Technical-skills training in the 21st century

Sacrospinous Hysteropexy-Video Tutorial of Construction and Application of a Feasible and Inexpensive Teaching Model for Simulation

INTRODUCTION AND HYPOTHESIS

Sacrospinous hysteropexy is one of the preeminent uterus-preserving surgical techniques for treating pelvic organ prolapse supported by level one evidence. As training on models greatly improves surgical skills and outcomes, we developed a simple and inexpensive model to simulate sacrospinous hysteropexy.

METHODS

A step-by-step instruction for the production of the model is available to be viewed online. To keep production costs low, readily available materials were used, with a total cost per model of about 2 EUR (Austria, August 2023). All important anatomical landmarks (prolapsing uterus, vagina, ischial spine and sacrospinous ligament) were all represented. We present a detailed instructional video on how to construct the model and the practical training, detailing the individual steps of a successful sacrospinous hysteropexy, available online. Thus, trainees are able to practice the individual movements of the entire surgical procedure on this simulator model guided by the tutorial video. In this way, trainees will be able to practice the entire surgical procedure.

RESULTS

An introduction to the model with explanation of all anatomical landmarks and a standardised explanation of the surgery with its individual steps (handout distributed).

CONCLUSION

The presented video showcases the feasibility of the easy construction and application of a model for the surgical skill training of sacrospinous hysteropexy. Easily accessible, inexpensive material and its simple build make this a reproducible model regardless of geographic or socioeconomic resources.

Development of a Novel, Reusable Task Trainer for Foreign Body Removal and Abscess Incision and Drainage

INTRODUCTION

Cutaneous abscess incision and drainage and foreign body removal are 2 common procedures in a variety of outpatient settings. The goal of this project was to create a novel, clean, reusable task trainer that could more accurately reproduce all the steps necessary to perform cutaneous abscess drainage or foreign body removal including ultrasound to identify the abscess cavity or foreign body.

METHODS

The novel task trainer was constructed using silicone for both the base and the top skin. Toothpaste mixed with saline was used for the abscess material as this produced an ultrasound image that mimicked purulent material. A piece of a metal paper clip was imbedded in the top skin to mimic a cutaneous foreign body. Physician assistant (PA) students given a didactic lecture then used the novel task trainer as part of a clinical skills course.

RESULTS

After the activity, the PA students were asked to voluntarily complete a brief preretrospective/postretrospective survey comprised 8 questions that addressed their self-perceived knowledge and skills using a 5-point Likert scale. Survey data from an initial cohort of PA students at one university show effectiveness of the models when used with the associated curriculum.

DISCUSSION

This study demonstrates the feasibility of constructing a practical, low-cost, non-animal-based task trainer for the purpose of training incision and drainage of cutaneous abscesses and removal of cutaneous foreign bodies. This novel task trainer allows for ultrasound skill development and provides realistic imaging experience.

The transition of surgical simulation training and its learning curve: a bibliometric analysis from 2000 to 2023

BACKGROUND

Proficient surgical skills are essential for surgeons, making surgical training an important part of surgical education. The development of technology promotes the diversification of surgical training types. This study analyzes the changes in surgical training patterns from the perspective of bibliometrics, and applies the learning curves as a measure to demonstrate their teaching ability.

METHOD

Related papers were searched in the Web of Science database using the following formula: TS=[(training OR simulation) AND (learning curve) AND (surgical)]. Two researchers browsed the papers to ensure that the topics of articles were focused on the impact of surgical simulation training on the learning curve. CiteSpace, VOSviewer, and R packages were applied to analyze the publication trends, countries, authors, keywords, and references of selected articles.

RESULT

Ultimately, 2461 documents were screened and analyzed. The USA is the most productive and influential country in this field. Surgical endoscopy and other interventional techniques publish the most articles, while surgical endoscopy and other interventional techniques is the most cited journal. Aggarwal Rajesh is the most productive and influential author. Keyword and reference analyses reveal that laparoscopic surgery, robotic surgery, virtue reality, and artificial intelligence were the hotspots in the field.

CONCLUSION

This study provided a global overview of the current state and future trend in the surgical education field. The study surmised the applicability of different surgical simulation types by comparing and analyzing the learning curves, which is helpful for the development of this field.

Simulation training in urology

PURPOSE OF REVIEW

This review outlines recent innovations in simulation technology as it applies to urology. It is essential for the next generation of urologists to attain a solid foundation of technical and nontechnical skills, and simulation technology provides a variety of safe, controlled environments to acquire this baseline knowledge.

RECENT FINDINGS

With a focus on urology, this review first outlines the evidence to support surgical simulation, then discusses the strides being made in the development of 3D-printed models for surgical skill training and preoperative planning, virtual reality models for different urologic procedures, surgical skill assessment for simulation, and integration of simulation into urology residency curricula.

SUMMARY

Simulation continues to be an integral part of the journey towards the mastery of skills necessary for becoming an expert urologist. Clinicians and researchers should consider how to further incorporate simulation technology into residency training and help future generations of urologists throughout their career.

Incorporation of Simulation in Graduate Medical Education: Historical Perspectives, Current Status, and Future Directions

Technological advancement and improved training strategies have transformed the healthcare practice environment in the last few decades. Simulation has evolved as one of the leading training models for the next generation of healthcare professionals. Simulation-based training enables healthcare professionals to acquire knowledge and skills in a safe and educationally oriented environment and can be a valuable tool for improving clinical practice and patient outcomes. The field of healthcare simulation has been rapidly growing, and various graduate medical education programs around the world have started incorporating this modality into their curricula. In graduate medical education, simulation-based training helps implement an outcome-based curriculum that tests the trainee's actual skill level as the primary factor for the trainee's competency rather than relying on the current model of a predetermined training period. However, the major challenge revolves around developing an educational curriculum incorporating a simulation-based educational model, understanding the value of this new technology, the overall cost factor, and the lack of adequate infrastructure. Hence, embracing the full potential of simulation technology in graduate medical education curricula requires an innovative approach with participation from institutions and stakeholders.

Anesthesiology resident preferences regarding learning to perform epidural anesthesia procedures in obstetrics: a qualitative phenomenological study

BACKGROUND

Learning to perform neuraxial techniques in obstetrics is considered one of the most difficult skills for anesthesiology trainees to acquire and no consensus exists regarding the best practices for teaching these procedures. Utilizing a qualitative, phenomenological approach, we aimed to explore what trainees perceive as the best approaches to teaching epidural anesthesia techniques; identify how these perceptions align or differ from those of faculty anesthesiologists; and examine how these approaches fit into the cognitive apprenticeship framework, which describes a process of reflection on how learning occurs in the authentic environment.

