Collating evidence to support the validation of a simulated laparotomy incision and closure-training model

BACKGROUND

It is essential to evaluate the functionality of surgical simulation models, in order to determine whether they perform as intended. In this study, we assessed the use of a simulated laparotomy incision and closure-training model by collating validity evidence to determine its utility as well as pre and post-test interval data.

METHOD

This was a quantitative study design, informed by Messick's unified validity framework. In total, 93 participants (surgical trainees ​= ​80, experts ​= ​13) participated in this study. Evaluation of content validity and the models' relationships with other variables was conducted, along with a pre and post-test confidence assessment.

RESULTS

The model was deemed realistic and useful as a teaching tool, providing strong content validity evidence. In assessment of relationships with other variables, the expert group out-performed the novice group conclusively. Pre and post-test evaluation reported a statistically significant increase in confidence levels.

CONCLUSION

We present strong validity evidence of a novel laparotomy incision and closure simulation-training model.

Barbed Pharyngoplasty simulation using a 3D-printed model: design and validation study

PURPOSE

Learning how to use barbed sutures and perform Barbed Pharyngoplasty (BP) is challenging due to limited surgical training opportunities. This work aims to design, develop, and validate a new 3D surgical simulator to train ENT residents and specialists in performing BP.

METHODS

The Barbed Pharyngoplasty Simulator (BPS) was designed using diagnostic images of the facial mass and testing different materials to replicate the mucosal and bony tissues. ENT specialists with experience in BP and ENT residents were included in the validation study and were asked to perform the Alianza BP. After the simulation, they compiled the Face and Content Validity Questionnaires.

RESULTS

The BPS consists of a reusable cranial structure that contains the disposable palatopharyngeal structure, replicating the palatal structures and the tongue. Fifteen experienced ENT specialists and nine residents were included in the study. Findings demonstrated that the BPS faithfully replicated the muscular and fibrous-bony palatopharyngeal structures, with only 11% of residents having a negative opinion of the mucosal tissue. All the participants positively rated the sensation of using surgical instruments on the simulator. Also, ENT residents rated all aspects of the content validity test from normal to excellent, while specialists rated the BPS as a general training tool from normal to excellent; for lateral pharyngoplasty, BP, and Alianza, only 6.7% of participants disagreed with its usefulness, and 13.3% disagreed with it for anterior pharyngoplasty.

CONCLUSION

The BPS proposed in this preliminary study can potentially be a valuable tool in BP surgical training for residents and young otolaryngologists.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors

Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted.

Methods

This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years.

Results

In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05).

Conclusion

Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway.

Level of Evidence

IV.

Can Non-Virtual Reality Simulation Improve Surgical Training in Endoscopic Sinus Surgery? A Literature Review

Simulation in endoscopic sinus surgery allows residents to learn anatomy, to achieve the correct handling of various rhinological instruments, and to practice different surgical procedures. Physically or non-virtual reality models are the main items in endoscopic sinus surgery simulation. The objective of this review is to identify and make a descriptive analysis of non-virtual endoscopic sinus surgery simulators which have been proposed for training. As a new state of the art, surgical simulators are developed continuously, so they can be used to learn basic endoscopic surgery skills by repetitive maneuvers, permitting detection of surgical error and incidents without risk for the patient. Of all training physical models, the ovine model stands out because of the similarities of the sinonasal pathways, the wide availability, and the low costs. Considering the similar nature of the tissues involved, the techniques and surgical instruments can be used almost interchangeably with minimal differences. Every surgical technique studied until now has a degree of risk and the only aspects that consistently reduced the number of complications are training, repetition, and hands-on experience.

