Surgical training for the next millennium

Skills transfer after proficiency-based simulation training in superficial femoral artery angioplasty

INTRODUCTION

The purpose of this study was to explore whether basic endovascular skills acquired using proficiency-based simulation training in superficial femoral artery (SFA) angioplasty translate to real-world performance.

METHODS

Five international experts were invited to evaluate a preliminary 28-item rating scale for SFA angioplasty using a modified Delphi study. To test the procedural scale, 4 experts and 11 final-year medical students then performed 2 SFA angioplasties each on the vascular intervention simulation trainer simulator. Thereafter, 10 general surgical residents (novices) received didactic training in SFA angioplasty. Trainees were then randomized with 5 trainees receiving further training on the vascular intervention simulation trainer simulator up to proficiency level. All 10 trainees then performed 1 SFA angioplasty on a patient within 5 days of training. The trainees' performance was assessed by 1 attending consultant blinded to the trainees' training status, using the developed procedural scale and a global rating scale.

RESULTS

Four items were eliminated from the procedural scale after the Delphi study. There were significant differences in the procedural scale scores between the experts and the students in the first trial [mean (SD), 94.25 (2.22) vs. 74.90 (8.79), P = 0.001] and the second trial [95.25 (0.50) vs. 76.82 (9.44), P < 0.001]. Simulation-trained trainees scored higher than the controls on the procedural scale [86.8 (5.4) vs. 67.6 (6), P = 0.001] and the global rating scale [37.2 (4.1) vs. 24.4 (5.3), P = 0.003].

CONCLUSIONS

Basic endovascular skills acquired using proficiency-based simulation training in SFA angioplasty do translate to real-world performance.

Minimally invasive techniques in common surgical procedures: implications for training

BACKGROUND

Laparoscopic techniques are increasingly used in common surgical procedures. Many of these procedures are used to teach basic surgical trainees (BST) and therefore introduction of these techniques may have implications for training.

AIMS

To establish whether the introduction of laparoscopic techniques reduced the opportunity of BSTs to perform surgical procedures.

METHODS

Patients undergoing hernia repair or appendicectomy in 1991 (when laparoscopy was first introduced) and 1997 (when laparoscopy was readily available) were identified using the Hospital In-Patient Enquiry (HIPE) database. The principal operator and whether the procedure was open or laparoscopic were identified by chart review.

RESULTS

The data showed a 50% reduction in the number of appendicectomies performed by BSTs following the introduction of laparoscopic techniques. The number of hernia repairs performed by BSTs has been preserved but the proportion by BSTs fell from 10 to 6%. The proportion of BST-performed procedures carried out laparoscopically has been reduced compared with the registrar-performed group.

CONCLUSIONS

The use of minimally invasive techniques has had a negative effect on surgical training. Appropriate measures must be taken to minimise this and such measures should include a structured approach to laparoscopic training and greater access to laparoscopic training facilities.

Surveillance of surgical training by detailed electronic registration of logical components

OBJECTIVE

To obtain detailed information about the degree of surgical trainee supervision and delegation of procedures in a subspecialised department.

DESIGN

Operative procedures and their logical components were recorded in a database constructed in Microsoft Access. Information about operating surgeon and assistants and their grade was registered prospectively over 12 months.

SUBJECTS AND METHODS

A total of 1250 intermediate or major procedures were performed by eight consultants, one staff specialist, four senior registrars, three specialist registrars, and five registrars.

MAIN MEASURE

Number of components performed by surgeons in each grade and the degree of supervision and delegation.

RESULTS

Eight hundred and eighty five of the operations were elective, while 365 were done as emergency procedures. Emergency procedures were far more often done by surgeons in training than by a staff surgeon, while the opposite was true for elective operations. Out of 323 elective operations done by surgeons in training, 189 were done under supervision (58.5%), while 119 out of 276 emergency operations done by surgeons in training were supervised (43.1%; p=0.0002). One hundred and twenty eight of 638 (20%) open abdominal operations were done by the most junior surgeons, and yet they closed 36% of all abdominal wounds. Although the most junior surgeons only served as operating surgeons in 39 of 334 bowel operations (12%), they constructed 24% of all stomas, and 20% of all anastomoses. Registrars and specialist registrars never constructed stomas or anastomoses without supervision.

CONCLUSION

Detailed information about individual and general training and supervision was achieved by a simple registration. Significant additional information was obtained about the extent of delegation of components compared with standard registration of operative procedures.