METHODS

Semi-scripted interviews were conducted with 10 residents and three faculty members from the division of obstetric anesthesiology at an academic center. Interviews were transcribed, de-identified, fragmented, and coded. A thematic analysis was conducted, and codes re-organized into the cognitive apprenticeship framework of (1) content, (2) method (including subcategories modeling, coaching, scaffolding, articulation, reflection, and exploration), (3) sequence, and (4) sociology (including situated learning and culture of expert practice).

RESULTS

Trainees valued a staged approach to learning epidural techniques, independent trouble-shooting, graded independence, focused feedback, and a calm instructor. The challenges of learning and teaching epidural techniques identified by trainees and instructors included the tactile nature of the procedure, teaching on awake, non-sedated patients, limited teaching time, and creating an environment of psychological safety.

CONCLUSION

Trainee and instructor preferences for teaching epidural procedures in obstetrics aligned with the cognitive apprenticeship framework. These concepts may be applied to curriculum design, evaluation, feedback, self-assessment and faculty development.

Exploring factors that influence the behavioural intention of medical students to use 3D gastroscopic model to learn how to operate gastroscope using UTAUT Model

BACKGROUND

The application of virtual reality (VR) in gastroscopic operation teaching can be safe and effective, but the advantages can be realized only when students accept and use it. This study aims to identify the factors influencing Chinese clinical medical postgraduates on their intention to use the 3D gastroscopic model constructed based on VR technology using Unified Theory of Acceptance and Use of Technology (UTAUT) model. Students' demographic factors are also taken into consideration.

METHODS

All methods were carried out in accordance with relevant guidelines. Data were collected from clinical medical postgraduates students in China using stratified sampling. A total of 292 questionnaires including valid responses were used in this study. Data were processed using Amos 24.0 and SPSS 26.0 software and the statistical analysis technique was based on structural equation modeling (SEM).

RESULTS

The results showed that different from the mediator of home location and year of clinical learning, mediator of gender, university kind and graduate degree did not affect the behavioral intention. In addition, performance expectancy, facilitating condition, and social influence directly and indirectly have effect on behavioral intention. Also, the significance between social influence and performance expectancy, social influence and effort expectancy were verified.

CONCLUSIONS

This study manifested that the proposed framework based on the UTAUT had explanatory power to identify the factors influencing the students' behavioral intention to use the 3D gastroscopic model constructed based on VR technology. Whereas, an important variable of effort expectancy in the frame of the SEM were not certified, thereby indicating that particular attention should be paid to this variable by universities and teachers before applying 3D gastroscopic model constructed based on VR technology in teaching. Added preparatory work is required such as explaining the basic knowledge of the operating steps of VR model and make students adequately understand its accessibility, which can probably improve the intentions of them to use it. The positive effects of social influence on performance expectancy and effort expectancy we proposed was also verified in this study, which provided a direction for future research.

Mental training in dentistry: A scoping review

INTRODUCTION

Clinical motor skills are essential to train dental students. There is evidence that imagery serves to acquire and improve motor skills, but there is scarce information on its application in dental education. In order to broadly map the available evidence and to detect knowledge gaps in the mental training used to develop motor skills in dentistry, a scoping review was conducted.

MATERIALS AND METHODS

A structured search was conducted to identify relevant references from the Web of Science, Scopus and MEDLINE/PubMed databases for studies addressing mental training methods applied to develop motor skills in dentistry.

RESULTS

A total of 758 articles were screened and four were selected, all of which were randomized clinical trials. Three studies investigated the effectiveness of visual imagery, and one investigated kinesthetic imagery. The research theme identified was motor skill acquisition.

CONCLUSION

The reviewed studies indicate the usefulness of mental training for skill acquisition in dentistry. To improve the generalizability of the results, further research with standardized mental training on motor skills in dentistry is needed.

Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams

Cardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p < 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.

Failing to fail phenomena

INTRODUCTION

Clinical competence is the backbone of competence-based dental education. Over time, there has been a paradigm shift toward training students who are capable of independent practice, as opposed to mere academic success.

METHODS

A mixed-method study was undertaken by anonymised email questionnaire to all restorative tutors at the UK Dental School. Demographics and teaching experience were ascertained, along with key questions on the utilisation of online assessment software iDentity. The assessment process for tutors was explored, and barriers experienced when grading students were reported.

RESULTS

The questionnaire was sent to all 51 restorative tutors with a response rate of 59% (n = 30). Only 3.5% of tutors provided verbal feedback and grading to students in person, with 20.7% only completing iDentity gradings following an email reminder. The majority of staff (93.3%) felt comfortable in raising concerns; however, one of the three clinical tutors admitted they had allowed a failing student to a pass. Qualitative analysis demonstrated several themes why tutors were reluctant to fail students: maintaining good relationships, limited supervision, time delay of grading, one-off event and the student's first attempt.

CONCLUSIONS

Grading students as competent as a one-off experience could potentially mask a recurring problem with a student, in turn impacting the student's ability to assess their own weakness and believe themselves to be competent, and potentially be overconfident. Fair and accurate assessment has a significant benefit to student and staff, enabling targeted development to motivate the students and improve the quality of care provided to the patients.

Validity Evidence for a Novel, Comprehensive Bag-Mask Ventilation Assessment Tool

OBJECTIVE

To develop a comprehensive competency assessment tool for pediatric bag-mask ventilation (pBMV) and demonstrate multidimensional validity evidence for this tool.

STUDY DESIGN

A novel pBMV assessment tool was developed consisting of 3 components: a 22-item-based checklist (trichotomized response), global rating scale (GRS, 5-point), and entrustment assessment (4-point). Participants' performance in a realistic simulation scenario was video-recorded and assessed by blinded raters. Multidimensional validity evidence for procedural assessment, including evidence for content, response-process, internal structure, and relation to other variables, was assessed. The scores of each scale were compared with training level. Item-based checklist scores also were correlated with GRS and entrustment scores.

RESULTS

Fifty-eight participants (9 medical students, 10 pediatric residents, 18 critical care/neonatology fellows, 21 critical care/neonatology attendings) were evaluated. The pBMV tool was supported by high internal consistency (Cronbach α = 0.867). Inter-rater reliability for the item-based checklist component was acceptable (r = 0.65, P < .0001). The item-based checklist scores differentiated between medical students and other providers (P < .0001), but not by other trainee level. GRS and entrustment scores significantly differentiated between training levels (P < .001). Correlation between skill item-based checklist and GRS was r = 0.489 (P = .0001) and between item-based checklist and entrustment score was r = 0.52 (P < .001). This moderate correlation suggested each component measures pBMV skills differently. The GRS and entrustment scores demonstrated moderate inter-rater reliability (0.42 and 0.46).

