Surgical education and training in the new millennium

Colorectal travelling fellowships: Exploring current perspective and future direction

Travelling Surgical fellowships (TSF) have a longstanding tradition in promoting out-of-programme surgical training, fostering collegiality and collaboration among surgeons. In this retrospective review we explore its historical context and examine existing practices and likely future trends. More specifically, we focus on colorectal travelling fellowships (CTF) and provide additional quantitative and qualitative analyses, highlighting the most valued theme-based surgical experiences and examine their merits and impacts. The TSF time-series analysis was based on a total of 350 awarded fellowships from 2000 to 2019. CTF analysis was based on 98 fellowships. The accelerated utilization of internet-based virtual interaction during the COVID-19 Pandemic has offered an opportunity to examine its possible intermediate and long-term disruptive effects.

The reliability of trabeculectomy surgical videos on the internet for educational purposes in the changing world

BACKGROUND AND PURPOSE OF THE STUDY

The use of social media that facilitates access to surgical training is increasing among general practitioners/surgeons. The present study aimed to evaluate the educational quality of videos on social media and the medical education websites in terms of trabeculectomy surgery.

METHODS

In this cross-sectional and register-based study, the term "trabeculectomy" has been searched on 22 websites containing medical surgery training videos. Demographical features and descriptive statistics of videos are noted. All videos were evaluated independently by two ophthalmologists according to DISCERN, Journal of American Medical Association, and Global Quality scoring system. The main 11 steps of trabeculectomy surgery were taken into consideration in each video and Video Quality Score was determined based on these steps.

THE MAIN FINDINGS

In total, 731 videos were watched and 634 were excluded and 97 videos were included in the study. The total quality of all videos according to DISCERN, JAMA, GQS, and VQS scores were 31.6 ± 9.1 (poor quality), 1.3 ± 0.4 (poor quality), 2.6 ± 0.9 (fair quality), and 6.9 ± 2.1 (poor quality) respectively. Only 6 of the 97 evaluated videos included all the steps of trabeculectomy surgery. Videos have longer duration, videos with narration or videos with descriptive subtitles were found to be significantly higher quality than those are not.

CONCLUSSION

The educational quality of internet videos may be far from the quality it should be and it is indisputable that it is necessary to be able to access surgical educational videos that are peer-viewed and whose quality is not doubted.

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 Student And Faculty Perceptions Of Undergraduate Surgical Training In The South African And Swedish Tertiary Institutions: A Cross-Sectional Survey

PURPOSE

To evaluate and compare medical student and faculty perceptions of undergraduate surgical training and compare results between South Africa and Sweden.

PATIENTS AND METHODS

An electronic, online questionnaire was anonymously distributed to medical students and surgical faculty at the University of Cape Town (UCT), South Africa, and the Karolinska Institutet (KI), Sweden. The questionnaire explored the perceptions of medical students and surgical faculty regarding the current undergraduate surgical curriculum, as well as existing clinical and theoretical instructional methods.

RESULTS

A total of 120 students (response rate of 24.4%) and 41 faculty (response rate of 74.5%) responded. Students believed they ought to receive significantly more teaching when compared to surgical faculty (p=0.018). Students and faculty generally agreed that students should expect to study approximately six to 20 hrs per week outside of clinical duty. There was general agreement that "small-group tutorials" was the area students learn the most from, whereas students reported "lectures" least helpful. Registrars were reported as the first person students should consult regarding patient care. Fifty-one (42.5%) medical students believed that faculty viewed students as an inconvenience, and 42 (35.0%) students believed that faculty would rather not have students on the clinical team. The majority of faculty (68.3%) reported significantly more negative views on the current undergraduate surgical curriculum when compared to students (p=0.002). UCT faculty reported giving significantly less feedback to students during their surgical rotation when compared to KI faculty (p=0.043).

CONCLUSION

Significant differences exist between surgical faculty and medical student perceptions regarding undergraduate surgical training in developing and developed countries. In order to increase surgical interest among undergraduate medical students, it is imperative for surgical educators to be aware of these differences and find specific strategies to bridge this gap.

