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Desir A, Marques C, Farah E, R Hegde S, Holcomb C, Scott DJ, Sankaranarayanan G. Validity and reliability evidence support task-specific metrics for laparoscopic fundoplication. Surg Endosc 2024; 38:2219-2230. [PMID: 38383688 DOI: 10.1007/s00464-024-10675-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/30/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Laparoscopic hiatal hernia repair (LHHR) is a complex operation requiring advanced surgical training. Surgical simulation offers a potential solution for learning complex operations without the need for high surgical volume. Our goal is to develop a virtual reality (VR) simulator for LHHR; however, data supporting task-specific metrics for this procedure are lacking. The purpose of this study was to develop and assess validity and reliability evidence of task-specific metrics for the fundoplication phase of LHHR. METHODS In phase I, structured interviews with expert foregut surgeons were conducted to develop task-specific metrics (TSM). In phase II, participants with varying levels of surgical expertise performed a laparoscopic Nissen fundoplication procedure on a porcine stomach explant. Video recordings were independently assessed by two blinded graders using global and TSM. An intraclass correlation coefficient (ICC) was used to assess interrater reliability (IRR). Performance scores were compared using a Kruskal-Wallis test. Spearman's rank correlation was used to evaluate the association between global and TSM. RESULTS Phase I of the study consisted of 12 interviews with expert foregut surgeons. Phase II engaged 31 surgery residents, a fellow, and 6 attendings in the simulation. Phase II results showed high IRR for both global (ICC = 0.84, p < 0.001) and TSM (ICC = 0.75, p < 0.001). Significant between-group differences were detected for both global (χ2 = 24.01, p < 0.001) and TSM (χ2 = 18.4, p < 0.001). Post hoc analysis showed significant differences in performance between the three groups for both metrics (p < 0.05). There was a strong positive correlation between the global and TSM (rs = 0.86, p < 0.001). CONCLUSION We developed task-specific metrics for LHHR and using a fundoplication model, we documented significant reliability and validity evidence. We anticipate that these LHHR task-specific metrics will be useful in our planned VR simulator.
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Affiliation(s)
- Alexis Desir
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Carolina Marques
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Emile Farah
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Shruti R Hegde
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Carla Holcomb
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Daniel J Scott
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Ganesh Sankaranarayanan
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
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Kaijser MA, van Ramshorst GH, van Wagensveld BA, Veeger NJGM, Pierie JPEN. A New Procedure-Based Assessment of Operative Skills in Gastric Bypass Surgery, Evaluated by Video Fragment Rating. Obes Surg 2024; 34:1113-1121. [PMID: 38400947 PMCID: PMC11026254 DOI: 10.1007/s11695-023-07020-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/16/2023] [Accepted: 12/17/2023] [Indexed: 02/26/2024]
Abstract
PURPOSE Feedback on technical and procedural skills is essential during the training of residents and fellows. The aim of this study was to assess the performance of a newly created instrument for the assessment of operative skills using laparoscopic Roux-en-Y gastric bypass (LRYGB) video fragments. MATERIALS AND METHODS A new procedure-based assessment (PBA) was created by combining LRYGB key steps with a 5-point independence scale. LRYGB performed by residents and surgeons with different levels of expertise were video recorded. Fragments of the pouch creation, gastro-jejunostomy and jejunojejunostomy, were review by 12 expert bariatric surgeons and the operative skills assessed with the PBA, Objective Structured Assessment of Technical Skill (OSATS), and the Bariatric OSATS (BOSATS). The PBA was compared to the OSATS and BOSATS. Mean scores for all items of the different assessments were summarized and compared using a T-test. RESULTS The scores of the procedural steps were combined and compared for all levels. The mean scores for beginner, intermediate, and expert level were 2.71, 3.70, and 3.90 for the PBA; for the OSATS 1.84, 2.86, and 3.44; and for the BOSATS 2.78, 3.56, and 4.19. Each of these assessments differentiated between the three skill levels (all p < 0.05). CONCLUSION The PBA discriminates well between different levels of operative skills. Similar patterns were found for the OSATS and BOSATS, showing that the randomly selected video fragments are representative samples for assessing skill level. Future research will demonstrate whether these results can be extrapolated to clinical training, and which scores allow for procedure certification.