CONCLUSIONS

We established evidence of multidimensional validity for a novel entrustment-based pBMV competence assessment tool, incorporating global and entrustment-based assessments. This comprehensive tool can provide learner feedback and aid in entrustment decisions as learners progress through training.

Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

BACKGROUND

Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees.

QUESTIONS/PURPOSES

(1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience?

METHODS

We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant.

RESULTS

Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively).

CONCLUSION

Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations.

CLINICAL RELEVANCE

Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

Surgical Training on Ex Vivo Ovine Model in Otolaryngology Head and Neck Surgery: A Comprehensive Review

Background: Nowadays, head and neck surgical approaches need an increased level of anatomical knowledge and practical skills; therefore, the related learning curve is both flat and long. On such procedures, surgeons must decrease operating time as much as possible to reduce the time of general anesthesia and related stress factors for patients. Consequently, little time can be dedicated for training skills of students and young residents in the operating theater. Fresh human cadavers offer the most obvious surrogate for living patients, but they have several limitations, such as cost, availability, and local regulations. Recently, the feasibility of using ex vivo animal models, in particular ovine ones, have been considered as high-fidelity alternatives to cadaveric specimens. Methods: This comprehensive review explores all of head and neck otolaryngology applications with this sample. We analyzed studies about ear surgery, orbital procedures, parotid gland and facial nerve reanimation, open laryngeal and tracheal surgery, microlaryngoscopy procedures, laryngotracheal stenosis treatment, and diagnostic/operative pediatric endoscopy. For each different procedure, we underline the main applications, similarities, and limitations to human procedures so as to improve the knowledge of this model as a useful tool for surgical training. Results: An ovine model is easily available and relatively inexpensive, it has no limitations associated with religious or animal ethical issues, and it is reliable for head and neck surgery due to similar consistencies tissues and neurovascular structures with respect to humans. However, some other issues should be considered, such as differences about some anatomical features, the risk of zoonotic diseases, and the absence of bleeding during training. Conclusion: This comprehensive review highlights the potentials of an ex vivo ovine model and aims to stimulate the scientific and academic community to further develop it for other applications in surgical education.

Development of a 3D printed patient-specific neonatal brain simulation model using multimodality imaging for perioperative management

BACKGROUND

Medical-imaging-based three-dimensional (3D) printed models enable improvement in skills training, surgical planning, and decision-making. This pilot study aimed to use multimodality imaging and to add and compare 3D ultrasound as a future standard to develop realistic neonatal brain models including the ventricular system.

METHODS

Retrospective computed tomography (CT), magnetic resonance imaging (MRI), and 3D ultrasound-based brain imaging protocols of five neonatal patients were analyzed and subsequently segmented with the aim of developing a multimodality imaging-based 3D printed model. The ventricular anatomy was analyzed to compare the MRI and 3D ultrasound modalities.

RESULTS

A realistic anatomical model of the neonatal brain, including the ventricular system, was created using MRI and 3D ultrasound data from one patient. T2-weighted isovoxel 3D MRI sequences were found to have better resolution and accuracy than 2D sequences. The surface area, anatomy, and volume of the lateral ventricles derived from both MRI and 3D ultrasound were comparable.

CONCLUSIONS

We created an ultrasound- and MRI-based 3D printed patient-specific neonatal brain simulation model that can be used for perioperative management. To introduce 3D ultrasound as a standard for 3D models, additional dimensional correlations between MRI and ultrasound need to be examined.

IMPACT

We studied the feasibility of implementing 3D ultrasound as a standard for 3D printed models of the neonatal brain. Different imaging modalities were compared and both 3D isotropic MRI and 3D ultrasound imaging are feasible for printing neonatal brain models with good dimensional accuracy and anatomical replication. Further dimensional correlations need to be defined to implement it as a standard to produce 3D printed models.

Mind the Gap: a Competency-Based Scoping Review of Aesthetic and Reconstructive Reported Simulation Training Models

BACKGROUND

Simulation training has become an integral part of plastic surgery postgraduate curricula. It facilitates the acquisition of skills in a safe environment that can be later transferred to real-life settings. A variety of models have been described covering some aspects of the specialty better than others. The aim of this study was to identify and classify all the previously reported plastic surgery simulation models and the possible gaps having the Accreditation Council for Graduate Medical Education (ACGME) list of competencies as a guide.

METHODS

Through a Delphi process, the complete list of ACGME minimum requirements for certification was analyzed to identify domains amenable for simulation training. A systematic search was conducted in Pubmed looking for all previously reported simulation models in plastic surgery. Predefined inclusion and exclusion criteria and parallel blind review were used to identify eligible models.

RESULTS

A total of 81 ACGME competencies were identified. Following a 3-round Delphi process, consensus was reached on 19 reconstructive and 15 aesthetic surgery domains suitable for simulation training. 1667 articles were initially retrieved from Pubmed, of which 66 articles were eligible for inclusion. Descriptive (65%), quasi-experimental (24%) and experimental studies (11%) were found. For the 34 identified ACGME competencies, there were simulation models described for 58.8% of these, mostly covering reconstructive surgery (84.2%) while for aesthetic surgery it was 13.3%.

CONCLUSIONS

This scoping review has identified that there are still gaps in ACGME competencies that could benefit from new simulation training models, especially in those related to aesthetic surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Prospective Assessment of Knee Arthroscopy Skills Between Medical Students and Residents-Simulator Exercises for Partial Meniscectomy and Analysis of Learning Curves

Background

The Covid-19 pandemic has created the largest disruption of education in history. In a response to this, we aimed to evaluate the knee arthroscopy learning curve among medical students and orthopaedic residents.

Methods

An arthroscopy simulator was used to compare the learning curves of two groups. Medical students with any prior knowledge of arthroscopy (n=24) were compared to a residents group (n=16). Analyzed parameters were “time to complete a task,” assessment of the movement of tools and values scoring damage to the surrounding tissues.

Results

After several repetitions, both groups improved their skills in terms of time and movement. Residents were on average faster, had less camera movement, and touched the cartilage tissue less often than did students. Students showed a steeper improvement curve than residents for certain parameters, as they started from a different experience level.

Conclusion

The participants were able to reduce the time to complete a task. There was also a decrease in possible damage to the virtual surrounding tissues. In general, the residents had better mean values, but the students had the steeper learning curve. Particularly less experienced surgeons can especially train their hand–eye coordination skills required for arthroscopy surgery. Training simulators are an important training tool that supplements cadaveric training and participation in arthroscopic operations and should be included in training.

Applicability of a sheep model for training in plastic surgery of eyelids and orbit

OBJECTIVE

To test the applicability of a fresh tissue model for teaching facial plastic techniques and approaches to the eyelids and orbit.