Thinking Beyond the Temporal Bone Lab: A Systematic Process for Expanding Surgical Simulation in Otolaryngology Training

The COVID-19 pandemic led to a temporary lapse in the development of otolaryngology trainee operative skills due to the cancellation of elective procedures and redeployment of trainees and attendings to COVID-19 units. Although transient, this disruption provided an opportunity for otolaryngology programs to develop contingency plans and formalize nascent simulation training curricula. Integration of formal simulation training alongside current didactic and surgical education may offset lost exposure during surgically lean times while providing the framework and resources for enhanced baseline training. Here, we provide an up-to-date overview of surgical simulation models in otolaryngology and identify easily implementable, low-cost, low fidelity models for junior trainees. By taking advantage of rapid advancements in technology and a paradigm shift to a more hands-on approach in medical education, formal simulation training may prove to be a beneficial tool at all stages of residency training, allowing for expanded peer-mentored skill development and providing a safe haven during unforeseen disruptions in surgical case volume.

Introducing a Realistic, Low-Cost Simulation Model for Clipping of Brain Aneurysms

BACKGROUND

The current trend toward endovascular treatment of brain aneurysms may have a negative impact on young neurosurgeons who are less exposed to these lesions, thus affecting the acquisition of surgical skills in the field. Different training models have emerged to help cope with this issue, but these have specific pitfalls. Training models based on live animals or cadaveric specimens face increasing restrictions as regulations become a barrier in accessibility for everyday skills development. We introduce a novel, realistic, and inexpensive simulation model using a fresh bovine brain, and we assess its face and content validity as a training tool.

METHODS

A fresh bovine brain is used to simulate microsurgical fissure dissection. Arterial and aneurysmal components are created with arteries and veins harvested from chicken thigh. A 12-item questionnaire using the Likert numeric scale (grades 1 - 5) was used to assess the validity of model in 10 surgeons.

RESULTS

Ten neurosurgeons performed the simulated clipping of the aneurysm and completed a questionnaire. All surgeons surveyed responded "agree" or "strongly agree" that the simulator, and the skills trained with it, are comparable to clipping brain aneurysms. All respondents believed that this simulator could improve patient safety.

CONCLUSIONS

We present a novel, realistic, and inexpensive simulation model for the clipping of brain aneurysms. This model was partially validated by the opinion of field experts. We believe this model has the potential to become a useful training tool for young neurosurgeons who have little exposure to real aneurysm cases.

Emergency airway training: "Who are you going to FONA?"

OBJECTIVES

To demonstrate face and content validity of a home-made simulation model as a training tool for front of neck access (FONA) procedures.

DESIGN

This was a prospective evaluation study, in which experienced otolaryngologists and trainees were recruited to complete 3 tasks using our FONA model.

SETTING

The study was completed during regular simulation training days and international conferences.

PARTICIPANTS

A total of 52 participants completed the questionnaire and were included in the study; 25 were experts and 27 were trainees.

MAIN OUTCOME MEASURES

All participants completed a validated 15-item questionnaire using a 5-point likert scale to assess the model across 4 domains: face validity (FV), global content (GC), task-specific content (TSC) and curriculum applicability (CTR).

RESULTS

There were no statistically significant differences between the groups ratings for FV, GC, TSC or CTR (P = .76, .13, .4 and .67, respectively). The model achieved a median FV of 4 (IQR 4-5) with the agreement of experienced and trainee groups (68.9% and 92%, respectively). The median GC validity score was 5 (IQR 4-5) with the agreement of 87.6% and 98.4% in respected groups. The model achieved a median TSC of 4.8 (IQR 4-5) with the agreement of 54.5% and 99% in respected groups. The median CTR score was 5 (IQR 4-5) with the agreement of 54.4% and 100% in respected groups.

CONCLUSION

Our home-made FONA model achieved face and content validity for training and is safe and affordable for teaching basic front of neck access skills to otolaryngology trainees.

Medical Liability in Sinus Surgery: A Westlaw Database Analysis From 2000 to 2017

BACKGROUND

Medical malpractice occurs when a hospital or health-care provider through negligent act or omission results in an injury to a patient. More than 50% of otolaryngologists have faced at least 1 claim, with rhinology being the most litigated subspecialty. This study aims to analyze medical litigation trends in Rhinology from 2000 to 2017 in the United States.

