Simulating Laparoscopic Renal Hilar Vessel Injuries: Preliminary Evaluation of a Novel Surgical Training Model for Residents

Impact of Assistant Experience on Perioperative Outcomes of Simple and Radical Laparoscopic Nephrectomy: Does It Really Matter?

Background and Objectives: While systematic reviews highlight the advantages of laparoscopic nephrectomy over traditional open surgery, the impact of an assistant's experience on surgical outcomes remains unclear. This study aims to evaluate whether the level of assistant expertise influences laparoscopic nephrectomy outcomes. Materials and Methods: Retrospective data from our institutional database were analyzed for patients who underwent laparoscopic nephrectomy between January 2018 and December 2022. Procedures were performed by a highly experienced surgeon, including postgraduate year (PGY)-3 to PGY-5 residents as assistants. Senior-level assistants had completed at least 10 procedures. Patient characteristics, surgical outcomes, and postoperative details were collected. Multivariable linear and logistic regression models were performed to test the effect of assistant experience (low vs. high) on estimated blood loss (EBL), length of stay (LOS), operative time (OT), and postoperative complications. Results: 105 patients were included, where 53% had highly experienced assistants and 47% had less experienced ones. Low assistant experience and higher BMI predicted longer operative time (OT), confirmed by multivariable regression (β = 40.5, confidence interval [CI] 18.7-62.3, p < 0.001). Assistant experience did not significantly affect EBL or LOS after adjusting for covariates (β = -14.2, CI -91.8-63.3, p = 0.7 and β = -0.83, CI -2.7-1.02, p = 0.4, respectively). There was no correlation between assistant experience and postoperative complications. Conclusions: Assistant experience does not significantly impact complications, EBL, and LOS in laparoscopic nephrectomy. Surgeries with less experienced assistants had longer OT, but the overall clinical impact seems limited. Trainee involvement remains safe, guided by experienced surgeons.

The State of Urotrauma Education Among Residency Programs in the United States: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Management of urotrauma is a crucial part of a urologist's knowledge and training. We therefore sought to understand the state of urotrauma education in the United States.

RECENT FINDINGS

Using themes of "Urotrauma" and "Education," we performed a systematic review and meta-analysis by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, BIOSIS, Scopus, and Web of Science through May 2023. The primary outcome was the pooled rate of urology trainee and program director attitudes toward urotrauma education. Secondary outcomes involved a descriptive summary of existing urotrauma curricula and an assessment of factors affecting urotrauma exposure. Of 12,230 unique records, 11 studies met the final eligibility criteria, and we included 2 in the meta-analysis. The majority of trainees and program directors reported having level 1 trauma center rotations (range 88-89%) and considered urotrauma exposure as an important aspect of residency education (83%, 95% CI 76-88%). Despite possible increases in trainee exposure to Society of Genitourinary Reconstructive Surgeons (GURS) faculty over the preceding decade, nearly a third of trainees and program directors currently felt there remained inadequate exposure to urotrauma during training (32%, 95% CI 19-46%). Factors affecting urotrauma education include the limited exposure to GURS-trained faculty and clinical factors such as case infrequency and non-operative trauma management. Urology resident exposure to urotrauma is inadequate in many training programs, underscoring the potential value of developing a standardized curriculum to improve urotrauma education for trainees. Further investigation is needed to characterize this issue and to understand how it impacts trainee practice readiness.

Specific steps in the operation determine resident speed: Experience with a live tissue simulation model of laparoscopic nephrectomy

INTRODUCTION

It is increasingly important to identify and eliminate inefficiencies in resident education. We hypothesize that slower performance of specific operative steps in laparoscopic nephrectomy accounts for much of the slower operative speed observed in junior residents vs. their senior colleagues. Therefore, we sought to evaluate the by-step time-differential between experienced senior residents and their junior colleagues in a live-tissue simulation.

MATERIALS AND METHODS

Residents participated in our swine model surgical simulation of laparoscopic radical and partial nephrectomy (LRNx and LPNx). PGY5 and 6 residents were considered senior; junior residents were PGY3 and 4. We defined discrete surgical steps. Residents' post-graduate training levels were tracked and time-to-completion of each operative step was recorded.

RESULTS

Seven live-tissue simulations sessions took place, with 12 residents conducting 22 operations (12 LRNx, 10 LPNx). On average, each resident operated in 2 simulation sessions (range 1-4). The average time required by senior residents for LPNx was 152 min; junior residents required 173 min (p = 0.35). When considering the operative steps, juniors required nearly twice as much time to achieve hilar control (42 min vs. 23 min, p = 0.03). Significant differences in performance time were not seen in the other steps.

DISCUSSION

The performance differential between senior and junior residents conducting nephrectomies was most evident during hilar dissection. Our study suggests that specific efforts should be focused on teaching junior residents the skills required for this step early in their training.

Understanding and Assessing Nontechnical Skills in Robotic Urological Surgery: A Systematic Review and Synthesis of the Validity Evidence

OBJECTIVE

Robotic urological surgery (RUS) has seen widespread adoption across institutions in the last decade. To match this rapid growth, it is imperative to develop a structured RUS curriculum that addresses both technical and nontechnical competencies. Emerging evidence has shown that nontechnical skills form a critical component of RUS training. The purpose of this review is to examine the validity evidence of available nontechnical skills assessment tools in RUS.