DESIGN

Observational animal experiments.

SUBJECTS

Ten prepubescent sheep heads harvested following humane euthanasia at the completion of unrelated live animal research.

METHODS

Young sheep were saline perfused at the end of an in vivo protocol. Head and neck tissues were harvested and refrigerated for 3-7 days. An experienced oculoplastic surgeon and an otolaryngologist explored the feasibility of common oculoplastic procedures in the ovine model.

RESULTS

The model has potential for teaching basic principles in eyelid surgery including upper lid blepharoplasty, aponeurotic ptosis repair, upper lid gold weight lid loading for facial paralysis, lateral canthotomy and inferior limb cantholysis, lower lid tightening, and transconjunctival approach to the orbital floor. Eye muscle advancement, optic nerve sheath fenestration, and enucleation also accurately simulated human surgery. Anatomic variations limit the sheep model for orbital floor reconstruction and lacrimal drainage procedures.

CONCLUSIONS

The sheep head and neck provide an inexpensive, safe model for developing skills in several oculoplastic procedures. Formal simulation testing is needed to confirm these expert opinions.

Virtual Education in Pediatric Surgery during the COVID-19 Era: Facing and Overcoming Current Challenges

The novel coronavirus disease 2019 (COVID-19) pandemic has impacted our way of living in an unprecedented manner. Medical professionals at all levels have been forced to adapt to the novel virus. The delivery of surgical services and the subsequent learning opportunities for surgical residents have especially been disrupted and the pediatric surgical community has not been exempted by this. This article highlights the challenges imposed by the pandemic and outlines the various learning modalities that can be implemented to ensure continued learning opportunities throughout the pandemic and beyond. Furthermore, it aims to show how the utilization and expansion of technologies maintain and further increase the communication, as well as the exchange of and access to knowledge among peers. Virtual education-, application-, and simulation-based learning and social media, as well as telemedicine and online conferences, will play a considerable role in the future of surgical specialties and surgical education.

Detection of adverse events leading to inadvertent injury during laparoscopic cholecystectomy using convolutional neural networks

Uncontrolled movements of laparoscopic instruments can lead to inadvertent injury of adjacent structures. The risk becomes evident when the dissecting instrument is located outside the field of view of the laparoscopic camera. Technical solutions to ensure patient safety are appreciated. The present work evaluated the feasibility of an automated binary classification of laparoscopic image data using Convolutional Neural Networks (CNN) to determine whether the dissecting instrument is located within the laparoscopic image section. A unique record of images was generated from six laparoscopic cholecystectomies in a surgical training environment to configure and train the CNN. By using a temporary version of the neural network, the annotation of the training image files could be automated and accelerated. A combination of oversampling and selective data augmentation was used to enlarge the fully labeled image data set and prevent loss of accuracy due to imbalanced class volumes. Subsequently the same approach was applied to the comprehensive, fully annotated Cholec80 database. The described process led to the generation of extensive and balanced training image data sets. The performance of the CNN-based binary classifiers was evaluated on separate test records from both databases. On our recorded data, an accuracy of 0.88 with regard to the safety-relevant classification was achieved. The subsequent evaluation on the Cholec80 data set yielded an accuracy of 0.84. The presented results demonstrate the feasibility of a binary classification of laparoscopic image data for the detection of adverse events in a surgical training environment using a specifically configured CNN architecture.

Análisis bibliométrico y de mapeo de la educación en cirugía laparoscópica y robótica en urología

Objetivo Se realizó un análisis bibliométrico para conocer la situación actual de la educación en cirugía laparoscópica y robótica en urología.

Métodos La búsqueda fue realizada en la base de datos MEDLINE y EMBASE en marzo de 2020, a través del facilitador de búsqueda: FABUMED y PUBMED-PUBREMINER, utilizando los siguientes criterios (Laparoscopy OR robotics) AND (education urology) AND (1988:2019[dp])) y establecer los artículos disponibles respecto a educación en cirugía laparoscópica en urología. Adicionalmente se realizó un análisis de mapeo bibliométrico así como mapas de redes de colaboración.

Resultados Se obtuvieron 1383 revisiones en la literatura publicadas en 172 revistas. Las revistas con más publicaciones fueron: Journal of Endourology (167) y factor de impacto (FI) 2.26, BJU International (101, FI 4.52) Urology (90, FI 1.86) y Journal of Urology (71, FI 5.6). La producción total se dio en 49 países, los países con mayor número de publicaciones fueron Estados Unidos con 362 (26.1%) y Reino Unido 152 (10.9%), Latinoamérica estuvo encabezada por Brasil con 17 publicaciones.

Conclusiones El mayor número de publicaciones se observó a partir del 2006 years durante la última década ha estado liderado por Estados Unidos. En Colombia la investigación de educación en cirugía laparoscópica y robótica es mínima, posiblemente por carecer de programas de entrenamiento en los programas de residencia. Este análisis bibliométrico permite mostrar que la producción bibliográfica en esta área puede depender de que existan programas formales de entrenamiento que a futuro beneficien a toda la comunidad urológica.

Establishing Validity for a Vaginal Hysterectomy Simulation Model for Surgical Skills Assessment

OBJECTIVE

To use the Messick validity framework for a simulation-based assessment of vaginal hysterectomy skills.

METHODS

Video recordings of physicians at different levels of training and experience performing vaginal hysterectomy on a high-fidelity vaginal surgery model were objectively assessed using a modified 10-item Vaginal Surgical Skills Index, a one-item global scale of overall performance, and a pass-fail criterion. Participants included obstetrics and gynecology trainees and faculty from five institutions. Video recordings were independently assessed by expert surgeons blinded to the identities of the study participants.

RESULTS

Fifty surgeons (11 faculty, 39 trainees) were assessed. Experience level correlated strongly with both the modified Vaginal Surgical Skills Index and global scale score, with more experienced participants receiving higher scores (Pearson r=0.81, P<.001; Pearson r=0.74, P<.001). Likewise, surgical experience was also moderately correlated with the modified Vaginal Surgical Skills Index and global scale score (Pearson r=0.55, P<.001; Pearson r=0.58, P<.001). The internal consistency of the modified Vaginal Surgical Skills Index was excellent (Cronbach's alpha=0.97). Interrater reliability of the modified Vaginal Surgical Skills Index and global scale score, as measured by the intraclass correlation coefficient, was moderate to good (0.49-0.95; 0.50-0.87). Using the receiver operating characteristic curve and the pass-fail criterion, a modified Vaginal Surgical Skills Index cutoff score of 27 was found to most accurately (area under the curve 0.951, 95% CI 0.917-0.983) differentiate competent from noncompetent surgeons.