METHODS

The Westlaw database was reviewed from 2000 to 2017. Data were compiled on the demographics of the plaintiffs, procedures, nature of damages, legal allegations, and the use of expert witnesses, physician demographics/practice characteristics, verdicts, indemnities, and county/state of case.

RESULTS

There were 75 cases that met inclusion criteria after review of 125 cases. Majority of cases went to trial over settlement (80%) and were found in the Northeast region of the United States (36%). Most common cited legal allegations were improper performance and failure to follow standard of care. The most common nature of injuries were eye injury (29%) and intracranial complications (27%). The highest payouts were for progression of disease followed by intracranial injury. Of the 75 total cases analyzed, 37 (49.3%) used expert witnesses. When an expert witness was used at trial, the verdict statistically favored the defendant (62.5%).

CONCLUSIONS

Our analysis reveals the importance of meticulous surgical techniques and thorough preoperative evaluations.

Rhinology: Simulation Training (Part 2)

Purpose of Review

Recently, there has been an expansion of novel technologies in simulation training. The aim of this review was to examine existing evidence about training simulators in rhinology, their incorporation into real training programmes and translation of these skills into the operating room. The first part focuses on the virtual and augmented reality simulators. The second part describes the role of physical (i.e. non-computer-based) models of endoscopic sinus surgery.

Recent Findings

We learned that an ideal sinus surgery model would score highly in all standard measures of validity whilst maintaining an attainable cost. This is a challenging goal that is worthy of pursuit given that simulation training has been shown to be cost-effective option in other domains. Non-AR or VR models are attractive ways to fill gaps in simulation training whilst reducing compared with computer-based models.

Summary

In an era of improved computer technology and improved 3D printing, it will be increasingly important to focus on both the manufacture and validation process. One area that will benefit from further technological advancement is the realistic simulation of bleeding as this would obviate the need for animal models. Future studies on ESS simulation will also need to robustly demonstrate the validity of each model with the emphasis on the ability of a model to predict performance in operative environment.

Creating a Validated Simulation Training Curriculum in Otolaryngology

Purpose of Review

Simulation-based training is an integral component of surgical training. It allows practice of technical skills within a safe environment without compromising patient safety. This article seeks to review current virtual and non-virtual reality simulation models within the literature and review their validation status.

Recent Findings

Many simulation models exist within otolaryngology and are currently being used for education. New models are also continuously being developed; however, validity should be proven for the models before incorporating their use for educational purposes. Validity should be determined by experts and trainees themselves.

Summary

A validated simulation curriculum should be incorporated within the otolaryngology training programme. A curriculum based on the current training programme at our institution serves as an exemplar for local adoption.

Blinded Evaluation of Endoscopic Skill and Instructability After Implementation of an Endoscopic Simulation Experience

Background

Interest in endoscopic simulation is increasing. Past studies have used virtual reality or nonhuman models or residents with varying experience. Our aim was to evaluate the effect of simulation on procedural and psychomotor competence of medical students—surgical novices—performing endoscopic tasks on human cadavers and assess student perceptions.

Methods

Students (n = 22) completed a baseline sinus model skill evaluation graded by 2 blinded Rhinology fellows. Intervention and control groups with equal baselines were assigned. Intervention students practiced endoscopic tasks on the model for 45 minutes minimum over 2 weeks. All students reviewed sinus anatomy/disease and sinus surgery materials. The final cadaver evaluation was similar to the baseline. Fellows graded students on anatomy identification (sinuses, turbinates), psychomotor (navigation, camera alignment, instrument handling), and timed procedural (sinus object retrieval) skills, confidence, and instructability via fellow-guided frontal balloon placement.

Results

Participants included 16 males (72.7%) and 6 females (27.3%). Intervention and control groups contained 10 (45.4%) and 12 (54.6%) students, respectively. Intervention group final “Total Psychomotor” scores were higher (10.1/15 vs 7.8/15, P = .0231). “Surgical confidence” was 3.3/5 versus 2.5/5, and “Instructability” was 3.9/5 versus 3.4/5 in intervention versus control groups, respectively ( P < .050). Multivariate regression analysis demonstrated superior psychomotor skills, navigation, and confidence in the intervention group ( P < .036). Activity perception scores were higher in intervention students versus controls, 26.13 versus 18.36/40 ( P = .022).