Computer Simulation and Maxillary All-on-Four Surgery

Maxillary all-on-four implant reconstruction requires training beyond normal dental implant training. It conjoins technical surgical acumen, anatomic and complex spatial relationship understanding, thorough awareness of dental prosthodontic principles, and excellent patient management skills. Acquisition of appropriate training to the level of competence in an era of greater patient expectations and increased vigilance for patient safety and overall quality of care is limited. Repeated purposeful practice in performing complex psychomotor tasks is of paramount importance in achieving competence. Surgical simulation may assist surgical learners to acquire familiarity with relevant anatomic variations, instrumentation, surgical techniques, and management of intraoperative and postoperative complications.

Development and Evaluation of a New Formative Assessment of Surgical Performance

BACKGROUND

Formative assessment of operative performance is a mandatory part of surgical training. Engagement with assessment is limited in part by the time-consuming nature and the high perceived stakes of current assessment tools.

OBJECTIVES

Our aims were to develop and collect validity evidence for a new operative assessment tool that addresses barriers to assessment that current trainers and trainees experience.

METHODS

We developed the Generic Operative Supervised Learning Event (GOSLE). Orthopedic trainees were invited to complete GOSLEs with their trainers after surgical procedures. Experienced consultants assessed videotaped operations performed by trainees using the GOSLE. Validity evidence for content, relationships to other scores, internal structure, response process, and consequences of testing were evaluated.

RESULTS

A total of 250 GOSLEs were completed. A strong correlation was found between the GOSLE scores and the Procedure-Based Assessment ratings (r = 0.87, p < 0.001). Rasch analysis confirmed satisfactory internal structure of the rating scale, with sequential increases in rating as performance improved. The reproducibility coefficient was 0.88, with 10 assessments of the same trainee who has to achieve a reliability coefficient of 0.8. Over 90% of users found the GOSLE easy to use, with most preferring it to other assessment methods. Feedback quality was higher using the GOSLE than with current assessments.

CONCLUSION

We have collected validity evidence across multiple domains in support of the GOSLE. Its psychometric performance is comparable to that of current assessments. It is preferred by trainers and trainees over existing assessments. It stimulates high-quality, actionable feedback which better supports formative assessment. By addressing issues experienced with existing assessments, we expect engagement among users to be high.

The role and validity of surgical simulation

In the last three decades, simulation has become a key tool in the training of doctors and the maintenance of patient safety. Simulation offers an immersive, realistic way of learning technical skills. Recent changes to the training schemes in many surgical specialities mean that the hours spent working between senior house officer and consultant have been reduced. This, combined with other pressures (such as reduced operating hours), means that surgery has moved away from its traditional apprenticeship model and toward a competency-based one. Simulation can be a standardized and safe method for training and assessing surgeons. Use of simulation for training has become significant alongside the development of laparoscopic techniques, and evidence suggests that skills obtained in simulation are applicable in real clinical scenarios. Simulation allows trainees to make mistakes, to ask the "what if?" questions, and to learn and reflect on such situations without risking patient safety. Virtual reality simulators have been used to allow experts to plan complicated operations and assess perioperative risks. Most recently, fully immersive simulations, such as those with whole theater teams involved, and patient-centered simulations allow development of other key skills aside from purely technical ones. Use of simulation in isolation from traditional teaching methods will furnish the surgeon in training with skills, but the best time and place to use such skills comes only with experience. In this article we examine the role of simulation in surgical training and its impact in the context of reduced training time.

Is motion analysis a valid tool for assessing laparoscopic skill?

BACKGROUND

The use of simulation for laparoscopic training has led to the development of objective tools for skills assessment. Motion analysis represents one area of focus. This study was designed to assess the evidence for the use of motion analysis as a valid tool for laparoscopic skills assessment.

METHODS

Embase, MEDLINE and PubMed were searched using the following domains: (1) motion analysis, (2) validation and (3) laparoscopy. Studies investigating motion analysis as a tool for assessment of laparoscopic skill in general surgery were included. Common endpoints in motion analysis metrics were compared between studies according to a modified form of the Oxford Centre for Evidence-Based Medicine levels of evidence and recommendation.

RESULTS

Thirteen studies were included from 2,039 initial papers. Twelve (92.3 %) reported the construct validity of motion analysis across a range of laparoscopic tasks. Of these 12, 5 (41.7 %) evaluated the ProMIS Augmented Reality Simulator, 3 (25 %) the Imperial College Surgical Assessment Device (ICSAD), 2 (16.7 %) the Hiroshima University Endoscopic Surgical Assessment Device (HUESAD), 1 (8.33 %) the Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) and 1 (8.33 %) the Robotic and Video Motion Analysis Software (ROVIMAS). Face validity was reported by 1 (7.7 %) study each for ADEPT and ICSAD. Concurrent validity was reported by 1 (7.7 %) study each for ADEPT, ICSAD and ProMIS. There was no evidence for predictive validity.