CONCLUSION

We demonstrated validity evidence for using a high-fidelity vaginal surgery model with the modified Vaginal Surgical Skills Index or global scale score to assess vaginal hysterectomy skills.

Empowering Clinician Education With Patient-outcome Feedback

Emergency physicians (EPs) often lack the information they need about their patients' outcomes so that they can both optimally adjust and refine their diagnostic and treatment processes and recognize their clinical errors. Patient-outcome feedback (POF) provides that information by informing clinicians about a patient's clinical course after that clinician's evaluation and treatment. This feedback may encompass the period after the EP has transferred a patient's care to another EP or after the patient has left the ED or hospital. EPs obtain POF through various active and passive methods, depending on their institutional and medical record systems. Active methods require that clinicians or others spend time and effort acquiring the information; passive methods deliver it automatically. POF is an excellent performance-based measurement that helps clinicians to stimulate their learning and to build their own validated mental library of outcomes with which to make clinical decisions, i.e., heuristics and System 1 thinking. POF offers especially useful feedback about patients who have been admitted, were referred to specialists, had major interventions, had potentially significant tests pending on discharge, or were handed off to another EP. The current health care system makes it difficult for EPs to discover their patients' outcomes, squandering significant educational opportunities. Three stimuli to improve this situation would be to require EPs to receive passive POF as part of hospital accreditation, for reviewing POF to be classified as a Category 1 Continuing Medical Education activity, and to reimburse clinicians for learning activities related to POF. Research indicates that our health care institutions and systems would be well served to provide clinicians with ongoing automatic information about their patients' outcomes.

Video-Based Guided Simulation without Peer or Expert Feedback is Not Enough: A Randomized Controlled Trial of Simulation-Based Training for Medical Students

BACKGROUND

Feedback is a pivotal cornerstone and a challenge in psychomotor training. There are different teaching methodologies; however, some may be less effective.

METHODS

A prospective randomized controlled trial was conducted in 130 medical students to compare the effectiveness of the video-guided learning (VLG), peer-feedback (PFG) and the expert feedback (EFG) for teaching suturing skills. The program lasted 4 weeks. Students were recorded making 3-simple stitches (pre-assessment and post-assessment). The primary outcome was a global scale (OSATS). The secondary outcomes were performance time, specific rating scale (SRS) and the impact of the intervention (IOI), defined as the variation between the final and initial OSATS and SRS scores.

RESULTS

No significant differences were found between PFG and EFG in post-assessment results of OSATS, SRS scores or in the IOI for OSATS and SRS scores. Post-assessment results of PFG and EFG were significantly superior to VLG in OSATS and SRS scores [(19.8 (18.5-21); 16.6 (15.5-17.5)) and (20.3 (19.88-21); 16.8 (16-17.5)) vs (15.7 (15-16); 13.3 (12.5-14)) (p < 0.05)], respectively. The results of PFG and EFG were significantly superior to VLG in the IOI for OSATS [7 (4.5-9) and 7.4 (4.88-10) vs 3.5 (1.5-6) (p < 0.05)] and SRS scores [5.4 (3.5-7) and 6.3 (4-8.5) vs 3.1 (1.13-4.88) (p < 0.05)], respectively.

CONCLUSION

The video-guided learning methodology without any kind of feedback is not enough for teaching suturing skills compared to expert or peer feedback. The peer feedback methodology appears to be a viable alternative to handling the emerging demands in medical education.

Resident perceptions of Competency-Based Medical Education

BACKGROUND

Residency training programs in Canada are undergoing a mandated transition to competency-based medical education (CBME). There is limited literature regarding resident perspectives on CBME. As upper year residents act as mentors and assessors for incoming cohorts, and are themselves key stakeholders in this educational transition, it is important to understand how they view CBME. We examined how residents who are not currently enrolled in a competency-based program view that method of training, and what they perceive as potential advantages, disadvantages, and considerations regarding its implementation.

METHODS

Sixteen residents volunteered to participate in individual semi-structured interviews, with questions focussing on participants' knowledge of CBME and its implementation. We used a grounded theory approach to develop explanations of how residents perceive CBME.

RESULTS

Residents anticipated improved assessment and feedback, earlier identification of residents experiencing difficulties in training, and greater flexibility to pursue self-identified educational needs. Disadvantages included logistical issues surrounding CBME implementation, ability of attending physicians to deliver CBME-appropriate feedback, and the possibility of assessment fatigue. Clear, detailed communication and channels for resident feedback were key considerations regarding implementation.

CONCLUSIONS

Resident views align with educational experts regarding the practical challenges of implementation. Expectations of improved assessment and feedback highlight the need for both residents and attending physicians to be equipped in these domains. Consequently, faculty development and clear communication will be crucial aspects of successful transitioning to CBME.

Development and decay of procedural skills in surgery: A systematic review of the effectiveness of simulation-based medical education interventions

CONTEXT

Changes to surgical training programmes in the UK has led to a reduction in theatre time for trainees, and an increasing reliance on simulation to provide procedural experience. Whilst simulation offers opportunity for repetitive practice, the effectiveness of simulation as an educational intervention for developing procedural surgical skills is unclear.

METHODS

A systematic literature review was undertaken to retrieve all studies describing simulation-based medical education (SBME) interventions for the development of procedural surgical skills using the MEDLINE, PsycINFO, CINAHL, EMBASE and PUBMED databases. Studies measuring skill retention or demonstrating transferability of skills for improving patient outcomes were included in the review.

RESULTS

SBME is superior to no training and can lead to improvement in procedural surgical skills, such that skills transfer from simulated environments into theatre. SBME results in minimal skill degradation after 2 weeks, although more significant decay results after >90 days. Many studies recruited <10 participants, used a variety of methods and were restricted to endoscopic surgical techniques. All studies did not compare interventions with non-SBME teaching methods for developing procedural surgical skills. No studies compared the curriculum design of different surgical training programmes.

CONCLUSIONS

SBME interventions are effective for developing procedural skills in surgery. SBME interventions are also effective for preventing the decay of procedural surgical skills. Although no studies demonstrate non-inferiority of SBME interventions compared to time in theatre developing skills, SBME interventions do enable the transfer of skills into theatre, and the potential for improving patient outcomes.

The nature of learning from simulation: Now I know it, now I'll do it, I'll work on that

CONTEXT

Ongoing learning in complex clinical environments requires health professionals to assess their own performance, manage their learning, and modify their practices based on self-monitored progress. Self-regulated learning (SRL) theory suggests that although learners may be capable of such learning, they often need guidance to enact it effectively. Debriefings following simulation may be an ideal time to support learners' use of SRL in targeted areas, but the extent to which they are optimally fostering these practices has not been examined.