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Affiliation(s)
- Mirjam A Kaijser
- School of Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
- Center for Obesity Northern Netherlands, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
| | - Gabrielle H van Ramshorst
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Bart A van Wagensveld
- Weight Management Center, Department of Surgery, NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Nic J G M Veeger
- Department of Epidemiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jean-Pierre E N Pierie
- School of Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Villarreal ME, Rothwell C, Huang E. Uncovering patient safety considerations in laparoscopic cholecystectomy using cognitive task analysis. Surg Endosc 2023; 37:3921-3925. [PMID: 37036502 DOI: 10.1007/s00464-023-09970-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/21/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION Educating residents on laparoscopic operations requires direct teaching and deliberate practice. Attending surgeons are often systematic when performing surgery, which creates a challenge when instructing surgery residents. The aim of this study was to use cognitive task analysis to expand laparoscopic cholecystectomy into microsteps reflecting expert surgeon cognition (perceptions, assessments, decisions, etc.) throughout the operation such that these could be better formalized and conveyed to residents in educational materials or assessments and to attending surgeons as teaching scripts. MATERIALS AND METHODS One surgeon, a surgical resident, and a human factors specialist conducted cognitive task analyses with three expert general surgeons and one hepatobiliary surgeon using semi-structured interviews. These interviews expanded an existing task model of laparoscopic cholecystectomy to specifically add patient safety aspects including injury prevention, risk management, and complication detection for each step. Interview analysis resulted in an expanded task diagram. RESULTS Cognitive task analysis expanded the current laparoscopic cholecystectomy task model from 19 to 97 microsteps. In addition to microsteps, an additional major step was identified, the planning step or step zero. Steps with the greatest number of microsteps included dissection with 15 microsteps and intraoperative cholangiogram with 10 microsteps. DISCUSSION Laparoscopic cholecystectomies are complex operations with multiple microsteps. Identification of these steps can lead to explicit strategies that can improve training of surgeons, with an end towards efficacy and safety. The identification of a planning step prior to beginning the operation is a significant finding that should arguably be included in all future cognitive task analyses regardless of operation or procedure, to emphasize to trainees what senior surgeons have learned through experience. These findings inform the development of interventions for surgical training and evaluation of competency.
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Affiliation(s)
- Michael E Villarreal
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th, Suite 600, Columbus, OH, 43210, USA.
| | - Clayton Rothwell
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th, Suite 600, Columbus, OH, 43210, USA
| | - Emily Huang
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th, Suite 600, Columbus, OH, 43210, USA
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Ryan JF, Mador B, Lai K, Campbell S, Hyakutake M, Turner SR. Validity Evidence for Procedure-specific Competence Assessment Tools in General Surgery: A Scoping Review. Ann Surg 2022; 275:482-487. [PMID: 34520421 DOI: 10.1097/sla.0000000000005207] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery. SUMMARY OF BACKGROUND DATA Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences. METHODS A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework. RESULTS There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited. CONCLUSIONS This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Brett Mador
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Krista Lai
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Sandra Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Momoe Hyakutake
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Simon R Turner
- Department of Surgery, University of Alberta, Edmonton, Canada
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Schmidt MW, Haney CM, Kowalewski KF, Bintintan VV, Abu Hilal M, Arezzo A, Bahra M, Besselink MG, Biebl M, Boni L, Diana M, Egberts JH, Fischer L, Francis N, Hashimoto DA, Perez D, Schijven M, Schmelzle M, Soltes M, Swanstrom L, Welsch T, Müller-Stich BP, Nickel F. Development and validity evidence of an objective structured assessment of technical skills score for minimally invasive linear-stapled, hand-sewn intestinal anastomoses: the A-OSATS score. Surg Endosc 2022; 36:4529-4541. [PMID: 34755235 PMCID: PMC9085690 DOI: 10.1007/s00464-021-08806-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 10/17/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION The aim of this study was to develop a reliable objective structured