A Simple 3D Printed Model for Intracranial Vascular Anastomosis Practice and the Rochester Bypass Training Score

BACKGROUND AND OBJECTIVES

Surgical simulation models in cranial neurosurgery are needed to allow affordable, accessible, and validated practice in resident education. Current bypass anastomosis practice models revolve around basic tube tying or complex animal and 3-dimensional models. This study sought to design and validate a 3-dimensional printed model for intracranial anastomosis training.

METHODS

A computer-aided design (CAD) generic skull was uploaded into Meshmixer (v.3.5), and a 55-mm opening was created on the right side, mimicking a standard orbitozygomatic craniotomy. The model was rotated 15° upward and 35° left, before a 10-mm square frame was added 80-mm deep to the right orbit. The CAD model was uploaded to GrabCAD and printed using a J750 PolyJet 3D printer before being paired with a vascular anastomosis kit. The model was validated with standardized assessments of residents and attendings by simulating an "M2 to P2" bypass. The Rochester Bypass Training Score (RBTS) was created to assess bypass patency, back wall suturing, and suture quality. Postsimulation survey data regarding the realism and usefulness of the simulation were collected.

RESULTS

Five junior residents (Postgraduate Year 1-4), 3 senior residents (Postgraduate Year 5-7), and 2 attendings were participated. The mean operative time in minutes was as follows: junior residents 78, senior residents 33, and attendings 50. The RBTS means were as follows: junior residents 2.4, senior residents 4.0, and attendings 5.0. Participants agreed that the model was realistic, useful for improving operative technique, and would increase comfort in bypass procedures. There are a few different printing options, varying in model infill and printing material used. For this experiment, a mix of Vero plastics were used totaling $309.09 per model; however, using the more common printing material polylactic acid brings the cost to $17.27 for a comparable model.

CONCLUSION

This study presents an affordable, realistic, and educational intracranial vascular anastomosis simulator and introduces the RBTS for assessment.

Hand Sewn Anastomosis Skill Acquisition and In Vivo Transfer Using 3D-Printed Small Bowel Simulator

INTRODUCTION

General surgery residents need to master the hand-sewn bowel anastomosis (HSBA) technique. However, practice opportunities outside of the operating room are rare, and commercial simulators are often costly. The objective of this study is to assess the efficacy of a new, affordable silicone small bowel simulator, made with a three-dimensional (3D) printed mold, as a training tool to learn this technique.

METHODS

This was a single-blinded pilot randomized controlled trial comparing two groups of eight junior surgical residents. All participants completed a pretest using an inexpensive, custom developed 3D-printed simulator. Next, participants randomized to the experimental group practiced the HSBA skill at home (eight sessions), while those randomized to the control group did not receive any hands-on practice opportunities. A posttest was done using the same simulator as for the pretest and practice sessions, and the retention-transfer test was performed on an anesthetized porcine model. Pretests, posttests and retention-transfer tests were filmed and graded by a blinded evaluator using assessments of technical skills, quality of final product, and tests of procedural knowledge.

RESULTS

The experimental group significantly improved after practicing with the model (P = 0.01), while an equivalent improvement was not noted in the control group (P = 0.07). Moreover, the experimental group's performance remained stable between the posttest and the retention-transfer test (P = 0.95).

CONCLUSIONS

Our 3D-printed simulator is an affordable and efficacious tool to teach residents the HSBA technique. It allows development of surgical skills that are transferable to an in vivo model.

Rapid Prototyping Techniques for the Development of a Take-Home Surgical Anastomosis Simulation Model

OBJECTIVE

The objective of this paper is to describe the techniques and process of developing and testing a take-home surgical anastomosis simulation model.

DESIGN

Through an iterative process, a simulation model was customized and designed to target specific skill development and performance objectives that focused on anastomotic techniques in thoracic surgery and consist of 3D printed and silicone molded components. Various manufacturing techniques such as silicone dip spin coating and injection molding have been described in this paper and explored as part of the research and development process. The final prototype is a low-cost, take-home model with reusable and replaceable components.

SETTING

The study took place at a single-center quaternary care university-affiliated hospital.

PARTICIPANTS

The participants included in the model testing were 10 senior thoracic surgery trainees who completed an in-person training session held during an annual hands- on thoracic surgery simulation course. Feedback was then collected in the form of an evaluation of the model from participants.

