Changing Education Paradigms: Training Transplant Fellows for High Stake Procedures

Proposal for a uniform protocol and checklist for cadaveric courses for surgeons with special interest in open abdominal wall reconstruction

PURPOSE

Over the last decade, there has been a rapid rise in the development and refinement of abdominal wall repair (AWR) techniques. Numerous cadaveric AWR training courses have been set up with the goal of helping practicing surgeons learn and incorporate them into their surgical repertoire. Some maybe excellent but their quality and consistency are unknown. The aim of this article is to present a stepwise cadaveric dissection template and checklist to standardize all training on open AWR courses and to help course organizers benchmark the quality of their program.

METHODS

This article is based on both the authors experience as faculty and course leads of cadaveric AWR courses, and the published anatomical and operative literature. The authors represent the training committee of the European Hernia Society, and the AWR subcommittees of the British Hernia Society and Association of Coloproctology of Great Britain & Ireland.

RESULTS

A standardized stepwise approach for the cadaveric training of the most recognized procedures for open AWR, including retrorectus repair, posterior and anterior component separation techniques, is presented. Considerations on delegate selection, pre-course material and testing, course structure, and cadaveric models is also provided.

CONCLUSION

Time and financial resources for surgeons to attend courses to learn and hone the skills required for safe effective AWR is limited. Ideally all courses should deliver up to date consistent training of the highest quality. One step to achieve this is by developing a standardized approach to ensure delegate understanding of the operative steps and key anatomical features.

[Sex-specific differences in surgical confidence: results of the Endo Workshop of the German Society of Residents in Urology 2022]

BACKGROUND

Simulation-based training is gaining importance in urologic residents training.

OBJECTIVES

This prospective study evaluated the influence of the Endo Workshop of the German Society of Residents in Urology e. V. (GeSRU) on surgical confidence.

MATERIALS AND METHODS

GeSRU Endo Workshop 2022 included 1 h simulation-based training sessions on stone removal using ureteroscopy (URS) and transurethral resection of the bladder (TURB). Using an online questionnaire, surgical confidence was assessed before and after the workshop. Surgical assessment relied on the global rating scale (GRS).

RESULTS

Overall, 40 residents participated: 25 (62.5%) men and 15 (37.5%) women. In URS assessment, men vs. women achieved an average of 26.6 vs. 26.1/35 points on the GRS (p = 0.7) and completed the task in 8.1 ± 1.9 vs. 9.9 ± 0.4 min (p < 0.001). In TURB assessment, men vs. women achieved an average of 26.0 vs. 27.3/35 points on the GRS (p = 0.3) and required 7.6 ± 1.9 vs. 7.7 ± 2.2 min (p = 0.9), respectively. Among participants who answered the baseline survey and the evaluation (n = 33), 16 (80%) men vs. 3 (23%) women had surgical confidence to perform URS before (p = 0.01), and 19 (95%) men vs. 7 (54%) women after the workshop (p = 0.03). Regarding the performance of TURB, 10 (50%) men vs. 7 (54%) women reported surgical confidence before (p = 0.1), and 15 (75%) men vs. 10 (77%) women after the workshop (p = 1.0). An increase in surgical confidence to perform URS and TURB was reported by 9 (45%) and 10 (50%) men and 9 (69%) and 8 (62%) women, respectively.

CONCLUSIONS

Endourologic simulation-based training increases surgical confidence of both female and male residents. Despite comparable surgical outcomes, women approach URS with lower surgical confidence compared to their male counterparts.

Missing the Match: A National Survey Investigating Education in Renal Donor-Recipient Matching

PURPOSE

Clinical judgment in renal donor organ and recipient selection is gained through fellowship and mentorship in early career. We aim to understand the past and current state of organ acceptance education.

METHODS

We developed and distributed an anonymous, national survey to American Society of Transplant Surgeons faculty members and transplant surgery fellows in 2022. Survey questions explored in detail the evaluation of organ offers, the extent of formal education in organ evaluation, and attitudes regarding training adequacy.

FINDINGS

Ninety-eight attending surgeons (65 men, 25 women, and 3 nonbinary) and 38 fellows (25 men, 6 women, and 2 nonbinary) responded. Seventy-eight percent of attending surgeons and 6% of fellows take primary organ offers. Forty-four percent of fellows report no didactic education in donor evaluation and recipient selection. Fellows report that discussion with attending surgeons (37.2%) and independent study of the literature (35.4%) are their primary modes of learning. Fellows call for additional clinical decision-making experience (47.3%), further didactic sessions (44.7%), and additional discussions with faculty (44.7%). Sixty-four percent of fellows and 55% of attendings felt their training provided adequate education about donor selection.