assessment of technical skills (OSATS) score for linear-stapled, hand-sewn closure of enterotomy intestinal anastomoses (A-OSATS). MATERIALS AND METHODS The Delphi methodology was used to create a traditional and weighted A-OSATS score highlighting the more important steps for patient outcomes according to an international expert consensus. Minimally invasive novices, intermediates, and experts were asked to perform a minimally invasive linear-stapled intestinal anastomosis with hand-sewn closure of the enterotomy in a live animal model either laparoscopically or robot-assisted. Video recordings were scored by two blinded raters assessing intrarater and interrater reliability and discriminative abilities between novices (n = 8), intermediates (n = 24), and experts (n = 8). RESULTS The Delphi process included 18 international experts and was successfully completed after 4 rounds. A total of 4 relevant main steps as well as 15 substeps were identified and a definition of each substep was provided. A maximum of 75 points could be reached in the unweighted A-OSATS score and 170 points in the weighted A-OSATS score respectively. A total of 41 anastomoses were evaluated. Excellent intrarater (r = 0.807-0.988, p < 0.001) and interrater (intraclass correlation coefficient = 0.923-0.924, p < 0.001) reliability was demonstrated. Both versions of the A-OSATS correlated well with the general OSATS and discriminated between novices, intermediates, and experts defined by their OSATS global rating scale. CONCLUSION With the weighted and unweighted A-OSATS score, we propose a new reliable standard to assess the creation of minimally invasive linear-stapled, hand-sewn anastomoses based on an international expert consensus. Validity evidence in live animal models is provided in this study. Future research should focus on assessing whether the weighted A-OSATS exceeds the predictive capabilities of patient outcomes of the unweighted A-OSATS and provide further validity evidence on using the score on different anastomotic techniques in humans.
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Affiliation(s)
- Mona W. Schmidt
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany ,Department of Gynecology and Obstetrics, University Medical Centre Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Caelan M. Haney
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany ,Department of Urology, University Hospital Leipzig, Liebigstraße 20, Haus 4, 04103 Leipzig, Germany
| | - Karl-Friedrich Kowalewski
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany ,Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Vasile V. Bintintan
- Department of Surgery, 1st Surgical Clinic, University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Mohammed Abu Hilal
- Department of Surgery, Hepatobiliary Pancreatic and Minimally Invasive Unit, Poliambulanza Foundation Hospital, Brescia, Italy ,Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Marcus Bahra
- Department of Surgical Oncology and Robotics, Waldfriede Hospital, Berlin, Germany
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Matthias Biebl
- Department of Surgery, Charité—Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow Klinikum, Berlin, Germany
| | - Luigi Boni
- Fondazione IRCCS-Ca`Granda - Ospedale Maggiore Policlinico di Milano, University of Milan, Milan, Italy
| | - Michele Diana
- IRCAD Research Institute Against Digestive Cancer, Strasbourg, France ,IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France ,Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France ,ICube Lab, Photonics for Health, University of Strasbourg, Strasbourg, France
| | - Jan H. Egberts
- Department of General, Visceral, Thoracic, Transplantation and Pediatric Surgery, Kurt Semm Center for Minimally Invasive and Robotic Surgery, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Lars Fischer
- Department of Surgery, Hospital Mittelbaden, Baden-Baden, Germany
| | - Nader Francis
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, UK
| | | | - Daniel Perez
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlies Schijven
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Moritz Schmelzle
- Department of Surgery, Charité—Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow Klinikum, Berlin, Germany
| | - Marek Soltes
- 1St Department of Surgery, University of Pavol Jozef Safarik, Košice, Slovakia
| | - Lee Swanstrom
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Thilo Welsch
- Department of Visceral, Thoracic, and Vascular Surgery, Medical Faculty, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Beat P. Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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The Complexity of the Retropubic Midurethral Sling: A Cognitive Task Analysis. Female Pelvic Med Reconstr Surg 2021; 27:90-93. [PMID: 31083019 DOI: 10.1097/spv.0000000000000736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon's internal thought processes during the surgery. METHODS Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery. RESULTS Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps). CONCLUSIONS The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.