CONCLUSIONS

Evidence exists to validate motion analysis for use in laparoscopic skills assessment. Valid parameters are time taken, path length and number of hand movements. Future work should concentrate on the conversion of motion data into competency-based scores for trainee feedback.

Learning styles of medical students, general surgery residents, and general surgeons: implications for surgical education

BACKGROUND

Surgical education is evolving under the dual pressures of an enlarging body of knowledge required during residency and mounting work-hour restrictions. Changes in surgical residency training need to be based on available educational models and research to ensure successful training of surgeons. Experiential learning theory, developed by David Kolb, demonstrates the importance of individual learning styles in improving learning. This study helps elucidate the way in which medical students, surgical residents, and surgical faculty learn.

METHODS

The Kolb Learning Style Inventory, which divides individual learning styles into Accommodating, Diverging, Converging, and Assimilating categories, was administered to the second year undergraduate medical students, general surgery resident body, and general surgery faculty at the University of Alberta.

RESULTS

A total of 241 faculty, residents, and students were surveyed with an overall response rate of 73%. The predominant learning style of the medical students was assimilating and this was statistically significant (p < 0.03) from the converging learning style found in the residents and faculty. The predominant learning styles of the residents and faculty were convergent and accommodative, with no statistically significant differences between the residents and the faculty.

CONCLUSIONS

We conclude that medical students have a significantly different learning style from general surgical trainees and general surgeons. This has important implications in the education of general surgery residents.

Construct validation of a low-fidelity endoscopic sinus surgery simulator

BACKGROUND

Before a simulator becomes widely accepted, it must be relevant, affordable, and accessible. We have developed a low-cost model emphasizing the basic skills required for endoscopic sinus surgery (ESS). It is noninvasive, free from risk of infection, and an excellent low-pressure learning opportunity. The current study was designed to assess the construct validity of our simulator.

METHODS

We conducted a stratified randomized crossover-control study. Otolaryngology residents, fellows, and faculty performed predetermined tasks on the model or cadaver, and then switched. Evaluation included hand motion analysis, task time, and blinded expert review.

RESULTS

Sixteen subjects at various levels of training participated. Cadaver performance correlated well with level of training and previous experience with ESS. However, model performance did not demonstrate statistically significant correlation.

CONCLUSION

Our model was unable to demonstrate clear construct validity at this time. Materials and structural modifications are in progress. Pending further validation, its low-cost construction possesses potential for integration into otolaryngology residency curricula. Assessment of the simulator's ability to improve surgical skill is also planned.

Simulation in laparoscopic surgery: a concurrent validity study for FLS

BACKGROUND

Current assessments using the fundamentals of laparoscopic surgery (FLS) tasks are labour intensive and depend heavily on expert raters. Hand motion analysis may offer an alternative method of objective evaluation of FLS performance.

PURPOSE

The aim of this study was to assess whether a correlation exists between the expert rated assessments of the FLS tasks and computer-based assessment of motion efficiency using the Imperial College surgical assessment device (ICSAD).

METHODS

We recruited 26 volunteer subjects who were stratified into three experience groups: juniors (PGY1-3) (N = 13), seniors (PGY4,5) (N = 7) and staff surgeons (N = 6). All subjects performed four FLS tasks: (1) peg transfer, (2) pattern cut, (3) endoloop and (4) intracorporeal suturing. Performance was assessed by both standard FLS expert rating and motion analysis using ICSAD. Group differences were analyzed using the Kruskal-Wallis test, and Spearman coefficient analyses were employed to compare FLS and ICSAD scores.

RESULTS

FLS expert-derived scores discriminated effectively between experience groups for all tasks (p < 0.05). Motion efficiency scores discriminated between experience groups for tasks 1, 3 and 4 for number of movements (p < 0.05), tasks 1 and 4 for total distance (p < 0.05) and tasks 1, 2, 3 and 4 for total time (p < 0.005). There was a significant correlation between total FLS expert scores and the motion efficiency metrics of total distance, number of movements and total time (Spearman coefficient and p values of 0.81, < 0.001; 0.76; < 0.001; and 0.93, < 0.001, respectively).