Conclusion

In surgical novices, endoscopic simulation leads to superior endoscopic navigation and task performance in cadavers. This simulation presents a novel method for incorporating Otolaryngology simulation in medical student education.

Evaluating Simulator-Based Teaching Methods for Endoscopic Sinus Surgery

A multitude of simulator systems for endoscopic sinus surgery (ESS) are available as training tools for residents preparing to enter the operating room. These include human cadavers, virtual reality, realistic anatomic models, and low-fidelity gelatin molds. While these models have been validated and evaluated as independent tools for surgical trainees, no study has performed direct comparison of their outcomes. To address this deficiency, we aimed to evaluate the utility of high-fidelity and low-fidelity trainers as compared to a traditional control (no simulator exposure) for novice trainees acquiring basic ESS skills. Thirty-four first-year medical students were randomized to 3 groups and taught basic sinus anatomy and instrumentation. Two groups received training with either the high-fidelity or low-fidelity trainer, while 1 group served as control. These groups were then tested with cadaveric specimens. These sessions were recorded and graded by an expert. There was no statistical difference in performance between the 3 study groups with regard to identification of anatomy, endoscopic competency, or completion of basic tasks. When the high-fidelity and low-fidelity arms were grouped into a single "trained" cohort, they demonstrated significantly improved time to completion for basic anatomy (P = .043) and total time (P = .041). This is the first study to perform a direct comparison of performance between high-fidelity and low-fidelity ESS simulators and controls. Although we found no difference in performance of novice trainees with regard to basic anatomical identification or procedural tasks associated with ESS, the use of ESS simulators may improve time to completion.

Intraoperative Functional Endoscopic Sinus Surgery Training: Efficient Teaching Techniques-A New Method

Introduction:

Functional endoscopic sinus surgery is a complex procedure used by otorhinolaryngologists to treat a host of nasal sinus pathologies. Due to the involved nasal anatomy and the nature of the procedure, teaching residents to use an endoscope is challenging. Simulation labs have been helpful but intraoperative instruction can still present difficulty in communication between resident and attending physicians during the teaching process. The purpose of this is to hypothesize a method of teaching intraoperatively that can be used supplemental to or independently of virtual reality teaching.

Method:

Literature review to determine current intraoperative verbal teaching methods used by surgeons was performed. Review was also performed on the effects of simulation techniques in preparing residents for the operating room. Although this was not a systematic review including statistical analysis, a gap was found in the literature on how residents can be efficiently taught intraoperatively to navigate an endoscope while maintaining patient safety. A novel and inexpensive method has been devised as a possible teaching method.

Conclusions:

Extensive literature is not available in intraoperative teaching techniques. It is therefore uncertain whether such a method has been used before. Further study, possibly in the form of surveys and intraoperative trials, must be done to determine the effectiveness of this mechanism.

Training and assessment in functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery is a common procedure performed within otolaryngology, but it carries potential for significant life-changing complications. It is therefore essential that trainees undergo adequate training. The European Working Time Directive has led to reduced operating time for the trainee surgeon. With variable access and the cost implications associated with cadaveric specimens, simulation can be an invaluable educational resource in surgical training. The current literature regarding the various simulation methodologies that have been used in functional endoscopic sinus surgery training is discussed.

METHOD

A literature search was conducted using the key words 'nasal', 'nasal polyps', 'endoscope', 'education and simulation', 'endoscopic sinus surgery' and 'training'.

RESULTS

Twelve articles were identified; of these, eight trialled the use of simulators, two utilised ovine models and two used task trainers.

CONCLUSION

Simulation has shown benefit in functional endoscopic sinus surgery training; however, a robust platform accessible to ENT trainees is lacking.

