A structured program for teaching pancreatojejunostomy to surgical residents and fellows outside the operating room: a pilot study

General surgery residents have better technical skills and less stress performing complex drills in open fashion over robotic approach

INTRODUCTION

Despite growing diversity of surgical approaches, surgical residents must learn the breadth of general surgery in a finite time. Accordingly, there is increasing demand for the development of standardized, proficiency-based training curricula to help teach novice surgeons the necessary technical skills quickly. The aim of this study was to evaluate resident performance and opinion of an open versus robotic approach after completion of a robotic training curriculum.

METHODS

From 2019 to 2022, PGY-3 general surgery residents completed a two-week dedicated robotic simulation curriculum, which included open and robotic interrupted hepaticojejunostomy (IHJ) and pancreaticojejunostomy (PJ) drills on biotissue models. The drills were recorded and graded according to the modified Objective Structured Assessment of Technical Skills (OSATS) by two independent blinded graders, in addition to time duration. The primary outcomes were OSATS score and drill duration. Mental demand was assessed using the NASA Task Load Index (TLX), Borg Exertion Scale, and Edwards Arousal Rating.

RESULTS

Twenty-three residents participated in the study. For IHJ drills, residents had higher OSATS scores (p = 0.0297) and were faster (p < 0.0001) with an open approach. A similar trend was observed for PJ drills, with higher OSATS scores and shorter time duration with an open approach. However, there was no significant difference in NASA-TLX, Borg Exertion Scale, or Edwards Arousal Rating for robotic IHJ compared to open. The residents endorsed higher NASA-TLX scores for robotic PJ. 100% of the residents viewed open training as extremely important, while 73.9% reported the same for robotic training.

CONCLUSION

PGY-3 surgical residents have greater comfort and skill with open techniques compared to robotic. This may be due to lack of robotic exposure early in surgical training, as opposed to open technique which is established early in residency. More deliberate integration of robotic training into residency is necessary for residents to catch up to open techniques.

Pancreatic anastomosis training models: Current status and future directions

Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback.

Surgical skills assessment of pancreaticojejunostomy using a simulator may predict patient outcomes: A multicenter prospective observational study

BACKGROUND

Pancreatoduodenectomy, an advanced surgical procedure with a high complication rate, requires surgical skill in performing pancreaticojejunostomy, which correlates with operative outcomes. We aimed to analyze the correlation between pancreaticojejunostomy assessment conducted in a simulator environment and the operating room and patient clinical outcomes.

METHODS

We recruited 30 surgeons (with different experience levels in pancreatoduodenectomy) from 11 institutes. Three trained blinded raters assessed the videos of the pancreaticojejunostomy procedure performed in the operating room using a simulator according to an objective structured assessment of technical skill and a newly developed pancreaticojejunostomy assessment scale. The correlations between the assessment score of the pancreaticojejunostomy performed in the operating room and using the simulator and between each assessment score and patient outcomes were calculated. The participants were also surveyed regarding various aspects of the simulator as a training tool.

RESULTS

There was no correlation between the average score of the pancreaticojejunostomy performed in the operating room and that in the simulator environment (r = 0.047). Pancreaticojejunostomy scores using the simulator were significantly lower in patients with postoperative pancreatic fistula than in those without postoperative pancreatic fistula (P = .05). Multivariate analysis showed that pancreaticojejunostomy assessment scores were independent factors in postoperative pancreatic fistula (P = .09). The participants highly rated the simulator and considered that it had the potential to be used for training.

CONCLUSION

There was no correlation between pancreaticojejunostomy surgical performance in the operating room and the simulation environment. Surgical skills evaluated in the simulation setting could predict patient surgical outcomes.