RESULTS

All 10 participants had an opportunity to test the model and complete at least 1 pulmonary artery and bronchial anastomosis. The overall experience was rated highly, with minor feedback provided regarding the set- up and fidelity of the materials used for the anastomoses. Overall, the trainees agreed that the model was suitable for teaching advanced anastomotic techniques and expressed an interest in being able to use this model to practice skill development.

CONCLUSIONS

Developed simulation model can be easily reduced, with customized components that accurately simulate real-life vascular and bronchial components suitable for training of anastomoses technique amongst senior thoracic surgery trainees.

Do Skills Naturally Transfer Between Multiport and Single-Port Robotic Platforms? A Comparative Study in a Simulated Environment

Introduction and Objective: With introduction of the da Vinci single-port (SP) system, we evaluated which multiport (MP) robotic skills are naturally transferable to the SP platform. Methods: Three groups of urologists: Group 1 (5 inexperienced in MP and SP), Group 2 (5 experienced in MP without SP experience), and Group 3 (2 experienced in both MP and SP) were recruited to complete a validated urethrovesical anastomosis simulation using MP followed by SP robots. Performance was graded using both GEARS and RACE scales. Subjective cognitive load measurements (Surg-TLX and difficulty ratings [/20] of instrument collisions camera and EndoWrist movement) were collected. Results: GEARS and RACE scores for Groups 1 and 3 were maintained on switching from MP to SP (Group 3 scored significantly higher on both systems). Surg-TLX and difficulty scores were also maintained for both groups on switching from MP and SP except for a significant increase in SP camera movement (+7.2, p = 0.03) in Group 1 compared to Group 3 that maintained low scores on both. Group 2 demonstrated significant lower GEARS (-2.9, p = 0.047) and RACE (-5.1, p = 0.011) scores on SP vs MP. On subanalysis, GEARS subscores for force sensitivity and robotic control (-0.7, p = 0.04; -0.9, p = 0.02) and RACE subscores for needle entry, needle driving, and tissue approximation (-0.9, p = 0.01; -1.0, p = 0.02; -1.0, p < 0.01) significantly decreased. GEARS (depth perception, bimanual dexterity, and efficiency) and RACE subscores (needle positioning and suture placement) were maintained. All participants scored significantly lower in knot tying on the SP robot (-1.0, p = 0.03; -1.2, p = 0.02, respectively). Group 2 reported higher Surg-TLX (+13 pts, p = 0.015) and difficulty ratings on SP vs MP (+11.8, p < 0.01; +13.6, p < 0.01; +14 pts, p < 0.01). Conclusions: The partial skill transference across robots raises the question regarding SP-specific training for urologists proficient in MP. Novices maintained difficulty scores and cognitive load across platforms, suggesting that concurrent SP and MP training may be preferred.

Reduction of the Number of Live Animals Used for Microsurgical Skill Acquisition: An Experimental Randomized Noninferiority Trial

BACKGROUND

 Live animals have been used for decades as one of the many training models for developing surgical skills. Microsurgery in particular relies on training for skill acquisition and maintenance, using live animal models, especially rats (murine models). Efforts are underway to reduce the number of rats sacrificed to achieve this objective.

METHODS

 A group of students with minimal microsurgical experience, after having gone through a basic microsurgical course, were randomly split into three equal groups, all three groups following a 24-week standard training program based on low- and medium-fidelity training models with standardized murine training days. In addition to the standard training regimen, each participant performed supplementary training on live rats every 4, 6, or 8 weeks. According to the training program, the procedures have been performed on chicken legs, flower petals, and rats, each procedure being blindly assessed and evaluated using validated models and scales. The primary evaluated outcome was the Stanford Microsurgery and Resident Training (SMaRT) scale result of the final rat anastomosis performed by each group, for which the tested hypothesis was one of noninferiority. The secondary outcomes were represented by the final rat anastomosis time, final chicken leg anastomosis result and time, and the final petal score.

RESULTS

 After the 24th week, no differences were observed between the three groups regarding their microsurgical skills, as measured by the aforementioned surgical outcomes. All participants improved significantly during the study (mean [standard deviation] 19 ± 4 points on the SMaRT scale), with no significant differences between the groups, p < 0.001 for noninferiority.

