The Effect of an Interval Training on Skill Retention of High-Complex Low-Volume Minimal Invasive Pediatric Surgery Skills: A Pilot Study

Self-assessment, and not continuous training, improves basic open suturing skills

BACKGROUND

To develop and maintain suturing skills, clinical exposure is important. When clinical exposure cannot be guaranteed, an adequate training schedule for suturing skills is required. This study evaluates the effect of continuous training, 'reflection before practice' and self-assessment on basic open suturing skills.

METHODS

Medical students performed four basic suturing tasks on a simulation set up before ('pre-test') and after their surgical rotation ('after-test'). Participants were divided in three groups; the 'clinical exposure group' (n = 44) had clinical exposure during their rotation only, the 'continuous training group' (n = 16) completed a suturing interval training during their rotation and the 'self-assessment group' (n = 16) also completed a suturing interval training, but with the use of reflection before practice and self-assessment. Parameters measured by a tracking system during the suturing tasks and a calculated 'composite score' were compared between groups and test-moments.

RESULTS

A significantly better composite score was found at the after-test compared to the pre-test for all groups for all basic suturing tasks (0.001 ≤ p ≤ 0.049). The self-assessment group scored better at the pre-test than the other two groups for all tasks, except for 'knot tying by hand' (0.004 ≤ p ≤ 0.063). However, this group did not score better at the after-test for all tasks, compared to the other two groups. This resulted in a smaller delta of time ('transcutaneous suture', p = 0.013), distance ('Donati suture' and 'intracutaneous suture', 0.005 ≤ p ≤ 0.009) or composite score (all tasks, except for knot tying by hand, 0.007 ≤ p ≤ 0.061) in the self-assessment group.

CONCLUSION

Reflection before practice and self-assessment during continuous training of basic open suturing tasks, may improve surgical skills at the start of the learning curve.

Society for Simulation in Healthcare Guidelines for Simulation Training

BACKGROUND

Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist.

METHODS

Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

OBJECTIVE

These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare.

RESULTS

Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided.

CONCLUSIONS

The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Objective assessment for open surgical suturing training by finger tracking can discriminate novices from experts

It is difficult, time consuming and expensive to assess manual skills in open surgery. The aim of this study is to investigate the construct validity of a low-cost, easily accessible tracking technique for basic open suturing tasks. Medical master students, surgical residents, and surgeons at the Radboud University Medical Center were recruited between September 2020 until September 2021. The participants were divided, according to experience, in a novice group (≤10 sutures performed) and an expert group (>50 sutures performed). For objective tracking, a tablet with SurgTrac software was used, which tracked a blue and a red tag placed on respectively their left and right index finger. The participants executed four basic tasks on a suturing model: 1) knot tying by hand, 2) transcutaneous suturing with an instrument knot, 3) 'Donati' (vertical mattress suture) with an instrument knot and 4) continuous intracutaneous suturing without a knot. In total 76 participants were included: 57 novices and 19 experts. All four tasks showed significant differences between the novice group and expert group for the parameters time (p<0.001), distance (p<0.001 for Task 1, 2 and 3 and p=0.034 for Task 4) and smoothness (p<0.001). Additionally, Task 3 showed a significant difference for the parameter handedness (p=0.006) and Task 4 for speed (p=0.033). Tracking index finger movements using SurgTrac software on a tablet while executing basic open suturing skills on a simulator shows excellent construct validity for time, distance and motion smoothness in all four suturing tasks.

The feasibility and benefit of unsupervised at-home training of minimally invasive surgical skills

BACKGROUND

Simulation-based training may be used to acquire MIS skills. While mostly done in a simulation center, it is proposed that this training can be undertaken at-home as well. The aim of this study is to evaluate whether unsupervised at-home training and assessment of MIS skills is feasible and results in increased MIS skills.

METHODS

Medical doctors and senior medical students were tested on their innate abilities by performing a pre-test on a take-home simulator. Henceforth, they followed a two-week interval training practicing two advanced MIS skills (an interrupted suture with knot tying task and a precise peg transfer task) and subsequently performed a post-test. Both tests and all training moments were performed at home. Performance was measured using motion analysis software (SurgTrac) and by expert-assessment and self-assessment using a competency assessment tool for MIS suturing (LS-CAT).

RESULTS

A total of 38 participants enrolled in the study. Participants improved significantly between the pre-test and the post-test for both tasks. They were faster (632 s vs. 213 s, p < 0.001) and more efficient (distance of instrument tips: 9.8 m vs. 3.4 m, p = 0.001) in the suturing task. Total LS-CAT scores, rated by an expert, improved significantly with a decrease from 36 at the pre-test to 20 at the post-test (p < 0.001) and showed a strong correlation with self-assessment scores (R 0.771, p < 0.001). The precise peg transfer task was completed faster (300 s vs. 163 s, p < 0.001) and more efficient as well (14.8 m vs. 5.7 m, p = 0.005). Additionally, they placed more rings correctly (7 vs. 12, p = 0.010).