A systematic review of validated sinus surgery simulators

BACKGROUND

Simulation provides a safe and effective opportunity to develop surgical skills. A variety of endoscopic sinus surgery (ESS) simulators has been described in the literature. Validation of these simulators allows for effective utilisation in training.

OBJECTIVE OF REVIEW

To conduct a systematic review of the published literature to analyse the evidence for validated ESS simulation.

SEARCH STRATEGY

Pubmed, Embase, Cochrane and Cinahl were searched from inception of the databases to 11 January 2017.

EVALUATION METHOD

Twelve thousand five hundred and sixteen articles were retrieved of which 10 112 were screened following the removal of duplicates. Thirty-eight full-text articles were reviewed after meeting search criteria. Evidence of face, content, construct, discriminant and predictive validity was extracted.

RESULTS

Twenty articles were included in the analysis describing 12 ESS simulators. Eleven of these simulators had undergone validation: 3 virtual reality, 7 physical bench models and 1 cadaveric simulator. Seven of the simulators were shown to have face validity, 7 had construct validity and 1 had predictive validity. None of the simulators demonstrated discriminate validity.

CONCLUSION

This systematic review demonstrates that a number of ESS simulators have been comprehensively validated. Many of the validation processes, however, lack standardisation in outcome reporting, thus limiting a meta-analysis comparison between simulators.

Patient Safety and Quality Improvement in Otolaryngology Education: A Systematic Review

Objective

The breadth and depth of patient safety/quality improvement (PS/QI) research dedicated to otolaryngology–head and neck surgery (OHNS) education remains unknown. This systematic review aims to define this scope and to identify knowledge gaps as well as potential areas of future study to improved PS/QI education and training in OHNS.

Data Sources

A computerized Ovid/Medline database search was conducted (January 1, 1965, to May 15, 2015). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar.

Review Methods

The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were classified by year, subspecialty, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass.

Results

Computerized searches yielded 8743 eligible articles, 267 (3.4%) of which met otolaryngology PS/QI inclusion criteria; 51 (19%) were dedicated to resident/fellow education and training. Simulation studies (39%) and performance/competency evaluation (23.5%) were the most common focus. Most projects involved general otolaryngology (47%), rhinology (18%), and otology (16%). Classification by the IOM included effective care (45%), safety/effective care (41%), and effective and efficient care (7.8%). Most research fell into the WHO category of “identifying solutions” (61%).

Conclusion

Nineteen percent of OHNS PS/QI articles are dedicated to education, the majority of which are simulation and focus on effective care. Knowledges gaps for future research include facial plastics PS/QI and the WHO category of “studies translating evidence into safer care.”

Current Status of Simulation in Otolaryngology: A Systematic Review

OBJECTIVE

Otolaryngology is a highly technical and demanding specialty and the requirements for surgical trainees to acquire proficiency remains challenging. Simulation has been purported to be an effective tool in assisting with this. The aim of this systematic review is to identify the available otolaryngology simulators, their status of validation, and evaluation the level of evidence behind each training model and thereby establish a level of recommendation.

DESIGN

PubMed, ERIC, and Google Scholar databases were searched for articles that described otolaryngology simulators or training models between 1980 and April 2016. Any validation studies for simulators were also retrieved. Titles and abstracts were screened for relevance using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Level of evidence (LoE) and Level of recommendation (LoR) was awarded to each study and model, respectively.

RESULTS

A total of 70 studies were identified describing 64 simulators. Out of these, at least 54 simulators had 1 validation study. Simulators for the ear and temporal bone surgery were the most common (n = 32), followed by laryngeal and throat (n = 20) and endoscopic sinus surgery (n = 12). Face validity was evaluated by 29 studies, 20 attempted to show construct, 20 assessed content, 20 transfer, and only 2 assessed concurrent validity. Of the validation assessments, 2 were classified as Level 1b, 10 Level 2a, and 48 Level 2b. No simulators received the highest LoR, but 8 simulators received a LoR of 2.