CONCLUSION

 A training regimen based on low- and moderate-fidelity models, with the addition of training on a live rat every 8 weeks was noninferior to a training regimen that used a live rat every 6 weeks and also noninferior to a training regimen that used a live rat every 4 weeks.

Knowledge gain of the non-vascular surgeons after attending a course on traumatic vascular emergencies

OBJECTIVE

To measure the effectiveness of the workshop in enhancing the knowledge and skills of the non-vascular surgeons in dealing with traumatic vascular emergencies.

METHODOLOGY

It was a Quasi-experimental pre-post design study conducted at Section of Vascular Surgery, Aga Khan University Hospital, Karachi (Pakistan) in February 2019. One-day workshop was conducted to enhance the knowledge and operative skills of the non-vascular surgeons in managing traumatic vascular emergencies. A written test and course evaluation survey were used to evaluate the effectiveness of the course in achieving the desired objectives.

RESULTS

Total of 21 participants attended the workshop with mean age of 29 ± 6.06 years. Majority of participants 15 (71%) were surgery residents from different subspecialties. Only 3 (14%) had prior exposure in Vascular Surgery. Mean pretest score was 11.9 ± 4.27 (59.52% ± 21.3) which improved to 16.14 ± 3.69 (81.6% ± 16.6). Gain in knowledge was measured using paired t-test and there was 21% of gain in knowledge of the participants compared between the pretest and posttest score. Overall participants found this workshop to be very useful in refining their skills and learning innovative techniques in managing vascular emergencies.

CONCLUSIONS

Carefully designed workshop improves the knowledge of non-vascular surgeons in dealing with common vascular emergencies.

Crowdsourced Assessment of Inanimate Biotissue Drills: A Valid and Cost-Effective Way to Evaluate Surgical Trainees

OBJECTIVE

Providing feedback to surgical trainees is a critical component for assessment of technical skills, yet remains costly and time consuming. We hypothesize that statistical selection can identify a homogenous group of nonexpert crowdworkers capable of accurately grading inanimate surgical video.

DESIGN

Applicants auditioned by grading 9 training videos using the Objective Structured Assessment of Technical Skills (OSATS) tool and an error-based checklist. The summed OSATS, summed errors, and OSATS summary score were tested for outliers using Cronbach's Alpha and single measure intraclass correlation. Accepted crowdworkers then submitted grades for videos in 3 different compositions: full video 1× speed, full video 2× speed, and critical section segmented video. Graders were blinded to this study and a similar statistical analysis was performed.

SETTING

The study was conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital.

PARTICIPANTS

Thirty-six premedical students participated as crowdworker applicants and 2 surgery experts were compared as the gold-standard.

RESULTS

The selected hire intraclass correlation was 0.717 for Total Errors and 0.794 for Total OSATS for the first hire group and 0.800 for Total OSATS and 0.654 for Total Errors for the second hire group. There was very good correlation between full videos at 1× and 2× speed with an interitem statistic of 0.817 for errors and 0.86 for OSATS. Only moderate correlation was found with critical section segments. In 1 year 275hours of inanimate video was graded costing $22.27/video or $1.03/minute.

CONCLUSIONS

Statistical selection can be used to identify a homogenous cohort of crowdworkers used for grading trainees' inanimate drills. Crowdworkers can distinguish OSATS metrics and errors in full videos at 2× speed but were less consistent with segmented videos. The program is a comparatively cost-effective way to provide feedback to surgical trainees.

Prospective Trial of Low-Fidelity Deliberate Practice of Aortic and Coronary Anastomoses (TECoG 002)

OBJECTIVE

We sought to examine the feasibility of a home practice curriculum of vascular anastomosis in cardiovascular surgery using a low-fidelity simulation platform and to examine its effectiveness in skill acquisition in senior surgical trainees.

DESIGN

We organized a multicenter prospective randomized study of senior residents and fellows, who were oriented to a low-fidelity cardiac simulator and an 8-week curriculum of independent practice of aortic and coronary anastomosis. "Treatment" trainees received a simulator and the curriculum. Control trainees received only their usual operative experience. The groups then crossed over; all were studied for 16 weeks in total. Video skill assessments were captured at 0, 8, and 16 weeks and were scored by one blinded investigator using the Joint Council on Thoracic Surgery Education Assessment tool. A post-hoc survey was distributed to invited participants following study completion.