CONCLUSION

There is a high correlation between FLS standard scoring and motion efficiency metrics. The use of ICSAD for the objective assessment of FLS tasks may in the future offer an adjunctive method of evaluation. ICSAD metrics are potentially less labour intensive due to the instant and fully automated computerized scoring that it provides.

Short-phase training on a virtual reality simulator improves technical performance in tele-robotic surgery

BACKGROUND

The da Vinci tele-robot necessitates the acquisition of new skills and surgical educators must develop standardized training programmes. It is possible that virtual reality (VR) computer simulation maybe used and it is necessary to define whether a simulator is an appropriate tool.

METHODS

Ten surgical novices performed a series of five tasks, ten times on a commercially available VR robotic simulator. Two experts repeated the series of tasks twice in an attempt to validate the simulator.

RESULTS

Each of the five tasks displayed statistically significant learning curves. Error scores did not improve significantly over successive repetitions except in one task. The experts completed two of the tasks in a significantly faster time.

CONCLUSIONS

Practice sessions on a VR simulator improve technical performance. The simulator enables surgeons to mount the early part of the learning curve within a laboratory environment, which may lead to a more effective training programme.

Training opportunities and the role of virtual reality simulation in acquisition of basic laparoscopic skills

BACKGROUND

Within the past decade, there has been increasing interest in simulation-based devices for training and assessment of technical skills, especially for minimally invasive techniques such as laparoscopy. The aim of this study was to investigate the perceptions of senior and junior surgeons to virtual reality simulation within the context of current training opportunities for basic laparoscopic procedures.

METHODS

A postal questionnaire was sent to 245 consultants and their corresponding specialist registrar (SpR), detailing laparoscopic surgical practice and their knowledge and use of virtual reality (VR) surgical simulators.

RESULTS

One hundred ninety-one (78%) consultants and 103(42%) SpRs returned questionnaires; 16%(10/61) of junior SpRs (year 1-4) had performed more than 50 laparoscopic cholecystectomies to date compared with 76% (32/42) of senior SpRs (year 5-6) (P < 0.001); 90% (55/61) of junior SpRs and 67% (28/42) of senior SpRs were keen to augment their training with VR (P = 0.007); 81% (238/294) of all surgeons agreed that VR has a useful role in the laparoscopic surgical training curriculum.

CONCLUSIONS

There is a lack of experience in index laparoscopic cases of junior SpRs, and laparoscopic VR simulation is recognized as a useful mode of practice to acquire technical skills. This should encourage surgical program directors to drive the integration of simulation-based training into the surgical curriculum.

Tensiometry as a measure of improvement in knot quality in undergraduate medical students

INTRODUCTION

This study examined the validity of tensiometry as an objective method of assessing the improvements in the quality of knots and technical performance due to practice on suturing and knot-tying skills.

METHODS

We evaluated the quality of 1,830 knots produced by undergraduate medical students before training (pre-test), after (post-test), and after a week retention (retention-test) using tensiometry. These results were compared to expert-based assessments of products and performance.

RESULTS

Tensiometry, as well as expert-based assessments can detect changes in the quality of knots and technical performance from pre to post and retention-test ( p<0.05). However, these three methods may assess different dimensions of the same products and actions.

CONCLUSIONS

The development of trainee evaluation criteria for the acquisition of surgical skills is a crucial element in surgical education. Based on our patterns of results it is hypothesized that tensiometry can serve as an economic first approximation of the quality of knots and suturing performance.

The impact of objective assessment and constructive feedback on improvement of laparoscopic performance in the operating room

OBJECTIVES

The study was carried out to demonstrate the impact of assessment and constructive feedback on improvement of laparoscopic performance in the operating room (OR).

DESIGN

Sixteen surgical trainees performed a laparoscopic cholecystectomy in the OR. The participants were then divided into two groups. The procedure performed by group 1 was assessed by an experienced surgeon, and detailed and constructive feedback was provided to each trainee. Group 2 received no feedback. Subsequently, all subjects performed a new laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotapes and assessed by two independent and blinded observers using a validated scoring system.

MAIN OUTCOME MEASURES

Error and economy of movements score assessed during the laparoscopic procedures in the OR.