CONCLUSION

Our responses suggest gaps in education regarding donor and recipient selection. Increased clinical experience and standardized education at the national level represent opportunities for improvement.

Revitalizing pancreas transplantation: creation of a hands-on training course for pancreas allograft procurement, backbench preparation, and transplantation

Despite a steady increase in the number of organs available for transplant in the United States, over the last two decades there has been a precipitous decrease in the annual number of pancreas transplants performed. One overlooked consequence of this decline in pancreas transplant volume has been a decrease in experience in proper pancreas procurement and transplantation techniques for transplant surgeons as well as fewer trained abdominal transplant fellows entering the workforce certified for pancreas procurement and transplantation, with those achieving certification having less-developed judgment, skills, and experience. To augment current fellowship training and provide a concentrated experience in pancreas procurement and transplantation, the ASTS developed a hands-on surgical skills workshop focused on proper techniques for pancreas allograft procurement and backbench preparation.

Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study

INTRODUCTION

Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes.

MATERIALS AND METHODS

This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days.

RESULTS

A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS.

CONCLUSION

The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

Technical skills simulation in transplant surgery: a systematic review

Purpose

 Transplant surgery is a demanding field in which the technical skills of the surgeon correlates with patient outcomes. As such, there is potential for simulation-based training to play an important role in technical skill acquisition. This study provides a systematic assessment of the current literature regarding the use of simulation to improve surgeon technical skills in transplantation.

Methods

 Data were collected by performing an electronic search of the PubMed and Scopus database for articles describing simulation in transplant surgery. The abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 172 abstracts and agreed upon articles that met the inclusion criteria for the systematic review.

Results

 Simulators can be categorized into virtual reality simulators, cadaveric models, animal models (animate or inanimate) and synthetic physical models. No virtual reality simulators in transplant surgery are described in the literature. Three cadaveric models, seven animal models and eight synthetic physical models specific to transplant surgery are described. A total of 18 publications focusing on technical skills simulation in kidney, liver, lung, pancreas, and cardiac transplantation were found with the majority focusing on kidney transplantation.

Conclusions

 This systematic review identifies currently reported simulation models in transplant surgery. This will serve as a reference for general surgery and transplant surgery professionals interested in using simulation to enhance their technical skills.

Building a Low-Cost and Low-Fidelity Kidney Transplant Model: A Technical Report on the San Antonio Kidney Transplant Model

One of the most challenging aspects of the kidney transplant operation is performing vascular anastomoses in the confines and depths of the iliac fossa. General surgery residents need to be adequately trained in this skill to maximize their intraoperative experience during their transplant surgery rotation. While several kidney transplant models have been developed, they are limited in their ability to simulate the challenges of performing anastomoses at varying depths and in confined spaces. Furthermore, they may be expensive or require specialized equipment, such as three-dimensional printers, to build. In this technical report, we describe how to build a low-fidelity, low-cost, and portable kidney transplant model capable of simulating vascular anastomoses at varying depths. Our model can be easily replicated for less than 30 USD using materials available in local stores. It uses inexpensive and reusable parts, allowing trainees a high volume of repetitions.

The Creation of a Novel Low-Cost Bench-Top Kidney Transplant Surgery Simulator and a Survey on Its Fidelity and Educational Utility

Introduction Resident inexperience during time-sensitive vascular anastomoses of a kidney transplant can negatively impact outcomes. In light of this, we created a low-cost bench-top kidney transplant surgery simulator to help residents practice vascular anastomoses. Methods We searched for inexpensive materials to design an iliac fossa and kidney allograft. Eighteen residents with real-life kidney transplant experience trialed the simulator and scored its fidelity and educational utility on a 0-100 visual analog scale (VAS) survey. Results A 35.9 x 19.4 x 12.4 cm plastic box mimicked the iliac fossa. Hooks attached to the box's sidewall held under tension 1.27 and 0.64 cm diameter Penrose drains to replicate the external iliac vein and artery. A modified kidney-shaped stress ball with 1.27 x 4, 0.64 x 4, and 0.64 x 15 cm Penrose drains replicated a kidney allograft with its vein, artery, and ureter, respectively. Residents performed and assisted in vascular anastomoses on the simulator. The iliac fossa and allograft cost $20.20 and each practice run cost $7.20. Residents thought that the simulator was less difficult than real-life procedure, had acceptable fidelity levels, and they highly rated its educational utility. Conclusion Our novel low-cost bench-top kidney transplant surgery simulator focusing on vascular anastomoses received positive educational feedback from residents.