SETTING

University of Minnesota Department of Surgery, Mayo Clinic Department of Cardiovascular Surgery, and the University of Texas Health Science Center at Houston. Participants used the simulator in offices, call rooms, and their homes.

PARTICIPANTS

Program participation in the study was solicited through the Thoracic Education Cooperative Group. Four institutions expressed interest and a total of 29 trainees were invited to the study and randomized. Of these, 12 (38%) completed the curriculum and submitted the requisite 3 sets of videos (6 treatment, 6 control). All were senior residents and fellows in general and cardiothoracic surgery.

RESULTS

No significant differences were detected in assessment scores before and after the curriculum nor before or after the control period in the overall or postgraduate year-stratified populations. Participant case numbers during the study did not have a significant effect on assessment scores. Randomized participants reported strong interest in deliberate practice of technical skills but identified competing clinical and personal obligations and significant barriers to simulation.

CONCLUSIONS

Considerable variability in performance existed among participants who completed the study, but overall, the curriculum alone was insufficient to improve simulator Joint Council on Thoracic Surgery Education scores compared to those not undergoing the curriculum. Among senior residents and fellows, provision of a practice curriculum and simulator for repeated practice is feasible but clinical and personal responsibilities were barriers to repetitive practice.

Evaluating Surgery Resident Technical Skills: Intestinal Anastomosis in a Porcine Model

Because work hour restrictions and technological developments such as staplers change the surgical landscape, efficient resident training methods are necessary to ensure surgical quality. This study evaluates efficacy of a porcine skills laboratory for teaching surgery residents to perform handsewn intestinal anastomoses based on a validated subjective tool and novel objective measurements. We hypothesized that resident performance would improve postintervention; junior residents would improve more than the seniors would. This prospective study was completed over a period of four months in 2015. Participants performed standardized two-layer, handsewn, end-to-end small intestine anastomosis in a live porcine model before (pretest) and after (posttest) an educational intervention. The intervention consisted of an instructional module and skills laboratory teaching session by attending surgeons. Participants were evaluated based on objective measurements of the anastomosis and blinded video evaluations using objective structured assessment of technical skills. Twenty-eight residents in a six-year general surgery program started and completed the study. The objective structured assessment of technical skills ratings demonstrated that the whole resident cohort had statistically significant improvement in pre- to posttest scores, 11.16 to 24.59 (P < 0.001). Junior and senior residents improved independently, 9.59 versus 22.53 (P < 0.001) and 13.59 versus 27.77 (P < 0.001), respectively. Finally, the cohort significantly improved in number of full-thickness Lembert sutures (2.36 vs 0.93, P = 0.001) and time to completion (31.28 vs 28.2 minutes, P = 0.046). Anastomotic leak pressure, anastomotic narrowing, and anastomotic tensile strength all trended toward improvement. A structured educational intervention, teaching intestinal anastomosis in a live porcine model produced significant improvement in residents' technical skills.

A Vascular Anastomosis Simulation Can Provide a Safe and Effective Environment for Resident Skills Development

OBJECTIVE

Vascular anastomoses are complex surgical procedures, performed in time-sensitive circumstances, making intraoperative teaching more challenging. We sought to evaluate whether a vascular anastomosis simulation was effective in developing resident skills.

DESIGN, SETTING, PARTICIPANTS

General surgery residents participated in a vascular anastomosis simulation for 1 to 2hours during their transplant rotation. An attending transplant surgeon at the University of Colorado guided the resident through end-to-end and end-to-side anastomoses using bovine carotid artery (Artegraft). The residents completed a presimulation and postsimulation survey which quantitated their confidence. They also completed the MiSSES scale, which assessed the validity of the simulation.

RESULTS

Twenty residents participated in the simulation and completed the surveys. The residents reported increased understanding in how to set up an end-to-end anastomosis and an end-to-side anastomosis (p = 0.001 and p = 0.009, respectively). They reported increased ability to suture, forehand and backhand with a Castro-Viejo needle driver (both p < 0.001). The residents reported increased ability to manipulate the needle (p = 0.006), and increased ability to manipulate tissue without causing trauma (p = 0.021). They reported increased confidence in tying a surgical knot with 6-0 Prolene and in operating while wearing loupes (p = 0.002, and p < 0.001, respectively). Overall, the residents reported increased confidence when asked to perform part of a vascular anastomosis in the operating room (p < 0.001). Seventeen residents completed the MiSSES scale with median scores of "somewhat agree" to "strongly agree" on all domains of the scale.