RESULTS

No differences in baseline assessments were found between the two groups (t-test, p > 0.5). Surgeons, who received feedback (group 1) made significantly greater improvement in their time to complete the following procedure (independent sample t-test, p = 0.022), error (t-test, p = 0.003) and economy of movement scores (t-test, p < 0.001).

CONCLUSIONS

Surgeons who received constructive feedback made significantly greater improvement in their performance in the OR compared with those in the control group. The study provides objective evidence that assessment is beneficial for surgical training and should be implemented in the educational programmes in the future.

A comparison of single- and multiple-stage approaches to teaching laparoscopic suturing

BACKGROUND

This study assessed the effects of learning laparoscopic knot-tying through a series of progressively more difficult steps versus learning the skill in full complexity.

METHODS

Junior residents (N = 24) practiced either (1) suturing in full complexity under 2-dimensional conditions or (2) simple cone transfer drills under 3-dimensional and then 2-dimensional conditions, followed by suturing under 3-dimensional and then 2-dimensional conditions. Pre-, post-, and delayed (1 week) laparoscopic suturing performances were assessed by using objective motion efficiency variables and final product analyses.

RESULTS

Both groups showed similar improvements on all measures, which were well retained over the 1-week period (P < .01).

CONCLUSIONS

Despite spending less time practicing actual suturing, the group of residents who progressed through the sequence of steps performed as well as those who practiced the entire task in its full complexity, a finding that has implications for minimizing teaching resources and training costs.

Application of Motor Learning Principles to Complex Surgical Tasks: Searching for the Optimal Practice Schedule

Practice of complex tasks can be scheduled in several ways: as whole-task practice or as practice of the individual skills composing the task in either a blocked or a random order. The authors used those 3 schedules to study 18 participants' learning of an orthopedic surgical task. They assessed learning by obtaining expert evaluation of performance and objective kinematic measures before, immediately after, and 1 week after practice (transfer test). During acquisition, the blocked group showed superior performance for simple skills but not for more complex skills. For the expert-based measures of performance, all groups improved from pretest to posttest and remained constant from posttest to transfer. Measures of the final product showed that the whole-practice group's outcomes were significantly better than those of the random group on transfer. All groups showed better efficiency of motions in the posttest than in the pretest. Those measures were also poorer on the transfer test than on the posttest. The present evidence does not support the contextual interference effect--hypothetically, because of the inherent cognitive effort effect associated with some of the component skills. The authors recommend that surgical tasks composed of several discrete skills be practiced as a whole. The results of this study demonstrate the importance of critically appraising basic theories in applied environments.

Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills

BACKGROUND

Teaching of technical surgical skills to undergraduate medical students in a laboratory setting away from the patient is not common practice. Because of the large volume of students and shortage of available teaching faculty new methods of teaching must be developed for this group of trainees. In this study we examined the effectiveness of computer-based video training, different types of computer-based motion efficiency feedback (with and without expert criteria), and expert feedback on learning of a basic technical skill in medical students.

METHODS

Forty-five junior medical students were randomized into 3 groups and learned suturing and knot-tying skills. Group A received computer-generated feedback about the economy of their movements. Group B received the same motion economy feedback, as well as expert reference values. Group C received verbal feedback from an expert. All groups were pre-tested, allowed 18 practice trials, and post-tested, and their skill retention was retested after 1 month. Performance was assessed by expert analysis using an objective structured analysis of technical skill and by computer analysis (Imperial College Surgical Assessment Device [ICSAD]).

RESULTS

All groups showed improvement from pre-test to post-test. However, only group C showed retention of skill on delayed performance testing.

CONCLUSIONS

Verbal feedback from an expert instructor led to lasting improvements in technical skills performance. Providing information about motion efficiency did not lead to similar improvements.

Quantification of process measures in laparoscopic suturing

BACKGROUND

Process measures describing the generation of movement are useful for evaluation and performance feedback purposes. This study aimed to identify process measures that differ between novice and advanced laparoscopists while completing a suturing skill.

METHODS

A group of junior and a group of senior residents and fellows in surgery (n = 6) placed 10 laparoscopic sutures in a synthetic model. Process measures were quantified using an opto-electric motion/force sensor assembly that recorded: instrument rotation, applied forces, time, and time delays between force application and instrument rotation.

