and theoretical knowledge (SMD=-0.19, 95% CI: -0.71 ~ 0.33, P = 0.482) to PBL and LBL had no significant difference.

CONCLUSION

This study showed that the PBL teaching model is more effective than the LBL teaching model in surgical education on the aspects of enhancing clinical competence and student satisfaction. However, further well-designed studies are needed to confirm our findings.

Cognitive Load Management: An Invaluable Tool for Safe and Effective Surgical Training

This article highlights the importance of considering Cognitive Load (CL) and Cognitive Load Theory (CLT) during surgical training, focusing on the acquisition of intra-operative skills. It describes the basis of CLT with the overarching aim of describing CLT-based techniques to enhance current training strategies and surgical performance, many of which are instinctively already employed in surgical practice. Currently, methods of feedback and assessment are imperfect - typically subjective, unsystematic, opportunistic, or retrospective, and at risk of human bias. Surgical Sabermetrics, the advanced analytics of surgical and audio-visual data, aims to enhance this feedback by providing objective, real-time, digital-based feedback. This article introduces the benefit of real-time measurement of CL to enhance feedback and its applications to surgical performance that follow the ethos of Surgical Sabermetrics.¹ The 2022 theme for ICOSET was "Making it Better." Cognitive Load and Surgical Sabermetrics principles provide tools to make Surgical training better, with the goal of higher quality care for patients.

Scotland's "Incentivised Laparoscopy Practice" programme: Engaging trainees with take-home laparoscopy simulation

BACKGROUND

The transfer validity of portable laparoscopy simulation is well established. However, attempts to integrate take-home simulation into surgical training have met with inconsistent engagement worldwide, as for example in our 2014-15 study of an Incentivised Laparoscopy Practice programme (ILPv1). Drawing on learning from our subsequent multi-centre study examining barriers and facilitators, we revised the programme for 2018 onwards. We now report on engagement with the 2018-2022 versions of this home-based simulation programme (ILP v2.1-2.3).

METHODS

In ILP v2.1-2.3, three consecutive year-groups of new-start Core Surgical Trainees (n = 48, 46 and 53) were loaned portable simulators. The 6-month education programme included induction, technical support, and intermittent feedback. Six tasks were prescribed, with video instruction and charting of metric scores. Video uploads were required and scored by faculty. A pass resulted in an eCertificate, expected at Annual Review (but not mandatory for progression). ILP was set within a wider reform, "Improving Surgical Training".

RESULTS

ILP v2.1-2.3 saw pass rates of 94%, 76% and 70% respectively (45/48, 35/46 and 37/53 trainees), compared with only 26% (7/27) in ILP v1, despite now including some trainees not intending careers in laparoscopic specialties. The ILP v2.2 group all reported their engagement with the whole simulation strategy was hampered by the COVID19 pandemic.

CONCLUSIONS

Simply providing take-home simulators, no matter how good, is not enough. To achieve trainee engagement, a whole programme is required, with motivated learners, individual and group practice, intermittent feedback, and clear goals and assessments. ILP is a complex intervention, best understood as a "reform within a reform, within a context."

Look beyond the Mirror: Laparoscopic Cholecystectomy in Situs Inversus Totalis—A Systematic Review and Meta-Analysis (and Report of New Technique)

Background: Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality. Methods: We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients. Results: Out of the 121 patients included in the analysis, 94 were operated on using a “mirrored American” technique, 12 using the “Mirrored French”, 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil. Conclusions: Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations.

A Systematic Review on the Current Trend In Nonsurgical Aesthetic Training for Knowledge, Skill, and Professional Identity Formation

BACKGROUND

Non-surgical aesthetics is a rapidly growing healthcare domain and lacks pedagogically sound education and training programs. The trainee physicians often participate in short courses which are outside of the scope of an existing postgraduate training program to acquire the necessary knowledge and procedural skills. However, such training programs lack values and interests that shape critical thinking and holistic decision-making, often referred to as professional identity.

OBJECTIVES

This systematic review aims to analyse current trends in non-surgical aesthetic clinical education to form knowledge, skills, and professional identity.

METHODS

A detailed literature search was conducted in nine databases; PubMed [United States National Library of Medicine (NLM), Bethesda, MD], Cochrane (Wiley, Hoboken, NJ), Centre for Reviews and Dissemination [(CRD) University of York, York, United Kingdom], and Google Scholar (Google, Mountain View, CA) for relevant studies published between January 2010 and December 2020, with an update in September 2021.

RESULTS

Fifty-five articles were identified through electronic searches, amongst which forty were selected following a review of the abstracts. Sixteen articles were identified as the best evidence for the detailed and iterative review based on their relevance and fit to the inclusion criteria. Unfortunately, none of the included studies designed their questionnaire based on the Kirkpatrick Model, which is best known for analysing and evaluating the results of training and educational programs.

CONCLUSIONS

This systematic review provides valuable insight into graduate professional identity formation and graduates' readiness for independent clinical practice. Therefore, particular consideration should be given to incorporating these triggers when developing evidence-based postgraduate curricula for non-surgical aesthetics.