CONCLUSIONS

Despite the lack of evidence in outcome studies and limited number of high-validity otolaryngology simulators, the role of simulation continues to grow across surgical specialties Hence, it is imperative that the simulators are of high validity and construct for trainees to practice and rehearse surgical skills to develop confidence.

The Lamb's Head as a Model for Surgical Skills Development in Endonasal Surgery

Objectives To test the viability of a lamb's head model for sinonasal surgery training in Brazil by comparing performance of endoscopic procedures in the septum and inferior turbinates. Design Prospective study. Settings Universidade Federal do Rio Grande do Sul (2015). Participants Ten physicians performed septoplasty, inferior turbinoplasty, and middle turbinectomy on 30 lamb's heads. Main Outcome Measures Degree of difficulty and similarity, opinion of tissue color and texture, and degree of satisfaction. Results Participants completed a questionnaire at the end of each procedure and a satisfaction survey at the end of the project. Significant between-group differences were found for the perceived degree of difficulty in performing left inferior turbinoplasty, right inferior turbinoplasty, and septoplasty. Final satisfaction with training was scored 9 out of 10, and all participants reported that they would like to receive such training again. Conclusion The tested model is feasible due to its low cost, its easy availability, and its similarity to human anatomy in terms of dimensions of relevant structures and tissue consistency. It allows effective training in instrument handling and acquisition of the surgical skills related to two-dimensional vision needed for endoscopy. However, it should not be considered a substitute for training of specific surgical techniques.

Face, content, and construct validation of a low-cost, non-biologic, sinus surgery task trainer and knowledge-based curriculum

BACKGROUND

The purpose of this study was to evaluate face and content validity of a low-cost, low-technology, non-biologic endoscopic sinus surgery (ESS) task trainer and knowledge-based curriculum followed by construct validation of the task trainer.

METHODS

A sinus surgery task trainer and curriculum were developed. Attending otolaryngologists were surveyed regarding the utility of the task trainer and curriculum. A cross-sectional construct validation study was performed including medical students, residents, and attending otolaryngologists. Nine tasks were performed on the task trainer and graded using a global rating scale (GRS). Predictors of task trainer performance were evaluated, and spatial performance was measured. Regression analyses were performed to assess main associations.

RESULTS

All attending physicians (n = 7) agreed that the task trainer accelerates the learning curve and incorporates essential ESS techniques and that the knowledge-based curriculum describes anatomical and technical knowledge germane to ESS. Twelve medical students, 9 otolaryngology residents, and 5 attending otolaryngologists completed task trainer testing. GRS score varied by level of training after adjusting for potential confounders (slope = 2.63; p = 0.001). There was evidence of an association between a history of video gaming (slope = 1.33; p = 0.077), sports experience (slope = 2.08; p = 0.033), and sinus surgery simulation (slope = 2.72; p = 0.023) with GRS score, although not statistically significant.

CONCLUSION

This study demonstrated validity of a knowledge-based sinus surgery curriculum and low-cost, sinus task trainer supporting use in early training. Participants with prior video gaming, sports participation, and sinus surgery simulation experience perform better at baseline on the task trainer.

The role of simulation in teaching sinus surgery in otolaryngology residency: A survey of rhinologists

BACKGROUND

Simulation is currently recognized as an effective surgical training tool. However, no standardized curriculum exists for endoscopic sinus surgery (ESS) simulation training. The goal of this study was to obtain an understanding of current ESS simulation use to aid the future development of an ESS training curriculum.

METHODS

A 14-question survey regarding sinus simulation in residency training was developed through the education committee of the American Rhinologic Society. The survey was administered to academic American Rhinologic Society members in the United States, Canada, and Puerto Rico. The participants provided information regarding the type, amount, and effectiveness of simulation use in their residency program.

RESULTS

Responses were received from 67 training programs; 45% of the programs endorsed using simulation training, although only 23.9% used ESS simulation, and all the programs used cadavers. Only 12.5% of respondent programs required ESS simulation training before operating on live patients, and trainees had an average of <6 hours of simulation training before live operations. A majority of respondents observed subjective improvement in residents' endoscope handling, dexterity, and understanding of anatomy after ESS simulation. The greatest obstacles identified were associated cost and lack of realistic simulators.