RESULTS

Advanced trainees showed increased instrument rotation, higher peak applied force, and faster performance compared to novices (alll p < .01). However, over trials, only novices showed adaptations for instrument rotation and total time (interactions at p < .01) with no adaptation for the force application. The difference between the moments of force application and instrument rotation was not sensitive to participant training.

CONCLUSIONS

Movement process measures can enhance our understanding of early adaptation processes and how such factors might be used as feedback to facilitate skill acquisition.

The human face of simulation: patient-focused simulation training

Simulation is firmly established within health care training but often focuses on training for technical tasks and can overlook crucial skills such as professionalism and physician-patient communication. The authors locate this paper within current developments in health care and relate it to the literature on simulation. They make the case for placing real human "patients" (played by actors) within simulation environments, thereby ensuring that the training experience remains rooted in actual practice. By practicing repeatedly within a safe environment, technical skills, communication with patients and team members, decision making, and clinical judgment may all be practiced and mastered while preserving patient safety. In elaborating this concept of patient-focused simulation (PFS), the authors draw on work already published by their group and several recent studies that are in review. These explore PFS in low, medium, and high complexity settings. Important or rare situations can be recreated and practiced, as well as key procedures required across a range of experience levels and clinical specialties. Finally, the case is made for curriculum redesign to ensure that simulator-based technical skills training and assessment take place within an authentic context that reflects the wider elements of clinical practice.

Computer-assisted assessment of one-handed knot tying skills performed within various contexts: a construct validity study

BACKGROUND

The widespread use of computer-assisted assessment of technical proficiency in surgical residents shows the need for further investigations of the construct validity of these devices (eg, hand motion analysis) before implementation into competency testing.

METHODS

Thirty general surgery residents performed 1-handed knot tying in 2 contexts: superficial and deep. The Imperial College Surgical Assessment Device (ICSAD) was used to evaluate performance. It was hypothesized that senior residents (postgraduate year [PGY] 4-5) would perform better then junior residents (PGY 1-3) and that the superficial version of the skill would be easier than the deep.

RESULTS

Technical efficiency scores were better for seniors than for juniors (P < .001) and on the superficial versus the deep model (P < .001). Both groups were equally affected by the contextual changes to the skill, suggesting a consistent impact on the skill-specific movement patterns.

CONCLUSIONS

Additional evidence for the validity of ICSAD as a competency assessment tool has been shown. First, it distinguished senior and junior residents. Second, it discerned differences on the same skill performed in 2 different contexts.

Virtual Reality Simulation Training can Improve Inexperienced Surgeons' Endovascular Skills

PURPOSE

The aim of this study was to evaluate virtual reality (VR) simulation for endovascular training of surgeons inexperienced in this technique.

METHODS

Twenty consultant vascular surgeons were divided into those who had performed >50 endovascular procedures (e.g. aortic and carotid stent) as primary operator (n=8), and those having performed <10 procedures (n=12). To test for endovascular skill rather than procedural knowledge, all subjects performed a renal artery balloon angioplasty and stent procedure. The simulator uses real tools with active force feedback, and provides a realistic image of the virtual patient. Surgeons with endovascular skills performed two repetitions and those without completed six repetitions of the same task. The simulator recorded time taken for the procedure, the amount of contrast fluid used and total fluoroscopy time.

RESULTS

Initially, surgeons with endovascular skills were significantly faster (median 571.5 vs. 900.0 s, p=0.039) and used less contrast fluid (19.1 vs. 42.9 ml, p=0.047) than inexperienced operators, though differences for fluoroscopy time were not significant (273 vs. 441 s, p=0.305). Over the six sessions, the inexperienced group made significant improvements in performance for time taken (p=0.007) and contrast fluid usage (p=0.021), achieving similar scores at the end of the training program to the experienced group.

CONCLUSIONS

Surgeons with minimal endovascular experience can improve their time taken and contrast usage during short-phase training on a VR endovascular task. VR simulation may be useful for the early part of the learning curve for surgeons who wish to expand their endovascular interests.

Validation of a new basic virtual reality simulator for training of basic endoscopic skills

BACKGROUND

The aim of this study was to establish content, face, concurrent, and the first step of construct validity of a new simulator, the SIMENDO, in order to determine its usefulness for training basic endoscopic skills.