Higher Speciality Training Boot Camp in Otolaryngology: A Quantitative and Qualitative Analysis of the Northern National Formative Specialty Training 3 Induction Course

Background Opportunities for new otolaryngology trainees to develop their skills as they embark on specialty training can be limited. Our facility hosted a national simulation-based boot camp for new otolaryngology trainees in the UK. This study aimed to assess the effectiveness of the boot camp in improving trainee confidence as they transitioned from core surgical training (CST) to higher specialty training (HST) in otolaryngology. Methodology We conducted a prospective study on the effectiveness of the boot camp on trainee induction. The boot camp included hands-on simulation, small group teaching and didactic lectures addressing technical skills in the fields of otology, laryngology, rhinology, facial plastics, and paediatrics, as well as non-technical skills involving human factors, simulated ward round, and cognitive simulation. The boot camp curriculum reflected the competencies expected by the Joint Committee of Surgical Training (JCST) at this level of training. Participants completed a pre- and post-course questionnaire addressing their self-confidence for the technical and non-technical skills they developed during the boot camp. All participants were invited to participate in an interview 12 months after the boot camp. Results A total of 27 new otolaryngology trainees (approximately half of all new otolaryngology trainees in the UK) participated in the boot camp. A significant increase in median confidence was observed for all technical and non-technical stations (p < 0.0001). The increase in confidence observed was similar for participants regardless of prior experience in otolaryngology. Five candidates were interviewed a year after the boot camp. Analysis of the transcripts generated distinct comments that were grouped into five key themes. Conclusions A simulation-based boot camp mapped to the JCST curriculum can increase the confidence of new otolaryngology Specialty Training 3 trainees during their transition from CST to HST. It can provide valuable and durable technical and non-technical skills to aid trainees in the clinic, theatre environment, and when on-call during their inaugural year of training.

Cochlear implantation: Exploring the effects of 3D stereovision in a digital microscope for virtual reality simulation training - A randomized controlled trial

In cochlear implantation (CI), excellent surgical technique is critical for hearing outcomes. Recent advances in temporal bone Virtual Reality (VR) training allow for specific training of CI and through introduction of new digital microscopes with ultra-high-fidelity (UHF) graphics. This study aims to investigate whether UHF increases performance in VR simulation training of CI electrode insertion compared with conventional, screen-based VR (cVR).

METHODS

Twenty-four medical students completed a randomized, controlled trial of an educational intervention. They performed a total of eight CI electrode insertions each in blocks of four using either UHF-VR or cVR, in randomized order. CI electrode insertion performances were rated by two blinded expert raters using a structured assessment tool supported by validity evidence.

RESULTS

Performance scores in cVR were higher than in the UHF-VR simulation although this was not significant (19.8 points, 95% CI [19.3-20.3] vs. 18.8 points, 95% CI [18.2-19.4]; P = 0.09). The decisive factor for performance was participants' ability to achieve stereovision (mean difference = 1.1 points, 95% CI [0.15-2.08], P = 0.02).

DISCUSSION

No additional benefit was found from UHF-VR over cVR training of CI electrode insertion for novices. Consequently, standard cVR simulation should be used for novices' basic skills acquisition in CI surgery. Future studies should instead explore the effects of other improvements in CI surgery training and if the lacking benefit of UHF-VR also applies for more experienced learners.

CONCLUSION

The increased graphical perception and the superior lifelikeness of UHF-VR does not improve early skills acquisition of CI insertion for novices.

Microsurgical suturing assessment scores: a systematic review

Several scoring scales for the assessment of microsurgical skills have been established and validated with the same basic parameters. The study aims to review the existing scales to highlight those parameters, which can be utilized uniformly across all neurosurgical training centers. An online search was conducted and all the surgical scores pertinent to microsurgical suturing were reviewed. The scales were compared to identify parameters, which were important for skill development and assessment in neurosurgical trainees. Seven assessment scales were identified which assessed the trainee's proficiency in microsurgical suturing. The objective structured assessment of technical skills (OSATS) and Northwestern Objective Microanastomosis Assessment Tool (NOMAT) were identified as the most widely used and validated assessment scales. The newer scales University of Western Ontario microsurgical skills acquisition/assessment (UWOMSA) and structured assessment of microsurgery (SAMS) were notable for the division of the skills. The knot strength, suture separation, and suture intervals were the most important parameters in all scales. Each scale has its strength in the assessment of the microsurgical proficiency of neurosurgical trainees. However, a more uniform scale that can be applied as per the level of the neurosurgical trainee is necessary.

Appendectomy as Teaching Operation: No Compromise in Safety-An Audit of 17,106 Patients

OBJECTIVE

In a surgical career, teaching of surgical procedures plays a central role. In this study we want to evaluate the influence of teaching in appendectomies on the in-hospital outcome.

DESIGN AND SETTING

Retrospectively, 26,436 cases from the national quality measurement database (AQC) between the years 2009 and 2017 were evaluated using the diagnosis and the procedure codes. Included were all cases with appendicitis (International Classification of Diseases diagnostic codes K35-K37), surgical treatment (appendectomy), and a documented teaching status of the procedure. Variables were sought in bivariate and multivariate analyses. The occurrence of any complication was the primary outcome, whereas in-hospital mortality was the secondary outcome.

PARTICIPANTS

A total of 17,106 patients with a mean age of 37 ± 19 years remained for final analysis. A total of 6267 operations (37%), were conducted as teaching-operations. Seventy-four percent of all teaching procedures were performed by residents.

RESULTS

We found no statistical association between teaching operations and complication rates or mortality. However, the teaching group showed longer duration of surgery (+ 11%).

CONCLUSIONS

There was no influence of the training status of the appendectomy procedure on complication rates and in-hospital mortality. However, there was a prolonged duration of surgery. Despite these statistically significant differences, a comparable clinical outcome was observed in all patients, thus justifying the benefits of resident training.