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Al-Hakim L, Wang M, Xiao J, Gyomber D, Sengupta S. Hierarchical task analysis for identification of interrelationships between ergonomic, external disruption, and internal disruption in complex laparoscopic procedures. Surg Endosc 2019; 33:3673-3687. [DOI: 10.1007/s00464-018-06656-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/24/2018] [Indexed: 01/19/2023]
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A scoping review of assessment tools for laparoscopic suturing. Surg Endosc 2018; 32:3009-3023. [PMID: 29721749 DOI: 10.1007/s00464-018-6199-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND A needs assessment identified a gap in teaching and assessment of laparoscopic suturing (LS) skills. The purpose of this review is to identify assessment tools that were used to assess LS skills, to evaluate validity evidence available, and to provide guidance for selecting the right assessment tool for specific assessment conditions. METHODS Bibliographic databases were searched till April 2017. Full-text articles were included if they reported on assessment tools used in the operating room/simulation to (1) assess procedures that require LS or (2) specifically assess LS skills. RESULTS Forty-two tools were identified, of which 26 were used for assessing LS skills specifically and 26 for procedures that require LS. Tools had the most evidence in internal structure and relationship to other variables, and least in consequences. CONCLUSION Through identification and evaluation of assessment tools, the results of this review could be used as a guideline when implementing assessment tools into training programs.
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Knight S, Aggarwal R, Agostini A, Loundou A, Berdah S, Crochet P. Development of an objective assessment tool for total laparoscopic hysterectomy: A Delphi method among experts and evaluation on a virtual reality simulator. PLoS One 2018; 13:e0190580. [PMID: 29293635 PMCID: PMC5749811 DOI: 10.1371/journal.pone.0190580] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Total Laparoscopic hysterectomy (LH) requires an advanced level of operative skills and training. The aim of this study was to develop an objective scale specific for the assessment of technical skills for LH (H-OSATS) and to demonstrate feasibility of use and validity in a virtual reality setting. MATERIAL AND METHODS The scale was developed using a hierarchical task analysis and a panel of international experts. A Delphi method obtained consensus among experts on relevant steps that should be included into the H-OSATS scale for assessment of operative performances. Feasibility of use and validity of the scale were evaluated by reviewing video recordings of LH performed on a virtual reality laparoscopic simulator. Three groups of operators of different levels of experience were assessed in a Marseille teaching hospital (10 novices, 8 intermediates and 8 experienced surgeons). Correlations with scores obtained using a recognised generic global rating tool (OSATS) were calculated. RESULTS A total of 76 discrete steps were identified by the hierarchical task analysis. 14 experts completed the two rounds of the Delphi questionnaire. 64 steps reached consensus and were integrated in the scale. During the validation process, median time to rate each video recording was 25 minutes. There was a significant difference between the novice, intermediate and experienced group for total H-OSATS scores (133, 155.9 and 178.25 respectively; p = 0.002). H-OSATS scale demonstrated high inter-rater reliability (intraclass correlation coefficient [ICC] = 0.930; p<0.001) and test retest reliability (ICC = 0.877; p<0.001). High correlations were found between total H-OSATS scores and OSATS scores (rho = 0.928; p<0.001). CONCLUSION The H-OSATS scale displayed evidence of validity for assessment of technical performances for LH performed on a virtual reality simulator. The implementation of this scale is expected to facilitate deliberate practice. Next steps should focus on evaluating the validity of the scale in the operating room.