METHODS

A qualitative study informed by grounded theory methodology was conducted in the context of three interprofessional in situ trauma simulations at our level 1 trauma centre. A total of 18 participants were interviewed both immediately and 5-6 weeks after the simulation experience. Transcripts were analysed using an iterative constant comparative approach to explore concepts and themes regarding the nature of learning from and after simulation.

RESULTS

During initial interviews, there were many examples of acquired content knowledge and straightforward practice changes that might not require ongoing SRL to enact well in practice. However, even for skills identified as needing to be 'worked on,' SRL strategies were lacking. At follow-up interviews, some participants had evolved more specific learning goals and rudimentary plans for implementation and improvement, but suggested this was prompted by the study interview questions rather than the simulation debriefing itself.

CONCLUSIONS

Overall, participants did not engage in fulsome development of SRL plans based on the simulation and debriefing; however, there were elements of SRL present, particularly after participants were given time to reflect on the interview questions and their own goals. This suggests that simulation training can support the use of SRL. However, debriefing approaches might be better optimised to take full advantage of the opportunity to encourage and foster SRL in practice after the simulation is over.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review

PURPOSE

To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures.

METHODS

A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded.

RESULTS

A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies.

CONCLUSIONS

Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment.

LEVEL OF EVIDENCE

Level III, systematic review of level I to III studies.

Incisional hernia repair in a high-fidelity silicone model for open retro-muscular mesh implantation with preparation of the fatty triangle: validation and educational impact study

BACKGROUND

Incisional hernia repair requires detailed anatomic knowledge. Regarding median subxiphoidal hernias, the proper preparation of the fatty triangle is challenging. To foster proficiency-based training, a cost-efficient model for open median retromuscular mesh repair resembling the human body was developed, including the main anatomical structures related to the procedure. The aim is to create and validate a high-fidelity model on open retromuscular mesh repair suitable for "training before doing".

MATERIALS AND METHODS

Different types of fabrics for imitation of connective tissue and 2-component silicones were used to construct the incisional hernia model. Sample size for validation of the model was determined by a triangular testing approach. Operations from six beginners and six experts were assessed by three blinded-raters. Reliability and construct-validity were evaluated on a behaviorally anchored rating scale (highest score: 4) for the criteria: "instrument use", "tissue handling", "near misses and errors", and "end-product quality".

RESULTS

The model authentically mimicked an open median retromuscular mesh repair. Participants considered the procedure realistic. Reliability was excellent, ranging from 0.811 to 0.974 for "end-product quality", and "tissue handling" respectively. Construct-validity was confirmed with experts significantly outperforming beginners in the "use of instruments" (M_beg. = 2.33, M_exp. = 3.94, p < 0.001), "tissue handling" (M_beg. = 2.11, M_exp. = 3.72, p < 0.001), "near misses and errors" (M_beg. = 2.67, M_exp. = 3.67, p < 0.001), and "end-product quality" (M_beg. = 2.78, M_exp. = 3.72, p < 0.001). Criterion-validity revealed a paradox effect: beginners performed significantly better than experts (p < 0.05) when preparing the fatty triangle.

CONCLUSIONS

The model covers all relevant aspects involved in median-open retromuscular incisional hernia mesh repair. Performance differences between beginners and experts confirm construct-validity and thereby realism of the model. It enables to efficiently improve and practice technical skills of the demanding surgery.

Training for the surgical management of postpartum hemorrhage: a multicenter survey of resident physicians

Background: To actively address maternal morbidity and mortality in Mexico, proficiency among obstetrics and gynecology (OBGYN) residents in the surgical management of postpartum hemorrhage (PPH) is a priority. However, the capacity of programs to provide this training is unknown.Objective: The self-reported knowledge, education, and proficiency of common surgical techniques for the management of PPH among OBGYN residents in Mexico was evaluated. Educational resources, perceived barriers to acquiring skills, and clinical decision-making were explored.Materials and methods: In July of 2018, an anonymous electronic survey was sent to 86 residents at four hospitals throughout Mexico. Surgical techniques queried included uterine tamponade (UT), uterine compression sutures (UCS), uterine devascularization (UD), hypogastric artery ligation (HAL), and gravid hysterectomy (HT). Participants also answered case-based questions about a patient with PPH.Results: The survey response rate was 59.3% (51/86). Seventy-nine percent of residents reported understanding the rationale and techniques for the surgical intervention of PPH. However, 43.9% reported limited ability to perform these procedures with autonomy. Eighty-six percent of residents reported exposure to these techniques while performing a rescue procedure during PPH and 49% reported learning these procedures while performing prophylactic techniques in patients without PPH. Only 25.5% had been exposed to simulation training. Lack of a training module for these skills in their curriculum was noted by 74.5%. The majority of the participants chose UCS, UD, HAL, and HT as the first, second, third, and fourth rescue procedures to perform for PPH, respectively.Conclusion: Most residents reported theoretical knowledge of surgical interventions for PPH, but their self-rated ability to independently perform such skills and a curriculum focused on PPH management was suboptimal.

Verification of Proficiency in Basic Skills for PGY-1 Surgical Residents: 10-Year Update

OBJECTIVE

The American College of Surgeons and the Association of Program Directors in Surgery developed a curriculum in 2001 that involved instructional modules for 11 basic surgical skills and a standardized Verification of Proficiency (VOP) evaluation instrument. Our institution continues to employ a modified version of this curriculum and the purpose of this study was to provide a 10-year update on our VOP evaluation instrument used to assess postgraduate year 1 (PGY-1) residents on surgical skills.

DESIGN

All PGY-1 surgical residents over the past 10 years at our institution have completed the American College of Surgeons/the Association of Program Directors in Surgery-adapted basic surgical skills curriculum and VOP assessment. Retrospective analysis of VOP data for all residents was subjected to statistical analysis for internal validity and level of correlation.

SETTING

Department of Surgery at Southern Illinois University School of Medicine located in Springfield, Illinois.

PARTICIPANTS

All PGY-1 surgical residents (per year: 4 general surgery, 3 orthopedic surgery, 2 plastic surgery, 2 urology, 2 ENT, 1 vascular surgery, and 1 neurosurgery) over the past 10 years.

RESULTS

One hundred and thirty five residents underwent VOP evaluation over 10 years; 92 (68%) failed at least 1 module and 40 (30%) failed at least 2 modules. Residents who failed to demonstrate proficiency were mandated to complete remediation and retested until their scores were considered proficient. Performance on checklist items showed moderate internal consistency (⍺ ≥ 0.50) on 9 of 11 modules. Poor internal consistency (⍺ < 0.30) was noted for overall proficiency across all modules. Combined performance on checklist items and economy of time and motion demonstrated significant positive correlation (p < 0.05) with overall proficiency in every module.