Difference in Resident Versus Attending Perspective of Competency and Autonomy During Arthroscopic Rotator Cuff Repairs

A noted deficiency in orthopaedic resident education is a lack of intraoperative autonomy; however, no studies exist evaluating this issue. The purpose of this study was to determine whether there is a difference between resident and attending perception of resident competency and autonomy during arthroscopic rotator cuff repairs and whether increased perceived competency leads to more autonomy.

Assessing competence in cochlear implant surgery using the newly developed Cochlear Implant Surgery Assessment Tool

PURPOSE

To develop and gather validity evidence for a novel tool for assessment of cochlear implant (CI) surgery, including virtual reality CI surgery training.

METHODS

Prospective study gathering validity evidence according to Messick's framework. Four experts developed the CI Surgery Assessment Tool (CISAT). A total of 35 true novices (medical students), trained novices (residents) and CI surgeons performed two CI-procedures each in the Visible Ear Simulator, which were rated by three blinded experts. Classical test theory and generalizability theory were used for reliability analysis.

RESULTS

The CISAT significantly discriminated between the three groups (p < 0.001). The generalizability coefficient was 0.76 and most of the score variance (53.3%) was attributable to the participant and only 6.8% to the raters. When exploring a standard setting for CI surgery, the contrasting groups method suggested a pass/fail score of 36.0 points (out of 55), but since the trained novices performed above this, we propose using the mean CI surgeon performance score (45.3 points).

CONCLUSION

Validity evidence for simulation-based assessment of CI performance supports the CISAT. Together with the standard setting, the CISAT might be used to monitor progress in competency-based training of CI surgery and to determine when the trainee can advance to further training.

Influence of musical background on surgical skills acquisition

BACKGROUND

There is growing interest in identifying trainees with surgical aptitude predictive of eventual technical proficiency. Musical tasks involve complex, cerebral activity, and ambidextrousity, which may have a positive impact on the acquisition of surgical skill sets. The purpose of this study was to investigate the influence of prior musical experience on the performance of basic surgical skills.

METHODS

This was a prospective cross-sectional study involving 51 novice undergraduate and medical school trainees with no prior surgical exposure. Musicality was assessed with a detailed survey and objectively with the Mini-Profile of Music Perception Skills test. Dexterity was assessed using the Purdue Pegboard test. Surgical skills were then evaluated by performing 2 timed suturing trials after observing tutorial video, followed by a timed laparoscopic peg transfer test. Outcomes included both speed and quality of performance.

RESULTS

Participants with prior musical experience performed better than nonmusicians on the Mini-Profile of Music Perception Skills test (P = .015), dominant hand dexterity (P = .05), suture quality (P < .03), and laparoscopic peg transfer speed (P < .01). There was no significant difference in the suturing speed between musicians and nonmusicians. The dexterity and Mini-Profile of Music Perception Skills scores were predictive of suture quality (P < .01). Among musicians, duration of musical training, inactivity, instrument type, and certification levels did not correlate with differences in surgical task performance.

CONCLUSION

Musical background is associated with better performance of fundamental surgical skills among surgical novices, particularly technique quality. Although this does not imply superior ultimate surgical ability, musicality may be a marker for basic surgical skill development useful in identifying suitable candidates for surgical training.

Thoughtful surgical practice for therapeutic self: A randomized control trial

Objectives:

To determine the role of structured reflection in teaching basic surgical skills in undergraduate students.

Methods:

A randomized control trial was done in two medical colleges of Punjab, from January to December 2017 in which participants were divided into two groups through stratified random sampling. Structured reflection was done by interventional group after training. Post-test was taken to assess their surgical skills. Independent t-test compared the mean of two groups. One-way ANOVA was calculated to measure the difference within the different sub-categories of experimental group.

Results:

Out of 140 students that participated in the study, 138 students stayed till the end (retention rate 98.5%, attrition rate 1.5%). Independent t-test (p-value = 0.01) showed statistically significant difference in both control and interventional groups. One-way ANOVA with robust test of equality of Means showed a positive relationship of reflective capacity and acquisition of surgical skills.

Conclusion:

The novices who demonstrates better reflective capacity exhibit better acquisition of surgical skills.

Cognitive training for the prevention of skill decay in temporarily non-performing orthopedic surgeons

Surgical tasks are prone to skill decay. During unprecedented circumstances, such as an epidemic, personal illness, or injury, orthopedic surgeons may not be performing surgical procedures for an uncertain period of time. While not being able to execute regular surgical tasks or use surgical simulators, skill decay can be prevented with regular mental practice, using a scientifically proven skill acquisition and retaining tool. This paper describes different theories on cognitive training answering the question on how it works and offers a brief review of its application in surgery. Additionally, practical recommendations are proposed for performing mental training while not performing surgical procedures.

Surgical Competencies Required in Newly Commencing Colorectal Surgeons: an Educational and Training Spectrum

PURPOSE

Surgical training models have changed from master-apprentice to competency-based training. We aimed to determine the relative importance and peak periods of acquiring these competencies in newly commencing colorectal surgeons.

METHODS

A mailed questionnaire to all current Colorectal Surgical Society of Australia and New Zealand (CSSANZ) members was conducted between October and December 2016 assessing the relative importance of each competency and the period or activity of learning or training contributing most to achieving that competency.

RESULTS

The response rate was 43% (90/208) with 87% (n = 75) agreed or strongly agreed to the relevance and applicability of the nine RACS competencies. Competencies varied in perceived importance (strongly agreed: judgment-clinical decision-making (JU) 63%, collaboration/teamwork (CT) 53%, technical expertise (TE) 47%, communication (CO) 44%, medical expertise (ME) 34%, scholarship/teaching (ST) 33%, professionalism (PR) 33%/ethics (ET) 24%, health advocacy (HA) 18%, management (MX) 13%/leadership (LE) 17%), and the peak period for acquiring them (registrar: CO 39%, ST 30%; fellow: TE 62%, CT 44%, ME 40%, JU 38%; consultant: MX/LE 52%, HA 48%, PR/ET 33%).