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Affiliation(s)
- Sophie Knight
- Department of Obstetrics and Gynecology, Assistance Publique—Hôpitaux de Marseille, La Conception Hospital, Marseille, Aix Marseille Université, France
| | - Rajesh Aggarwal
- Department of Surgery, Thomas Jefferson University,Philadelphia, Pennsylvania, United States of America
- Office of Strategic Business Development and Partnerships, Jefferson Health, Philadelphia, Pennsylvania, United States of America
| | - Aubert Agostini
- Department of Obstetrics and Gynecology, Assistance Publique—Hôpitaux de Marseille, La Conception Hospital, Marseille, Aix Marseille Université, France
| | - Anderson Loundou
- Public Health Laboratory, Aix-Marseille University, Marseille, France
| | - Stéphane Berdah
- Aix Marseille Université, CERC, IFSTTAR, LBA UMR_T 24, Marseille, France
| | - Patrice Crochet
- Department of Obstetrics and Gynecology, Assistance Publique—Hôpitaux de Marseille, La Conception Hospital, Marseille, Aix Marseille Université, France
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Beyer-Berjot L, Berdah S, Hashimoto DA, Darzi A, Aggarwal R. A Virtual Reality Training Curriculum for Laparoscopic Colorectal Surgery. JOURNAL OF SURGICAL EDUCATION 2016; 73:932-941. [PMID: 27342755 DOI: 10.1016/j.jsurg.2016.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/13/2016] [Accepted: 05/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Training within a competency-based curriculum (CBC) outside the operating room enhances performance during real basic surgical procedures. This study aimed to design and validate a virtual reality CBC for an advanced laparoscopic procedure: sigmoid colectomy. DESIGN This was a multicenter randomized study. Novice (surgeons who had performed <5 laparoscopic colorectal resections as primary operator), intermediate (between 10 and 20), and experienced surgeons (>50) were enrolled. Validity evidence for the metrics given by the virtual reality simulator, the LAP Mentor, was based on the second attempt of each task in between groups. The tasks assessed were 3 modules of a laparoscopic sigmoid colectomy (medial dissection [MD], lateral dissection [LD], and anastomosis) and a full procedure (FP). Novice surgeons were randomized to 1 of 2 groups to perform 8 further attempts of all 3 modules or FP, for learning curve analysis. SETTING Two academic tertiary care centers-division of surgery of St. Mary's campus, Imperial College Healthcare NHS Trust, London and Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, were involved. PARTICIPANTS Novice surgeons were residents in digestive surgery at St. Mary's and Nord Hospitals. Intermediate and experienced surgeons were board-certified academic surgeons. RESULTS A total of 20 novice surgeons, 7 intermediate surgeons, and 6 experienced surgeons were enrolled. Evidence for validity based on experience was identified in MD, LD, and FP for time (p = 0.005, p = 0.003, and p = 0.001, respectively), number of movements (p = 0.013, p = 0.005, and p = 0.001, respectively), and path length (p = 0.03, p = 0.017, and p = 0.001, respectively), and only for time (p = 0.03) and path length (p = 0.013) in the anastomosis module. Novice surgeons' performance significantly improved through repetition for time, movements, and path length in MD, LD, and FP. Experienced surgeons' benchmark criteria were defined for all construct metrics showing validity evidence. CONCLUSIONS A CBC in laparoscopic colorectal surgery has been designed. Such training may reduce the learning curve during real colorectal resections in the operating room.
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Affiliation(s)
- Laura Beyer-Berjot
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, United Kingdom; Centre for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France.
| | - Stéphane Berdah
- Centre for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ara Darzi
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rajesh Aggarwal
- Arnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Development and content validation of performance assessments for endoscopic third ventriculostomy. Childs Nerv Syst 2015; 31:1247-59. [PMID: 25930722 DOI: 10.1007/s00381-015-2716-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/08/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE This study aims to develop and establish the content validity of multiple expert rating instruments to assess performance in endoscopic third ventriculostomy (ETV), collectively called the Neuro-Endoscopic Ventriculostomy Assessment Tool (NEVAT). METHODS The important aspects of ETV were identified through a review of current literature, ETV videos, and discussion with neurosurgeons, fellows, and residents. Three assessment measures were subsequently developed: a procedure-specific checklist (CL), a CL of surgical errors, and a global rating scale (GRS). Neurosurgeons from various countries, all identified as experts in ETV, were then invited to participate in a modified Delphi survey to establish the content validity of these instruments. In each Delphi round, experts rated their agreement including each procedural step, error, and GRS item in the respective instruments on a 5-point Likert scale. RESULTS Seventeen experts agreed to participate in the study and completed all Delphi rounds. After item generation, a total of 27 procedural CL items, 26 error CL items, and 9 GRS items were posed to Delphi panelists for rating. An additional 17 procedural CL items, 12 error CL items, and 1 GRS item were added by panelists. After three rounds, strong consensus (>80% agreement) was achieved on 35 procedural CL items, 29 error CL items, and 10 GRS items. Moderate consensus (50-80% agreement) was achieved on an additional 7 procedural CL items and 1 error CL item. The final procedural and error checklist contained 42 and 30 items, respectively (divided into setup, exposure, navigation, ventriculostomy, and closure). The final GRS contained 10 items. CONCLUSIONS We have established the content validity of three ETV assessment measures by iterative consensus of an international expert panel. Each measure provides unique assessment information and thus can be used individually or in combination, depending on the characteristics of the learner and the purpose of the assessment. These instruments must now be evaluated in both the simulated and operative settings, to determine their construct validity and reliability. Ultimately, the measures contained in the NEVAT may prove suitable for formative assessment during ETV training and potentially as summative assessment measures during certification.