METHODS

The validation started with an explanation of the goals, content, and features of the simulator (content validity). Then, participants from eight different medical centers consisting of experts (> or =100 laparoscopic procedures performed) and surgical trainees (<100) were informed of the goals and received a "hands-on tour" of the virtual reality (VR) trainer. Subsequently, they were asked to answer 28 structured questions about the simulator (face validity). Ratings were scored on a scale from 1 (very bad/useless) to 5 (excellent/very useful). Additional comments could be given as well. Furthermore, two experiments were conducted. In experiment 1, aimed at establishing concurrent validity, the training effect of a single-handed hand-eye coordination task in the simulator was compared with a similar task in a conventional box trainer and with the performance of a control group that received no training. In experiment 2 (first step of construct validity), the total score of task time, collisions, and path length of three consecutive runs in the simulator was compared between experts (>100 endoscopic procedures) and novices (no experience).

RESULTS

A total of 75 participants (36 expert surgeons and 39 surgical trainees) filled out the questionnaire. Usefulness of tasks, features, and movement realism were scored between a mean value of 3.3 for depth perception and 4.3 for appreciation of training with the instrument. There were no significant differences between the mean values of the scores given by the experts and surgical trainees. In response to statements, 81% considered this VR trainer generally useful for training endoscopic techniques to residents, and 83% agreed that the simulator was useful to train hand-eye coordination. In experiment 1, the training effect for the single-handed task showed no significant difference between the conventional trainer and the VR simulator (concurrent validity). In experiment 2, experts scored significantly better than novices on all parameters used (construct validity).

CONCLUSION

Content, face, and concurrent validity of the SIMENDO is established. The simulator is considered useful for training eye-hand coordination for endoscopic surgery. The evaluated task could discriminate between the skills of experienced surgeons and novices, giving the first indication of construct validity.

Randomised, controlled study investigating the optimal instructor: student ratios for teaching suturing skills

INTRODUCTION

Recently, there has been a shift away from practising procedures on patients for the first time and towards bench model teaching of clinical skills to undergraduate medical students. However, guidelines for the most effective instructor : student ratio for technical skills training are unclear. This has important implications for staffing laboratory based teaching sessions. The purpose of this study was to assess the optimal ratio of teachers to learners during the teaching of a simulated wound closure.

METHODS

A total of 108 undergraduate medical students participated in a 1-hour course on wound closure. They were randomised to 3 groups, each with a different instructor:student ratio (Group A: 6-12; Group B: 3-12; Group C: 1-12). Students were evaluated on a pre-test, an immediate post-test and a delayed retention test using an objective, computer-based technical skills assessment method. Collectively termed the "economy of movements", the total time taken to complete the task and the number of movements executed were the primary outcome measures.

RESULTS

Improvements in the economy of movements were the same for Groups A and B and were better than in Group C (P < 0.005).

DISCUSSION

The optimal instructor:student ratio was 1 instructor for 4 students. Higher ratios of instructors to students resulted in no improvements in learning, and lower ratios of instructors to students resulted in significantly less learning. These findings are in keeping with current motor learning theories.

Robotic prostatectomy: the first UK experience

BACKGROUND

We describe a teamwork approach to setting up the UK's first clinical programme for robotically assisted laparoscopic radical prostatectomy.

METHODS

On 22 November 2004 the Imperial Robotic Urological Surgery Group performed their first robotically assisted prostatectomy. Robotically assisted prostatectomy lends itself to division into eight definable stages. A team of four consultant urological surgeons utilized a structured rotating system, using these stages, for time at the console and tableside assisting. Fluidity of surgery was maintained by a surgeon acting as the tableside assistant for the stage prior to moving to the console. Data was collected prospectively for the first 50 cases and parameters associated with the learning curve compared to other reported series.

RESULTS

Median operative time of 369.5 mins, median blood loss of 700 ml, with 12% of patients requiring a blood transfusion. Four patients required conversion to an open procedure; one resulting from equipment failure and three due to failure of progression. Four patients had an anastomotic leak with resulting ileus and two patients sustained rectal injuries, which were repaired intraoperatively using the robot. Median hospital stay was 4 days with a 22% positive surgical margin rate.

CONCLUSION

Parameters indicative of the learning curve are comparable to existing published initial series of other robotic centres. The use of teamwork has enabled us to provide safe and time-efficient training for four surgeons simultaneously. The structured approach used in this setting demonstrates that urological surgeons of varying laparoscopic experience can acquire the skills necessary to competently perform laparoscopic radical prostatectomy.