CONCLUSION

Surgical competencies for colorectal surgeons are accumulated and acquired at varying degrees and periods across a spectrum of continuing registrar, fellow, and consultant education and training. These findings serve as a baseline for further refinement of current and continuing educational and training programs.

Learning theories and principles in surgical education and technical learning

What is important to think about in surgical education and technical skills training? Technical skills training is grounded in social cognitive theory and the concepts of modeling and self-efficacy. Cognitive and nontechnical learning is critical to supplement the overall proficiency of the surgical learner in performing an operation. Technical learning is cemented by deliberate practice and there is benefit to productive struggle and failure. External cognitive load should be minimized to maximized operative skills advancement.

Roadmap for Developing Complex Virtual Reality Simulation Scenarios: Subpial Neurosurgical Tumor Resection Model

BACKGROUND

Advancement and evolution of current virtual reality (VR) surgical simulation technologies are integral to improve the available armamentarium of surgical skill education. This is especially important in high-risk surgical specialties. Such fields including neurosurgery are beginning to explore the utilization of virtual reality simulation in the assessment and training of psychomotor skills. An important issue facing the available VR simulation technologies is the lack of complexity of scenarios that fail to replicate the visual and haptic realities of complex neurosurgical procedures. Therefore there is a need to create more realistic and complex scenarios with the appropriate visual and haptic realities to maximize the potential of virtual reality technology.

METHODS

We outline a roadmap for creating complex virtual reality neurosurgical simulation scenarios using a step-wise description of our team's subpial tumor resection project as a model.

RESULTS

The creation of complex neurosurgical simulations involves integrating multiple modules into a scenario-building roadmap. The components of each module are described outlining the important stages in the process of complex VR simulation creation.

CONCLUSIONS

Our roadmap of a stepwise approach for the creation of complex VR-simulated neurosurgical procedures may also serve as a guide to aid the development of other VR scenarios in a variety of surgical fields. The generation of new VR complex simulated neurosurgical procedures, by surgeons for surgeons, with the help of computer scientists and engineers may improve the assessment and training of residents and ultimately improve patient care.

Cadaveric Models for Renal Transplant Surgery Education: a Comprehensive Review

PURPOSE OF REVIEW

To evaluate the utility of cadaveric models for kidney transplant (KT) surgery training.

RECENT FINDINGS

Medline® and PubMed® databases were searched for English and Spanish language articles published describing different learning models used in KT formation. We evaluated the use of cadavers preserved by Thiel's embalming method (TEM) as KT simulation models. Students were divided in groups of 4 people: four trainees mentored by an expert in KT surgery. Among the trainees were surgical residents and low-experience surgeons. A total of 39 TEM preserved bodies were used, of which 75 viable renal grafts were obtained. In each cadaver, two complete transplantation processes were performed, each consisting of en bloc nephrectomy with the trunk of aorta and inferior vena cava, bench surgery and perfusion with saline of the organ, and KT surgery. As with any surgical procedure, learning KT surgery is a stepwise process that requires years of dedication. The models available for the surgical simulation of KT surgery allow to practice and achieve dexterity in performing the procedure in a safe and reproducible way. Training on TEM-preserved corpses offers a highly realistic model for the surgical simulation of KT surgery.

Teaching simulated arthroscopic Bankart repair: residents’ assessment at the Annual Shoulder Course

Background

This study’s aim was to evaluate the performance of senior orthopedic residents during simulated arthroscopic anterior stabilization (Bankart repair) before and after a national shoulder review course.

Methods

Participants were assessed before and after the Annual Shoulder Review Course over a 3-day period, using a multiple-choice examination and surgery performance assessment. The surgical evaluation was completed by fellowship-trained surgeons using a standardized procedure checklist and a global rating scale. All Canadian senior orthopedic residents were invited to participate in the course.

Results

The 57 participants showed improvement following the course. The written knowledge evaluation mean score increased, and all 3 surgical performance measurements improved: surgical task time improved from 4:40 min to 2:53 min (p < 0.001), surgical technique evaluation increased from 56% to 67% after the procedure checklist (p < 0.001), and anchor placement improved for all 3 aspects. Anchor entry point was the sole measure not to improve enough to reach statistical significance (p = 0.37).

Conclusion

Our data support the inclusion of dry model surgical simulation as part of a surgical skills course for both training and assessment of orthopedic surgery residents.

Barriers and facilitators to deliberate practice using take-home laparoscopic simulators

BACKGROUND

Several regions in the UK and Ireland have delivered home-based laparoscopic simulation programmes in an attempt to progress surgical trainees' skills through deliberate practice. However, engagement with these programmes has been poor. This study aims to uncover the barriers to engagement with home-based simulation, with a view to developing an improved programme.

METHODS

This was a qualitative study using focus groups with key stakeholders including junior surgical trainees, consultants/attendings and simulation faculty. Data were collected across four regions in three countries. Data were audio-recorded, transcribed and a thematic analysis was performed using NVivo software.