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Beyer-Berjot L, Palter V, Grantcharov T, Aggarwal R. Advanced training in laparoscopic abdominal surgery: a systematic review. Surgery 2014; 156:676-88. [PMID: 24947643 DOI: 10.1016/j.surg.2014.04.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/18/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator. METHODS Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles. RESULTS Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid. CONCLUSION Higher-quality studies are required to appraise educational value in this field.
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Affiliation(s)
- Laura Beyer-Berjot
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK; Center for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France.
| | - Vanessa Palter
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Teodor Grantcharov
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rajesh Aggarwal
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Koehler RJ, Amsdell S, Arendt EA, Bisson LJ, Braman JP, Butler A, Cosgarea AJ, Harner CD, Garrett WE, Olson T, Warme WJ, Nicandri GT. The Arthroscopic Surgical Skill Evaluation Tool (ASSET). Am J Sports Med 2013; 41:1229-37. [PMID: 23548808 PMCID: PMC4134966 DOI: 10.1177/0363546513483535] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgeries employing arthroscopic techniques are among the most commonly performed in orthopaedic clinical practice; however, valid and reliable methods of assessing the arthroscopic skill of orthopaedic surgeons are lacking. HYPOTHESIS The Arthroscopic Surgery Skill Evaluation Tool (ASSET) will demonstrate content validity, concurrent criterion-oriented validity, and reliability when used to assess the technical ability of surgeons performing diagnostic knee arthroscopic surgery on cadaveric specimens. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Content validity was determined by a group of 7 experts using the Delphi method. Intra-articular performance of a right and left diagnostic knee arthroscopic procedure was recorded for 28 residents and 2 sports medicine fellowship-trained attending surgeons. Surgeon performance was assessed by 2 blinded raters using the ASSET. Concurrent criterion-oriented validity, interrater reliability, and test-retest reliability were evaluated. RESULTS Content validity: The content development group identified 8 arthroscopic skill domains to evaluate using the ASSET. Concurrent criterion-oriented validity: Significant differences in the total ASSET score (P < .05) between novice, intermediate, and advanced experience groups were identified. Interrater reliability: The ASSET scores assigned by each rater were strongly correlated (r = 0.91, P < .01), and the intraclass correlation coefficient between raters for the total ASSET score was 0.90. Test-retest reliability: There was a significant correlation between ASSET scores for both procedures attempted by each surgeon (r = 0.79, P < .01). CONCLUSION The ASSET appears to be a useful, valid, and reliable method for assessing surgeon performance of diagnostic knee arthroscopic surgery in cadaveric specimens. Studies are ongoing to determine its generalizability to other procedures as well as to the live operating room and other simulated environments.
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Affiliation(s)
- Ryan J Koehler
- School of Medicine, University of Rochester, Rochester, NY 14642, USA
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Zevin B, Bonrath EM, Aggarwal R, Dedy NJ, Ahmed N, Grantcharov TP. Development, feasibility, validity, and reliability of a scale for objective assessment of operative performance in laparoscopic gastric bypass surgery. J Am Coll Surg 2013; 216:955-965.e8; quiz 1029-31, 1033. [PMID: 23490542 DOI: 10.1016/j.jamcollsurg.2013.01.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 01/08/2013] [Accepted: 01/08/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale. STUDY DESIGN The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons. RESULTS A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001). CONCLUSIONS The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.