CONCLUSION

A majority of responders observed improved surgical technique and knowledge in residents after simulation training. However, <25% of the survey responders used ESS simulation and cited cost and limited availability as the most common barriers. A curriculum of validated simulators has potential to improve the quality of ESS training during residency.

A Novel Peritonsillar Abscess Simulator

INTRODUCTION

In response to the growing demand for a peritonsillar abscess simulator, we developed a novel model to teach needle aspiration as well as incision and drainage of this common oropharyngeal disorder. The objectives of this study were to describe the construction of the simulator and to assess its realism and usefulness in the acquisition of drainage skills.

METHODS

The training model was created with reusable and readily available materials. During an otolaryngology emergencies boot camp, expert otolaryngologists performed abscess drainage and subsequently instructed novice learners on the techniques of the procedure. Each participant completed a questionnaire using a 5-point Likert-type scale to assess simulator realism and training usefulness.

RESULTS

A peritonsillar abscess drainage model was created using readily available materials. A total of 18 experienced attending otolaryngologists and senior otolaryngology residents (postgraduate year 4 and postgraduate year 5) participated in this study. All participants rated the trainer realistic, and 94% agreed that the model correlates with the essential skills needed for peritonsillar abscess management. All participants felt that this model would be useful in residency training to help develop dexterity, accuracy, and precision with peritonsillar abscess drainage instruments.

CONCLUSIONS

An easily reproducible peritonsillar abscess simulator was highly rated as a means of teaching peritonsillar abscess anatomy and provided opportunity for hands-on learning of drainage skills.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

The McGill simulator for endoscopic sinus surgery (MSESS): a validation study

Background

Endoscopic sinus surgery (ESS) is a technically challenging procedure, associated with a significant risk of complications. Virtual reality simulation has demonstrated benefit in many disciplines as an important educational tool for surgical training. Within the field of rhinology, there is a lack of ESS simulators with appropriate validity evidence supporting their integration into residency education. The objectives of this study are to evaluate the acceptability, perceived realism and benefit of the McGill Simulator for Endoscopic Sinus Surgery (MSESS) among medical students, otolaryngology residents and faculty, and to present evidence supporting its ability to differentiate users based on their level of training through the performance metrics.

Methods

10 medical students, 10 junior residents, 10 senior residents and 3 expert sinus surgeons performed anterior ethmoidectomies, posterior ethmoidectomies and wide sphenoidotomies on the MSESS. Performance metrics related to quality (e.g. percentage of tissue removed), efficiency (e.g. time, path length, bimanual dexterity, etc.) and safety (e.g. contact with no-go zones, maximum applied force, etc.) were calculated. All users completed a post-simulation questionnaire related to realism, usefulness and perceived benefits of training on the MSESS.

Results

The MSESS was found to be realistic and useful for training surgical skills with scores of 7.97 ± 0.29 and 8.57 ± 0.69, respectively on a 10-point rating scale. Most students and residents (29/30) believed that it should be incorporated into their curriculum. There were significant differences between novice surgeons (10 medical students and 10 junior residents) and senior surgeons (10 senior residents and 3 sinus surgeons) in performance metrics related to quality (p < 0.05), efficiency (p < 0.01) and safety (p < 0.05).

Conclusion

The MSESS demonstrated initial evidence supporting its use for residency education. This simulator may be a potential resource to help fill the void in endoscopic sinus surgery training.

Construct validity of the ovine model in endoscopic sinus surgery training

OBJECTIVES/HYPOTHESIS

To demonstrate construct validity of the ovine model as a tool for training in endoscopic sinus surgery (ESS).

STUDY DESIGN

Prospective, cross-sectional evaluation study.