RESULTS

Sixty-three individuals were interviewed in 12 focus groups (43 trainees, 20 trainers). Trainees cited competing commitments as a barrier to engaging with home-based simulation. They tended to focus on scoring 'points' towards career progression rather than viewing tasks as interesting, or associated with personal development. Their view was that this approach is perpetuated by the training system, which rewards trainees for publications and exams, but not for operative skill. Trainees were unsatisfied with metric feedback and wanted individual feedback from consultants (attendings). Trainees perceived consultants as lacking interest in the programmes and training in general. However, some consultants were unaware of the programmes being delivered and others felt lacking in confidence to deliver the necessary training.

CONCLUSIONS

Scheduled simulation sessions which provide trainees with the opportunity for consultant feedback may improve engagement. Tackling the 'point-scoring' culture is more challenging. This could be addressed by modified assessment structures, greater recognition and accountability for trainers, and recognition and funding of simulation strategies including in-house skills sessions.

A Systematic Review of the Educational Effectiveness of Simulation Used in Open Surgery

STATEMENT

The role of simulation to teach and access open surgical skills has become more prevalent in recent years. This systematic review synthesizes the totality of evidence with respect to the educational effectiveness of simulators used in open surgical training. A systematic literature search was conducted in PubMed, Embase, CINAHL, Scopus, and Web of Science. Only randomized controlled trials were included that explored the educational efficacy of theses simulators. Six randomized controlled trials were included from the 9934 studies found. The methodological quality of the included studies was variable. Overall, the use of the simulators was more educationally effective compared with standard teaching of the skill without a simulator (P < 0.05). Two studies showed that the simulator was as good as an animal model of much higher fidelity. Further studies are needed to secure higher evidence for the educational value, validity, and transferability of the skills to the hospital setting for all simulators.

How do visual-spatial and psychomotor abilities influence clinical performance in periodontal plastic surgery?

AIM

We want to evaluate the relationship of self-assessed experience and proficiency, manual dexterity and visual-spatial ability with surgical performance.

MATERIAL AND METHODS

A total of 26 professionals were included in the study which consisted of four parts: (a) self-assessment by a questionnaire regarding proficiency and experience, (b) evaluation of visual-spatial ability, (c) testing of manual dexterity assessed by validated psychomotor tests and (d) evaluation of surgical performance by Objective Structured Assessment of Technical Skills (OSATS).

RESULTS

Self-assessed proficiency and experience levels did not correlate with objectively evaluated surgical performances (OSATS). However, low-level visual-spatial ability tests strongly correlated with OSATS while intermediate- and high-level tests did not. No correlation was found between psychomotor ability and clinical performance.

CONCLUSIONS

Self-assessed proficiency is not a good predictor for surgical performance as experts tend to be overconfident. To evaluate and predict surgical performance, visual-spatial ability tests seem to be more appropriate than measuring manual dexterity which failed to correlate with the surgical outcome.

The Basic Surgical Skills Course in Sub-Saharan Africa: An Observational Study of Effectiveness

BACKGROUND

The Basic Surgical Skills (BSS) course is a common component of postgraduate surgical training programmes in sub-Saharan Africa, but was originally designed in a UK context, and its efficacy and relevance have not been formally assessed in Africa.

METHODS

An observational study was carried out during a BSS course delivered to early-stage surgical trainees from Rwanda and the Democratic Republic of the Congo. Technical skill in a basic wound closure task was assessed in a formal Objective Structured Assessment of Technical Skills (OSAT) before and after course completion. Participants completed a pre-course questionnaire documenting existing surgical experience and self-perceived confidence levels in surgical skills which were to be taught during the course. Participants repeated confidence ratings and completed course evaluation following course delivery.

RESULTS

A cohort of 17 participants had completed a pre-course median of 150 Caesarean sections as primary operator. Performance on the OSAT improved from a mean of 10.5/17 pre-course to 14.2/17 post-course (mean of paired differences 3.7, p < 0.001). Improvements were seen in 15/17 components of wound closure. Pre-course, only 47% of candidates were forming hand-tied knots correctly and 38% were appropriately crossing hands with each throw, improving to 88 and 76%, respectively, following the course (p = 0.01 for both components). Confidence levels improved significantly in all technical skills taught, and the course was assessed as highly relevant by trainees.

CONCLUSION

The Basic Surgical Skills course is effective in improving the basic surgical technique of surgical trainees from sub-Saharan Africa and their confidence in key technical skills.

Not just trust: factors influencing learners' attempts to perform technical skills on real patients

CONTEXT

As part of their training, physicians are required to learn how to perform technical skills on patients. The previous literature reveals that this learning is complex and that many opportunities to perform these skills are not converted into attempts to do so by learners. This study sought to explore and understand this phenomenon better.

METHODS

A multi-phased qualitative study including ethnographic observations, interviews and focus groups was conducted to explore the factors that influence technical skill learning. In a tertiary paediatric emergency department, staff physician preceptors, residents, nurses and respiratory therapists were observed in the delivery and teaching of technical skills over a 3-month period. A constant comparison methodology was used to analyse the data and to develop a constructivist grounded theory.

RESULTS

We conducted 419 hours of observation, 18 interviews and four focus groups. We observed 287 instances of technical skills, of which 27.5% were attempted by residents. Thematic analysis identified 14 factors, grouped into three categories, which influenced whether residents attempted technical skills on real patients. Learner factors included resident initiative, perceived need for skill acquisition and competing priorities. Teacher factors consisted of competing priorities, interest in teaching, perceived need for residents to acquire skills, attributions about learners, assessments of competency, and trust. Environmental factors were competition from other learners, judgement that the patient was appropriate, buy-in from team members, consent from patient or caregivers, and physical environment constraints.