CONCLUSIONS

The VOP instrument offers an internally valid means of assessing distinct basic skills of PGY-1 residents at basic surgical skills. The instrument provides critical formative and summative feedback on surgical skill performance to trainees.

Surgical skill levels: Classification and analysis using deep neural network model and motion signals

BACKGROUND AND OBJECTIVES

Currently, the assessment of surgical skills relies primarily on the observations of expert surgeons. This may be time-consuming, non-scalable, inconsistent and subjective. Therefore, an automated system that can objectively identify the actual skills level of a junior trainee is highly desirable. This study aims to design an automated surgical skills evaluation system.

METHODS

We propose to use a deep neural network model that can analyze raw surgical motion data with minimal preprocessing. A platform with inertial measurement unit sensors was developed and participants with different levels of surgical experience were recruited to perform core open surgical skills tasks. JIGSAWS a publicly available robot based surgical training dataset was used to evaluate the generalization of our deep network model. 15 participants (4 experts, 4 intermediates and 7 novices) were recruited into the study.

RESULTS

The proposed deep model achieved an accuracy of 98.2%. With comparison to JIGSAWS; our method outperformed some existing approaches with an accuracy of 98.4%, 98.4% and 94.7% for suturing, needle-passing, and knot-tying, respectively. The experimental results demonstrated the applicability of this method in both open surgery and robot-assisted minimally invasive surgery.

CONCLUSIONS

This study demonstrated the potential ability of the proposed deep network model to learn the discriminative features between different surgical skills levels.

Validation and educational impact study of the NANEP high-fidelity simulation model for open preperitoneal mesh repair of umbilical hernia

OBJECTIVE

The aim of the study was to develop, validate and analyze the educational impact of a high-fidelity simulation model for open preperitoneal mesh repair of an umbilical hernia. The number of surgical simulators available for training residents is limited. Primary for ethical reasons and secondary for the emerging pay-per-quality policies, practicing-on simulators rather than patients is considered gold standard. Validated full-procedural surgical models will become more and more important in training residents. Such models may assure that evidence-based standards regarding technical aspects of the procedures become integral part of the curriculum. Furthermore, they can be employed as a quality control of residents' skills (Fonseca et al. in J Surg Educ 70:129-137, 2013).

METHODS

In a repeated measures design, medical students, residents in their last year of training and attending surgeons performed an open preperitoneal mesh repair on the NANEP model [NANEP stands for the German acronym Nabelhernien-Netzimplatation-Präperitonal (English: Umbilical hernia mesh implantation preperitoneal)]. Subjects were categorized as "Beginners" (internship students) or "Experts" (residents and surgeons). Content validity was analyzed by criteria of subject-matter-experts. Blinded raters assessed surgical skills by means of the Competency Assessment Tool (CAT) using the online platform "CATLIVE". Differential validity was measured by group differences. Proficiency gain was analyzed by monitoring the learning curve (Gallagher et al. in Ann Surg 241:364-372, 2005). Post-operative examination of the simulators shed light on criterion validity.

RESULTS

The NANEP model-proofed content and construct-valid significant Bonferroni-corrected differences were found between beginners and experts (p < 0.05). Beginners showed a significant learning increase from the first to the second surgery (p < 0.05). Post-operative examination data confirmed criterion validity.

CONCLUSION

The NANEP model is an inexpensive, simple and efficient simulation model. It has highly realistic features, it has been shown to be of high-fidelity, full-procedural and benchtop-model. The NANEP model meets the main needs of surgical educational courses at the beginning of residency.

IMPACT OF A SIMULATED LAPAROSCOPIC TRAINING PROGRAM IN A THREE-YEAR GENERAL SURGERY RESIDENCY

Background:

A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents’ surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce.

Aim:

To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program.

Methods:

A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described.

Results:

Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05).

Conclusions:

The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.

Modeling Surgical Technical Skill Using Expert Assessment for Automated Computer Rating

OBJECTIVE

Computer vision was used to predict expert performance ratings from surgeon hand motions for tying and suturing tasks.

SUMMARY BACKGROUND DATA

Existing methods, including the objective structured assessment of technical skills (OSATS), have proven reliable, but do not readily discriminate at the task level. Computer vision may be used for evaluating distinct task performance throughout an operation.

METHODS

Open surgeries was videoed and surgeon hands were tracked without using sensors or markers. An expert panel of 3 attending surgeons rated tying and suturing video clips on continuous scales from 0 to 10 along 3 task measures adapted from the broader OSATS: motion economy, fluidity of motion, and tissue handling. Empirical models were developed to predict the expert consensus ratings based on the hand kinematic data records.

RESULTS

The predicted versus panel ratings for suturing had slopes from 0.73 to 1, and intercepts from 0.36 to 1.54 (Average R2 = 0.81). Predicted versus panel ratings for tying had slopes from 0.39 to 0.88, and intercepts from 0.79 to 4.36 (Average R2 = 0.57). The mean square error among predicted and expert ratings was consistently less than the mean squared difference among individual expert ratings and the eventual consensus ratings.

CONCLUSIONS

The computer algorithm consistently predicted the panel ratings of individual tasks, and were more objective and reliable than individual assessment by surgical experts.

A Global Rating Scale and Checklist Instrument for Pediatric Laceration Repair

INTRODUCTION

Laceration repair is a core procedural skill in which pediatric residents are expected to attain proficiency per the Accreditation Council for Graduate Medical Education. Restricted trainee work hours have decreased clinical opportunities for laceration repair, and simulation may be a modality to fill that clinical gap. There is a therefore a need for objective measures of pediatric resident competence in laceration repair.

METHODS

We created a global rating scale and checklist to assess laceration repair in the pediatric emergency department. We adapted the global rating scale from the Objective Structured Assessment of Technical Skills tool used to evaluate surgical residents' technical skills and adapted the checklist from a mastery training checklist related to infant lumbar puncture. We tested both tools in the pediatric emergency department. Eight supervising physicians used the tools to evaluate 30 residents' technical skills in laceration repair. We performed validation testing of both tools in the simulation environment. Based on formal evaluation, we developed a video to train future evaluators on the use of the global rating scale.

RESULTS

The global rating scale and checklist showed fair concordance across reviewers. Both tools received positive feedback from supervising physicians who used them.

DISCUSSION

We found that the global rating scale and checklist are more applicable to formative, rather than summative, training for resident laceration repair. We recommend using these educational tools with trainees in the simulation environment prior to trainees performing laceration repairs on actual patients.