METHODS

A literature search of MEDLINE, EMBASE, and PsycINFO was conducted to identify primary articles using nontechnical skills assessment tools in RUS. Messick's validity framework and the Medical Education Research Study Quality Instrument were utilized to evaluate the quality of the validity evidence of the abstracted articles.

RESULTS

Of the 566 articles identified, 12 used nontechnical skills assessment tools in RUS. The metrics used ranged from self-assessment using global rating scales, to objective measures such as electroencephalography. The setting of these evaluations ranged from immersive and virtual reality-based simulators to live surgery.

CONCLUSIONS

Limited effort has been made to develop nontechnical skills assessment tools in RUS. Recently, there has been a shift from subjective to objective measures of nontechnical performance, as well as the development of assessments specific to RUS. However, the validity evidence supporting these nontechnical assessments is limited at this time, including their relationship to technical skills, and their impact on surgical outcomes.

Simulation-Based Laparoscopic Surgery Crisis Resource Management Training-Predicting Technical and Nontechnical Skills

OBJECTIVES

To develop a unique simulation-based assessment using a laparoscopic inferior vena cava (IVC) injury scenario that allows for the safe assessment of urology resident's technical and nontechnical skills, and investigate the effect of personality traits performance in a surgical crisis.

METHODS

Urology residents from our institution were recruited to participate in a simulation-based training laparoscopic nephrectomy exercise. Residents completed demographic and multidimensional personality questionnaires and were instructed to play the role of staff urologist. A vasovagal response to pneumoperitoneum and an IVC injury event were scripted into the scenario. Technical and nontechnical skills were assessed by expert laparoscopic surgeons using validated tools (task checklist, GOALS, and NOTSS).

RESULTS

Ten junior and five senior urology residents participated. Five residents were unable to complete the exercise safely. Senior residents outperformed juniors on technical (checklist score 15.1 vs 9.9, p < 0.01, GOALS score 18.0 vs 13.3, p < 0.01) and nontechnical performance (NOTSS score 13.8 vs 10.1, p = 0.03). Technical performance scores correlated with NOTSS scores (p < 0.01) and pass/fail rating correlated with technical performance (p < 0.01 for both checklist and GOALS), NOTSS score (p = 0.02), and blood loss (p < 0.01). Only the conscientiousness dimension of the big five inventory correlated with technical score (p = 0.03) and pass/fail rating (p = 0.04).

CONCLUSIONS

Resident level of training and laparoscopic experience correlated with technical performance during a simulation-based laparoscopic IVC injury crisis management scenario, as well as multiple domains of nontechnical performance. Personality traits of our surgical residents are similar and did not predict technical skill.

Laparoscopic nephrectomy simplified - A "two-window technique" for safer approach to hilum for a novice

Though the overall safety of laparoscopic nephrectomy (simple or radical) is well established, for a novice it remains a challenge. The classical description of laparoscopic nephrectomy entails dissection either from caudal to cephalad side or vice versa. Herein we describe our "two window technique" for managing renal hilum during laparoscopic (simple/radical) nephrectomy. Our main intention in description of this technique is to reduce the level of apprehension for a novice urologist for performing laparoscopic nephrectomy. After colon mobilization, sequential lower and upper windows are created around the hilum following which hilar vessels are dissected circumferentially when the hilum is at a stretch by traction from either of the window. There are multiple potential advantages of this method which includes easier and safer dissection especially for novice in this field by giving a safety window of application of vascular clamp in cases of vascular bleeds. Intrahilar dissection in stretched condition becomes safer with vision from all around 360° for safe application of Hem-o-lok® clips. Due to the widely exposed field, injuries to adrenal vein and lumbar veins would be minimized and the chances of missed accessory vessel would be minimized. En mass hilar control with vascular clamp in cases of partial nephrectomy is possible with same approach as well as the en block stapling is feasible in cases of nephrectomy. This needs a validation across multiple centers with comparative studies before considering it as a standard of practice. We sincerely believe that this is safe and easily reproducible by a novice.

Survey on Barriers to Adoption of Laparoscopic Surgery

OBJECTIVE

To identify challenges that impede wider adoption of laparoscopy in gynecologic surgery and assessing whether the current training programs are addressing these challenges adequately.

METHODS

A survey was designed to examine barriers to adoption of laparoscopy for practicing gynecologists. The survey was piloted on gynecologic surgeons and was further refined following their feedback. Finally, the survey was deployed to 4273 gynecologists across the United States via e-mail using the national database of the American Medical Association. Respondents were grouped into two categories based on how often they report referral of patients for laparoscopy. Demographics, training, and practice characteristics were compared using Fisher exact tests for categorical variables and t tests for continuous variables. Participants rated factors that were thought to limit laparoscopy use on a 5-point Likert scale; median values of these scores were compared with Wilcoxon rank sum tests.

RESULTS

We received 210 responses (29% of people who opened the e-mail and 93% of those who opened the survey). Physicians who perform their own laparoscopies were on average younger and tended to be more subspecialized. Some of the most highly rated limiting factors included lack of adequate surgical volume, reluctance of managing unexpected surgical scenarios, difficulty with video-eye-hand coordination, altered depth perception, and laparoscopic suturing.

CONCLUSION

This survey identified barriers to adoption of laparoscopic surgical techniques beyond what has previously been identified. Based on these findings, novel simulation and continuing medical education curricula can be created to address the primary barriers in order to increase laparoscopic approach to surgery among gynecologists.