CONCLUSIONS

Our findings suggest that neither the presence of a learner in a clinical environment nor the trust of the supervisor is sufficient to ensure the learner will attempt a technical skill. We characterise this phenomenon as representing a pool of opportunities to conduct technical skills on live patients that shrinks to a much smaller pool of technical skill attempts. Learners, teachers and educators can use this knowledge to maximise the number of attempts learners make to perform technical skills on real patients.

Simulation in paediatric urology and surgery, part 2: An overview of simulation modalities and their applications

Surgical training has changed radically in the last few decades. The traditional Halstedian model of time-bound apprenticeship has been replaced with competency-based training. In our previous article, we presented an overview of learning theory relevant to clinical teaching; a summary for the busy paediatric surgeon and urologist. We introduced the concepts underpinning current changes in surgical education and training. In this next article, we give an overview of the various modalities of surgical simulation, the educational principles that underlie them, and potential applications in clinical practice. These modalities include; open surgical models and trainers, laparoscopic bench trainers, virtual reality trainers, simulated patients and role-play, hybrid simulation, scenario-based simulation, distributed simulation, virtual reality, and online simulation. Specific examples of technology that may be used for these modalities are included but this is not a comprehensive review of all available products.

A one-day surgical-skill training course for medical students' improved surgical skills and increased interest in surgery as a career

BACKGROUND

Despite many high-quality programs in basic surgical-skill education, the surgical skill of junior doctors varies widely. This, together with the waning interest in surgery as a career among medical students, is a serious issue confronted by hospitals and healthcare systems worldwide. We, therefore, developed and implemented an intensive one-day surgical-skill training course for two purposes; it would improve surgical skills and increase interest in surgery among medical students.

METHODS

The surgical-skill training program is named Surgical Skill Weekend (SSW) and it includes hands-on training sessions for surgical-suturing techniques and advanced surgical procedures (i.e. laparoscopic and robot-assisted surgery), hybrid simulation sessions, and an operating-room session where aforementioned sessions are all put together. By the end of the program, students' improvements in surgical-suturing skills were assessed by experts in a form of checklist, and changes in the interest in a surgical career, if there were any, were answered by the students who participated in the program.

RESULTS

A total of ninety-one (91) medical students participated in the 2015 and 2016 SSW courses. Their overall satisfaction level with the course was very high (Very satisfied: 78%, Quite satisfied: 22%). All of the participant's surgical-suturing skills significantly improved (median score range: 14-20, P < 0.05) and their interest in a surgical career increased significantly (from 56% to 81%, P < 0.05) by completing the program.

CONCLUSIONS

An intensive and comprehensive surgical-skill training program for medical students can not only improve surgical-suturing skills but also increase interest in surgery as a career.

Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors

RATIONALE, AIMS, AND OBJECTIVES

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept.

METHODS

A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive.

RESULTS

Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group.

CONCLUSIONS

This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas.

From humble beginnings … the evolution of the FRACS (Urology)

BACKGROUND

Surgery has a rich and colourful history dating as far back as, at least, the Neolithic period. There have been many advances in knowledge and technology, as well as changes to working conditions and public perception and expectations. The urology training programme is jointly managed by the Royal Australasian College of Surgeons and the Urological Society of Australia and New Zealand. Urological training in Australia and New Zealand has undergone a number of changes over the years.

METHODS

A PubMed search was performed to find articles related to surgical training and, more specifically, urological training in Australia and New Zealand. The search terms that were used included 'urology training', 'surgical training', 'Australian urology history' and 'New Zealand urology history'.

RESULTS

This narrative review outlines the origin and history of this training programme and describes the changes that have led to the current model of urology training. It also relates some of the current and future challenges faced as the training programme continues to evolve in order to improve its ability to train future urologists to meet the needs of the community and to ensure public safety.

CONCLUSION

The urological training programme has evolved a number of times in order to tackle the challenges presented by evolving technology, community expectation and the needs of the trainee.

Validation of a Novel Cognitive Simulator for Orbital Floor Reconstruction

PURPOSE

The increasing focus on patient safety in current medical practice has promoted the development of surgical simulation technology in the form of virtual reality (VR) training designed largely to improve technical skills and less so for nontechnical aspects of surgery such as decision making and material knowledge. The present study investigated the validity of a novel cognitive VR simulator called Touch Surgery for a core maxillofacial surgical procedure: orbital floor reconstruction (OFR).

MATERIALS AND METHODS

A cross-sectional study was carried out on 2 groups of participants with different experience levels. Novice graduate dental students and expert surgeons were recruited from a local dental school and academic residency programs, respectively. All participants completed the OFR module on Touch Surgery. The primary outcome variable was simulator performance score. Post-module questionnaires rating specific aspects of the simulation experience were completed by the 2 groups and served as the secondary outcome variables. The age and gender of participants were considered additional predictor variables. From these data, conclusions were made regarding 3 types of validity (face, content, and construct) for the Touch Surgery simulator. Dependent-samples t tests were used to explore the consistency in simulation performance scores across phases 1 and 2 by experience level. Two multivariate ordinary least-squares regression models were fit to estimate the relation between experience and phase 1 and 2 scores.

RESULTS

Thirty-nine novices and 10 experts who were naïve to Touch Surgery were recruited for the study. Experts outperformed novices on phases 1 and 2 of the OFR module (P < .001), which provided the measurement of construct validation. Responses to the questionnaire items used to assess face validity were favorable from the 2 groups. Positive questionnaire responses also were recorded from experts alone on items assessing the content validity for the module. Participant age and gender were not relevant predictors of performance scores.

CONCLUSION

Construct, content, and face validities were observed for the OFR module on a novel cognitive simulator, Touch Surgery. Therefore, OFR simulation on the smart device platform could serve as a useful cognitive training and assessment tool in maxillofacial surgery residency programs.