A review of eye tracking for understanding and improving diagnostic interpretation

Inspecting digital imaging for primary diagnosis introduces perceptual and cognitive demands for physicians tasked with interpreting visual medical information and arriving at appropriate diagnoses and treatment decisions. The process of medical interpretation and diagnosis involves a complex interplay between visual perception and multiple cognitive processes, including memory retrieval, problem-solving, and decision-making. Eye-tracking technologies are becoming increasingly available in the consumer and research markets and provide novel opportunities to learn more about the interpretive process, including differences between novices and experts, how heuristics and biases shape visual perception and decision-making, and the mechanisms underlying misinterpretation and misdiagnosis. The present review provides an overview of eye-tracking technology, the perceptual and cognitive processes involved in medical interpretation, how eye tracking has been employed to understand medical interpretation and promote medical education and training, and some of the promises and challenges for future applications of this technology.

Progress in Knee Arthroscopy Skills of Residents and Medical Students: A Prospective Assessment of Simulator Exercises and Analysis of Learning Curves

OBJECTIVE

Knee arthroscopies are very common orthopedic procedures. For a number of reasons, including increased public awareness for medical errors, patient safety, strict regulations governing duty-hours for residents, surgeons' liability, and an increasing emphasis on the efficient use of operating room time, interest in simulator training is on the rise. It was the purpose of this study to analyze learning curves of medical students and orthopedic resident surgeons using a virtual knee arthroscopy simulator.

DESIGN

Learning curves of medical students and orthopedic residents were measured perspective using an arthroscopic training simulator for 2 different exercises. Time, camera and probe movement as well as camera and probe roughness were the parameters to be compared. Mean and standard deviation of the initial and the final score for the consecutively performed exercises as well as their slope were reported.

SETTING

The study was performed at the Medical University of Innsbruck, Department of Orthopaedic Surgery. Level of clinical care: institutional.

PARTICIPANTS

A Students Group (n = 10) consisting of medical students at the Medical University of Innsbruck with no prior knowledge of arthroscopy but interest in orthopedic surgery was selected. The group was compared to a Residents Group (n = 9) which was comprised of orthopedic resident surgeons who had learned arthroscopy in operation courses. All participants involved in the study did several repetitions of the described exercises.

RESULTS

Both groups improved their skills after several repetitions. Residents were on average faster, moved the camera less, and touched the cortical tissue less than the students. For certain parameters students showed a steeper improvement curve than did residents, because the students started from a different experience level.

CONCLUSIONS

In conclusion, our results demonstrate the usefulness of virtual knee arthroscopy simulators as an important tool for improving surgical and arthroscopic skills in orthopedic resident surgeons, and medical students.

A Randomized Controlled Trial of Skills Transfer: From Touch Surgery to Laparoscopic Cholecystectomy

BACKGROUND

Surgical training has traditionally involved teaching trainees in the operating room. However, intraoperative training is time-intensive and exposes patients to greater risks. Touch Surgery (TS) is an application that uses animation to provide simulation training via cognitive task analysis as an adjunct to intraoperative training.

METHODS

Forty students were recruited and randomly allocated to either a control or intervention group. Each group received the same preparation before intervention, including a 10-min introduction to laparoscopic equipment and a 15-min educational tutorial on laparoscopic cholecystectomies. The participants then received training via either TS (intervention) or written information (control). Their performance was compared using a validated scoring tool on a porcine laparoscopic cholecystectomy model. Significance was defined as P < 0.050.

RESULTS

In total, n = 22 and n = 18 participants were randomly assigned to intervention and control groups, respectively. There was no significant difference between age (P = 0.320), year of medical school (P = 0.322), handedness (P = 1.000), or gender (P = 0.360) of the groups. The overall mean performance score was higher for intervention (mean ± SD = 41.9 ± 22.5) than control (mean ± SD = 24.7 ± 19.6; P = 0.016). There was no significant difference between scores for each intraoperative segment between the intervention and control group (P > 0.050).

CONCLUSIONS

This study demonstrates that TS is effective for providing cognitive training in laparoscopic cholecystectomies to medical students. It is likely that this effect will be seen across modules and other platforms that use cognitive task analysis alongside high-fidelity animation. Further work is necessary to extend this to other surgical procedures for evaluating its longitudinal effectiveness.

Validation of an educational simulation model for vaginal hysterectomy training: a pilot study

INTRODUCTION AND HYPOTHESIS

The Miya Model ™ (Miyazaki Enterprises, Winston-Salem, NC, USA) was designed as a realistic vaginal surgery simulation model. Our aim was to describe this model and present pilot data on validity and reliability of the model as an assessment tool of vaginal hysterectomy skills.

METHODS

We video recorded ten obstetrics and gynecology residents (novice group) and ten practicing gynecologists (expert group) performing vaginal hysterectomy using the Miya model. Blood loss and time taken to complete the procedure were documented. Participants evaluated the model using a postsimulation survey. In addition, two experienced gynecologic surgeons independently evaluated video recordings of each participant's performance using two previously validated global rating scales: Reznick's Objective Structured Assessment of Technical Skill (OSATS) and Vaginal Surgical Skills Index (VSSI).

RESULTS

Most participants (80% of novice and 100% of expert group) rated the model as effective or highly effective for vaginal hysterectomy training and assessment. Median time to procedure completion was significantly higher in the novice group, whereas median estimated blood loss was no different between groups. No significant differences were observed in the composite median OSATS or VSSI scores between groups. The interrater reliability indices for subscales and composite scores of the OSATS and VSSI were high and ranged from 0.79 to 0.90 and 0.77 to 0.93, respectively.

CONCLUSIONS

With further study, the Miya Model may be a useful tool for teaching and assessing vaginal surgical skills.

Ex vivo ovine model for teaching open laryngotracheal surgery

Objective

To develop an animal model for teaching open laryngotracheal surgical procedures.

Methods

The heads and necks from 5 pre-pubescent sheep were harvested after humane anesthesia. After 2–5 days to allow for rigor mortis to resolve, a specimen was supported with sandbags on an operating table. Operative procedures including tracheotomy, medialization laryngoplasty, anterior cartilage grafting, tracheal resection with primary anastomosis, and laryngectomy with closure of the pharynx were attempted.

Results

The ovine head and neck provided an accurate model for simulation of all attempted procedures. Ovine tissue resembled that of humans in mechanical properties and handling. Postsurgical endoscopy confirmed graft alignment.

Conclusions

The sheep head and neck provides an inexpensive, realistic, and safe model for surgical training for a variety of open laryngotracheal procedures. This is particularly relevant given the recent emphasis on surgical simulation and the relative rarity of some of these procedures in residency training.