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Zuckerman SL, Green CS, Carr KR, Dewan MC, Morone PJ, Mocco J. Neurosurgical checklists: a review. Neurosurg Focus 2012; 33:E2. [DOI: 10.3171/2012.9.focus12257] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Morbidity due to avoidable medical errors is a crippling reality intrinsic to health care. In particular, iatrogenic surgical errors lead to significant morbidity, decreased quality of life, and attendant costs. In recent decades there has been an increased focus on health care quality improvement, with a concomitant focus on mitigating avoidable medical errors. The most notable tool developed to this end is the surgical checklist. Checklists have been implemented in various operating rooms internationally, with overwhelmingly positive results. Comparatively, the field of neurosurgery has only minimally addressed the utility of checklists as a health care improvement measure. Literature on the use of checklists in this field has been sparse. Considering the widespread efficacy of this tool in other fields, the authors seek to raise neurosurgical awareness regarding checklists by reviewing the current literature.
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Affiliation(s)
- Scott L. Zuckerman
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
| | - Cain S. Green
- 2College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin R. Carr
- 3Vanderbilt University School of Medicine, Nashville; and
| | - Michael C. Dewan
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
| | - Peter J. Morone
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
| | - J Mocco
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
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Utilization of a cognitive task analysis for laparoscopic appendectomy to identify differentiated intraoperative teaching objectives. Am J Surg 2012; 203:540-5. [DOI: 10.1016/j.amjsurg.2011.11.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 11/18/2011] [Accepted: 11/18/2011] [Indexed: 11/18/2022]
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Jungmann F, Gockel I, Hecht H, Kuhr K, Räsänen J, Sihvo E, Lang H. Impact of perceptual ability and mental imagery training on simulated laparoscopic knot-tying in surgical novices using a Nissen fundoplication model. Scand J Surg 2012; 100:78-85. [PMID: 21737382 DOI: 10.1177/145749691110000203] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Performing minimally invasive surgery requires training and visual-spatial intelligence. The aim of our study was to examine the impact of visual-spatial perception and additional mental training on the simulated laparoscopic knot-tying task performed by surgical novices. METHODS A total of 40 medical students randomly assigned to two groups underwent two sessions of laparoscopic basic training on a VR simulator (SimSurgery®, Oslo, Norway). The variables time and tip trajectory (total path length of the instrument tip trajectory) were used to assess the performance of the intracorporeal knot-tying task using a laparoscopic Nissen fundoplication model. The experimental group completed additional mental practice during the interval between the two training sessions. All performed a cube subtest of a standard intelligence test (I-S-T 2000 R) to evaluate visual-spatial ability. RESULTS All participants achieved an improvement in time (t = 9.861; p < 0.001) and tip trajectory (t = 6.833; p < 0.001) in the second training session. High scores on the visual-spatial test correlated with a faster performance (r = -0.557; p < 0.001) and more precise movements (r = -0.377; p = 0.016). Comparison of the two groups did not show any statistical significant differences in the parameters time and tip trajectory. CONCLUSIONS Visual-spatial intelligence tested by a cube test correlated with simulated laparoscopic knot-tying skills in surgical novices. Additional mental practice did not improve the overall knot-tying performance. Further studies are therefore required to determine whether mental practice might be beneficial for experienced laparoscopic surgeons or for more complex tasks.
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Affiliation(s)
- F Jungmann
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
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Low-Beer N, Kinnison T, Baillie S, Bello F, Kneebone R, Higham J. Hidden practice revealed: using task analysis and novel simulator design to evaluate the teaching of digital rectal examination. Am J Surg 2011; 201:46-53. [DOI: 10.1016/j.amjsurg.2010.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 09/28/2010] [Accepted: 09/28/2010] [Indexed: 10/18/2022]
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Klingensmith ME, Brunt LM. Focused Surgical Skills Training for Senior Medical Students and Interns. Surg Clin North Am 2010; 90:505-18. [DOI: 10.1016/j.suc.2010.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Peyré SE, Peyré CG, Hagen JA, Sullivan ME. Reliability of a procedural checklist as a high-stakes measurement of advanced technical skill. Am J Surg 2010; 199:110-4. [DOI: 10.1016/j.amjsurg.2009.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 08/10/2009] [Accepted: 10/14/2009] [Indexed: 10/20/2022]
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