CONCLUSION

Unsupervised at-home training and assessment of MIS skills is feasible and resulted in an evident increase in skills. Especially in times of less exposure in the clinical setting and less education on training locations this can aid in improving MIS skills.

Feasibility of tracking in open surgical simulation

The aim of this study was to develop an adequate tracking method for open surgical training, using tracking of the instrument or hand motions.

An open surgical training model and the SurgTrac application were used to track four separate suturing tasks. These tasks were performed with colour markings of either instruments or fingers, to find the most promising setting for reliable tracking.

Four experiments were used to find the optimal settings for the tracking system. Tracking of instruments was not usable for knot tying by hand. Tracking of fingers seemed to be a more promising method. Tagging the fingers with a coloured balloon-tube, seemed to be a more promising method (1.2–3.0% right hand vs. 9.2–17.9% left hand off-screen) than covering the nails with coloured tape (1.5–3.5% right hand vs. 25.5–55.4% left hand off-screen). However, analysis of the videos showed that redness of the hand was seen as red tagging as well. To prevent misinterpreting of the red tag by redness of the hand, white surgical gloves were worn underneath in the last experiment. The off-screen percentage of the right side decreased from 1.0 to 1.2 without gloves to 0.8 with gloves and the off-screen percentage of the left side decreased from 16.9–17.9 to 6.6–7.2, with an adequate tracking mark on the video images.

This study shows that tagging of the index fingers with a red (right) and blue (left) balloon-tube while wearing surgical gloves is a feasible method for tracking movements during basic open suturing tasks.

The effect of continuous at-home training of minimally invasive surgical skills on skill retention

BACKGROUND

Skill deterioration of minimally invasive surgical (MIS) skills may be prevented by continuous training. The aim of this study is to evaluate whether unsupervised continuous at-home training of MIS skills results in better skill retention compared to no training.

METHODS

Medical doctors followed a two-week interval training for two MIS tasks (precise peg transfer and interrupted suture with knot tying), ending with a baseline test. They were randomly assigned to the no-practice group or continuous-practice group. The latter practiced unsupervised at home every two weeks during the study period. Skill retention was measured after three and six months on both tasks by the total time needed, distance traveled by instruments and LS-CAT score (8 best possible score and > 40 worst score).

RESULTS

A total of 38 participants were included. No significant differences in performance were found at pre-test or baseline. At six months the no-practice group needed more time for the suturing task (309 s vs. 196 s at baseline, p = 0.010) and the LS-CAT score was significantly worse (30 vs. 20 at baseline, p < 0.0001). The continuous-practice group performed the suturing task significantly better than the no-practice group at both three and six months (17 vs. 25, p < 0.001 and 17 vs. 30, p < 0.001) and faster as well (p = 0.034 and p = 0.001).

CONCLUSION

This study shows a skill decay after only a few months of non-use and shows better skill retention after continuous unsupervised at-home practice of MIS skills. This indicates an added value of regular at-home practice of surgical skills.

A Promising Future for Hands-On At-Home Training in Pediatric Surgery

INTRODUCTION

 Sufficient training is needed to acquire and retain the procedural skills needed for the surgical correction of congenital anatomical malformations. This study aims to assess the opinions of trainees and pediatric surgeons on the use of simulation-based continued at-home training, which can help to acquire these skills.

METHODS

 This study consisted of two parts. First, an international survey among trainees and pediatric surgeons assessed their opinions on simulation-based at-home training for pediatric surgical procedures (5-point Likert scale). Second, participants of pediatric colorectal courses were instructed to practice the posterior sagittal anorectoplasty procedure at-home on a simulation model and, subsequently, complete a questionnaire regarding their opinions on continuous at-home training (5-point Likert scale).

RESULTS

 A total of 163 participants (83% pediatric surgeons) completed the international survey (response rate 43%). Overall, participants considered the training useful for both laparoscopic (mean 4.7) and open procedures (mean 4.2) and agreed that it may be used at home after a hands-on course (mean 4.3).Twenty participants completed the questionnaire on continued training (response rate 36%). All agreed that at-home training was of added value (mean 4.5) and that the skills were transferable to the clinical setting (mean 4.3). At-home training was regarded a suitable exercise after a hands-on workshop (mean 4.3), but less so without a workshop (mean 3.7, p=0.017).

CONCLUSION

 Participating trainees and pediatric surgeons were of the opinion that simulation models and at-home training have added value. This implies that simulation-based training may be used more often in pediatric surgical training.