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.

Incentivising practice with take-home laparoscopic simulators in two UK Core Surgical Training programmes

Introduction

Practice using simulators has been validated as a mean for surgical trainees to improve basic laparoscopic skills and free their attention for higher cognitive functions. However, mere provision of equipment does not result in frequent practice. This study assesses one approach to incentivising practice within core surgical training programmes and leads to further recommendations.

Methods

30 core surgical trainees (CST) starting laparoscopic-based specialties were recruited from East and West of Scotland CST programmes and given take-home laparoscopic simulators, with six training modules. Attainment of target metric scores generated an eCertificate, to be rewarded by progression in the live theatre. Questionnaires assessed confounding variables and explored CSTs’ anxieties about laparoscopy.

Results

27 trainees (90%) agreed to participate (mean age 28 years, range 24–25; 17 males). 13 CSTs (48%) were in the first year of surgical training. 11 (41%) had no previous simulation experience and 7 (32%) CSTs played video games >3 hours/week. 12 of 27 trainees (44%) completed ≥1 task and 7 completed all (26%).

Performances improved in some participants, but overall engagement with the programme was poor. Reasons given included poor internet connectivity, busy rotations and examinations. CSTs who engaged in the study significantly reduced their anxiety (mean 4.96 vs 3.56, p<0.05).

Conclusions

The provision of take-home laparoscopic simulators with accompanying targets did not successfully incentivise CSTs to practise. However, the subgroup who did engage with the project reported performance improvements and significantly reduced anxiety. Proposals to overcome barriers to practising in simulation, including obligatory simulation-based assessments, are discussed.

Simulation-based education: understanding the socio-cultural complexity of a surgical training 'boot camp'

OBJECTIVE

The focus of simulation-based education (SBE) research has been limited to outcome and effectiveness studies. The effect of social and cultural influences on SBE is unclear and empirical work is lacking. Our objective in this study was to explore and understand the complexity of context and social factors at a surgical boot camp (BC).

METHODS

A rapid ethnographic study, employing the theoretical lenses of complexity and activity theory and Bourdieu's concept of 'capital', to better understand the socio-cultural influences acting upon, and during, two surgical BCs, and their implications for SBE. Over two 4-day BCs held in Scotland, UK, an observer and two preceptors conducted 81 hours of observations, 14 field interviews and 11 formal interviews with faculty members (n = 10, including the lead faculty member, session leaders and junior faculty members) and participants (n = 19 core surgical trainees and early-stage residents).

RESULTS

Data collection and inductive analysis for emergent themes proceeded iteratively. This paper focuses on three analytical themes. First, the complexity of the surgical training system and wider health care education context, and how this influenced the development of the BC. Second, participants' views of the BC as a vehicle not just for learning skills but for gaining 'insider information' on how best to progress in surgical training. Finally, the explicit aim of faculty members to use the Scottish Surgical Bootcamp to welcome trainees and residents into the world of surgery, and how this occurred.

CONCLUSIONS

To the best of our knowledge, this is the first empirical study of a surgical BC that takes a socio-cultural approach to exploring and understanding context, complexities, uncertainties and learning associated with one example of SBE. Our findings suggest that a BC is as much about social and cultural processes as it is about individual, cognitive and acquisitive learning. Acknowledging this explicitly will help those planning similar enterprises and open up a new perspective on SBE research.

Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases

INTRODUCTION

Tutoring in suturing was developed to compensate for a shortage of suturing cases. The objective of this study was to compare ideal suturing score (ISS; 9 points), suturing time (min:sec), and suture placement error (mm) between medical students completing the suturing tutoring program and medical students attending ordinary medical school training program.

METHODS

Participants consisted of 2 groups of medical students who had never performed suturing. The study group had the role of suturing tutor to teach interested high school students. The control group consisted of volunteers from the ordinary medical school program. Skills measurement was performed by having students from both the groups perform 3 vertical mattress sutures on a model. The study group was tested at weeks 1, 9, and 10 to assess improvement. Both the groups were tested at week 10 to compare final learning outcome.

RESULTS

There were 41 and 40 participants in the study group and the control group, respectively. ISS was significantly improved in the study group from week 1-week 10 (7.0 ± 1.3 vs. 8.2 ± 0.9, p = 0.01). At week 10, the study group had a higher mean ISS than the control group (8.2 ± 0.9 vs. 7.8 ± 1.1, p = 0.68). Mean suturing time and mean placement error were also lower in the study group at the end of suturing training (5:1 ± 1:0 vs. 5:2 ± 1:2, p = 0.13; 7.4 ± 7.4 vs. 8.0 ± 10.8, p = 0.44).

CONCLUSION

Tutoring trainees to suture can improve a student's ability to learn how to suture.

The role of non-technical skills in surgery

Non-technical skills are of increasing importance in surgery and surgical training. A traditional focus on technical skills acquisition and competence is no longer enough for the delivery of a modern, safe surgical practice. This review discusses the importance of non-technical skills and the values that underpin successful modern surgical practice. This narrative review used a number of sources including written and online, there was no specific search strategy of defined databases. Modern surgical practice requires; technical and non-technical skills, evidence-based practice, an emphasis on lifelong learning, monitoring of outcomes and a supportive institutional and health service framework. Finally these requirements need to be combined with a number of personal and professional values including integrity, professionalism and compassionate, patient-centred care.