METHODS

Over 18 consecutive months, trainees and experts were evaluated in their ability to perform a range of tasks (based on previous face validation and descriptive studies conducted by the same group) relating to ESS on the sheep-head model. Anonymized randomized video recordings of the above were assessed by two independent and blinded assessors. A validated assessment tool utilizing a five-point Likert scale was employed. Construct validity was calculated by comparing scores across training levels and experts using mean and interquartile range of global and task-specific scores. Subgroup analysis of the intermediate group ascertained previous experience. Nonparametric descriptive statistics were used, and analysis was carried out using SPSS version 21 (IBM, Armonk, NY).

RESULTS

Reliability of the assessment tool was confirmed. The model discriminated well between different levels of expertise in global and task-specific scores. A positive correlation was noted between year in training and both global and task-specific scores (P < .001). Experience of the intermediate group was variable, and the number of ESS procedures performed under supervision had the highest impact on performance.

CONCLUSIONS

This study describes an alternative model for ESS training and assessment. It is also the first to demonstrate construct validity of the sheep-head model for ESS training.

The Current State of United States Spine Surgery Training: A Survey of Residency and Spine Fellowship Program Directors

STUDY DESIGN

Program director survey.

OBJECTIVES

To collect data on spine surgical experience during orthopedic and neurological surgery residency and assess the opinions of program directors (PDs) from orthopedic and neurological surgery residencies and spine surgery fellowships regarding current spine surgical training in the United States.

SUMMARY OF BACKGROUND DATA

Current training for spine surgeons in the United States consists of a residency in either orthopedic or neurological surgery followed by an optional spine surgery fellowship. Program director survey data may assist in efforts to improve contemporary spine training.

METHODS

An anonymous questionnaire was distributed to all PDs of orthopedic and neurological surgery residencies and spine fellowships in the United States (N = 382). A 5-point Likert scale was used to assess attitudinal questions. A 2-tailed independent-samples t test was used to compare responses to each question independently.

RESULTS

A total of 147 PDs completed the survey. Orthopedic PDs most commonly indicated that their residents participate in 76 to 150 spine cases during residency, whereas neurological surgery PDs most often reported more than 450 spine cases during residency (p < .0001). Over 88% of orthopedic surgery program directors and 0% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform community spine surgery (p < .001). In contrast, 98.1% of orthopedic PDs and 86.4% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform spinal deformity surgery (p = .038). Most PDs agreed that surgical simulation and competency-based training could improve spine surgery training (76% and 72%, respectively).

CONCLUSIONS

This study examined the opinions of orthopedic and neurological surgery residency and spine fellowship PDs regarding current spine surgery training in the United States. A large majority of PDs thought that both orthopedic and neurological surgical trainees should complete a fellowship if they plan to perform spinal deformity surgery. These results provide a background for further efforts to optimize contemporary spine surgical training.

Teaching and assessing endoscopic sinus surgery skills on a validated low-cost task trainer

OBJECTIVES/HYPOTHESIS

To evaluate a previously validated low-cost sinus surgery task trainer as a means of acquiring basic endoscopic sinus surgery skills and as an objective structured assessment of technical skills (OSATS) to determine procedural competency.

STUDY DESIGN

Prospective blinded study.

METHODS

Medical students (N = 52) with no sinus surgery experience learned to perform nasal endoscopy and five specific sinus surgery tasks using the validated task trainer. Training included regimented expert instruction, peer instruction/observation, and experienced-based learning. Pre- and post-training video recordings of nasal endoscopy and five sinus surgery skills were obtained. Two blinded expert otolaryngologists compared pre- and post-training performance using a checklist and global rating scale.

RESULTS

Medical student post-training performance was significantly better than pre-training performance for each checklist item and global rating scale as calculated by paired t test (P < .001). Interrater reliability and internal consistency were confirmed by Kendall's coefficient of concordance and Cronbach's α calculations, respectively.

CONCLUSIONS

The sinus surgery task trainer provides an effective means of teaching and evaluating nasal endoscopy and basic sinus surgery skills for novice surgeons. With repeated practice, there was significant improvement in performance. An OSATS using the sinus surgery task trainer suggests that we can effectively measure endoscopic sinus surgery ability with the potential to reliably determine competency outside the operating room.