Urology residents training in laparoscopic surgery. Development of a virtual reality model

INTRODUCTION

The training and learning of residents in laparoscopic surgery has legal, financial and technological limitations. Simulation is an essential tool in the training of residents as a supplement to their training in laparoscopic surgery. The training should be structured in an appropriate environment, with previously established and clear objectives, taught by professionals with clinical and teaching experience in simulation. The training should be conducted with realistic models using animals and ex-vivo tissue from animals. It is essential to incorporate mechanisms to assess the objectives during the residents' training progress.

OBJECTIVE

We present the training model for laparoscopic surgery for urology residents at the University Hospital Valdecilla. The training is conducted at the Virtual Hospital Valdecilla, which is associated with the Center for Medical Simulation in Boston and is accredited by the American College of Surgeons.

MATERIAL AND METHOD

The model is designed in 3 blocks, basic for R1, intermediate for R2-3 and advanced for R4-5, with 9 training modules. The training is conducted in 4-hour sessions for 4 afternoons, for 3 weeks per year of residence. Residents therefore perform 240 hours of simulated laparoscopic training by the end of the course. For each module, we use structured objective assessments to measure each resident's training progress.

RESULTS

Since 2003, 9 urology residents have been trained, in addition to the 5 who are currently in training. The model has undergone changes according to the needs expressed in the student feedback. The acquisition of skills in a virtual reality model has enabled the safe transfer of those skills to actual practice.

CONCLUSIONS

A laparoscopic surgery training program designed in structured blocks and with progressive complexity provides appropriate training for transferring the skills acquired using this model to an actual scenario while maintaining patient safety.

An experimental model for training in renal transplantation surgery with human cadavers preserved using W. Thiel's embalming technique

OBJECTIVE

To describe a novel cadaver-based model for practicing renal transplant (RT) surgery.

DESIGN

A simulating model using cadavers preserved by Thiel's method is developed to teach surgical anatomy and operative skills in RT surgery. Participants were asked to complete a voluntary, anonymous survey evaluating perceptions of the model and comparing cadaver sessions to other types of learning (rating questions from 0-10).

SETTING

Large university teaching hospital.

PARTICIPANTS

A total of 28 residents, junior transplant surgeons, and faculty members were participants in the cadaver simulation.

RESULTS

Overall, 9 cadavers were used with 17 grafts transplanted. Kidney procurement in human cadavers preserved using Thiel's embalming technique was performed following the conventional protocol; en bloc nephrectomy with the trunk of aorta and inferior vena cava. Bench surgery was performed, perfusing artery with saline and checking vascular permeability. Once suitability is established, RT was performed as is done in clinical practice. This embalming method enables tissue dissection that is comparable to the living body and provides suitable conditions for realistic RT simulation; handling human tissues and vessels in the same surgical field as the clinical scenario. This experimental model approximates to in vivo RT, providing a realistic and interesting learning to inexperienced surgeons. Overall, participants held a positive view of the cadaver sessions, believed them to be useful in their daily practice, and felt that the proposed model was similar to the clinical setting. Trainees believed that these practices improved skills and confidence in performing an RT.

CONCLUSIONS

The proposed method of kidney procurement and RT in human cadavers preserved by Thiel's embalming technique is a promising, realistic, and reproducible method of practicing RT surgery.

Evidence-based microsurgical skills acquisition series part 2: validated assessment instruments--a systematic review

OBJECTIVES

To systematically review literature pertaining to microsurgical skill assessment tools to determine those specific to, and validated for, microsurgery training.

DESIGN

Multiple databases were searched with preset terms. The search dates included all years up to May 2014. The eligibility criteria included the presence of statistical comparison with a control group and the presence of a measure of validation. The articles and their references were independently reviewed by 2 assessors. Each assessment tool was evaluated for content, construct, face, and criterion validities as well observation/expectant bias and interrater/intrarater reliability. For individual studies, we screened for expectant and selection bias.

RESULTS

Of the 261 articles reviewed, 10 articles and 1 abstract were included. Those excluded were predominantly assessment tools that did not evaluate microsurgical skill or articles where no assessment tool was described. The assessment tools identified in this review include a self-assessment tool where trainees rate their skill confidence from 1 to 5, stereoscopic visual acuity as a predictor for microsurgical performance, an objective motion-tracking electronic device--the Imperial College of Surgical Assessment Device, and 6 global rating scales. Content, construct, and face validities were consistently demonstrated in addition to observation/expectant bias and interrater reliability. Criterion validity was only demonstrated for half of the instruments and intrarater reliability for only 1.

CONCLUSIONS

Overall, 10 articles and 1 abstract described validated methods. Reliability and validity were demonstrated by 6 global rating scales (University of Western Ontario microsurgical skills acquisition, structured assessment of microsurgery skills, and video-based objective structured assessment of technical skill). Motion analysis using the Imperial College of Surgical Assessment Device is a valid objective measure of skill.

An economical training model to teach and practice deep inferior epigastric artery perforator dissection

INTRODUCTION

Modern surgical training has placed a larger focus on procedural competency base training for surgical specialties. Although various simulators are in existence to teach laparoscopic skills, plastic surgery has a paucity of surgical training models.

METHODS AND MATERIALS

We developed a low-cost teaching model for the steps and techniques required in the deep inferior epigastric perforator flap and assessed the utility of this model with the resident surgeons using presurvey and postsurvey.

RESULTS

A total of 13 residents participated in the surgical skill exercise. The residents felt this exercise increased their proficiency in the steps and techniques required for a deep inferior epigastric perforator flap harvest [4 (0.4)].

CONCLUSIONS

Overall, residents felt this exercise should be included in the postgraduate years 1 and 2 educational curriculum.