CONCLUSIONS

The use of a simple, inexpensive vascular anastomosis simulation is an effective and safe environment to improve residents' surgical skills and the residents felt that the simulation was valid.

Predictive Validation of a Robotic Virtual Reality Simulator: The Tube 3 module for Practicing Vesicourethral Anastomosis in Robot-Assisted Radical Prostatectomy

OBJECTIVE

To predict actual performance in real surgery when vesicourethral anastomosis (VUA) is performed in patients after Tube 3 module training of robot-naive surgeons.

METHODS

Forty-five patients were enrolled and divided into 3 groups according to chronological trends (each containing 15 patients). Three robot-naive surgeons in a single center completed VUA in robot-assisted radical prostatectomy (RARP) following robotic virtual reality simulator (RVRS) training. The practicing tool used in robotic virtual reality simulator was Tube 3, which was invented for the dV-Trainer that imitates a VUA in RARP. The effects of performance were investigated by analyzing the number of repetitions and the time required to complete the task until achieving the predetermined proficiency level.

RESULTS

The targeted time (predetermined proficiency level) for completing tasks of Tube 3 and the number of required task repetitions to achieve the proficiency level were 283.1 s and 36 times, respectively, whereas in actual VUA procedures, the number of required attempts was 24, with an average time of 14.9 minutes. The mean time for completing VUA in real surgery significantly decreased with serial cases among all surgeons (1-15 vs 16-30 vs 31-45 cases, P <.001), as well as comparisons between groups (P <.001).

CONCLUSION

The Tube 3 module can represent a valuable educational tool for procedure-specific robotic training by bridging the gap between safe acquisition of surgical skills and effective performance during actual VUA in RARP.

Case Reporting, Competence, and Confidence: A Discrepancy in the Numbers

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) continues to play an integral role in accreditation of surgical programs. The institution of case logs to demonstrate competency of graduating residents is a key component of evaluation. This study compared the number of vascular cases a surgical resident has completed according to the ACGME operative log to their operative proficiency, quality of anastomosis, operative experience, and confidence in both a simulation and operative setting.

MATERIALS AND METHODS

General surgery residents ranging from PGY 1 to 5 participated in a simulation laboratory in which they completed an end-to-side vascular anastomosis. Each participant was given a weighted score based on technical proficiency and anastomosis quality using a previously validated Global Rating Scale (Duran et al, 2014). These scores were correlated to the General Surgery Milestones. Participants completed preoperative and postoperative surveys assessing resident operative experience using the 4-level Zwisch scale (DaRosa et al., 2013), confidence with vascular procedures and confidence performing simulated anastomoses. Confidence was assessed on a scale from 1 to 9 (not confident to extremely confident). Case logs were recorded for each participant. An IRB approved questionnaire was distributed to assess preoperative and postoperative roles of both the resident physician and faculty, with a defined goal. Univariate and multivariate analysis was performed.

RESULTS

Twenty-one general surgery residents were evaluated in the simulation laboratory and 8 residents were assessed intraoperatively. The residents were evenly distributed throughout clinical years. Groups of residents were divided into quartiles based upon the number of vascular cases recorded in the ACGME database. No correlation was found between number of cases, Milestones score and the weighted score (p = 0.94). No statistical significance was found between confidence and quality of anastomosis (p = 0.1). Resident operative experience per the Zwisch scale was categorized most commonly as "Smart Help" by both the trainee and attending surgeon, despite mean resident confidence ratings of 6.67 (± 1.61) with vascular procedures.

CONCLUSIONS

ACGME case logs, which are utilized to assess readiness for completion of general surgery residency, may not be indicative of a resident's operative competency and technical proficiency. Confidence is not correlated with technical ability. Faculty and resident insight as to their role in a procedure differ, as faculty feel that they are providing less help than the resident perceives. Careful examination of resident operative technique is the best measure of competency.

A New Synthetic Model for Microvascular Anastomosis Training? A Randomized Comparative Study Between Silicone and Polyvinyl Alcohol Gelatin Tubes

INTRODUCTION

Assessment of a resident's microsurgical competency with the rodent model remains the current gold standard. However, cost and ethical issues related to animal welfare may limit training opportunities. Therefore, synthetic alternatives such as silicone tubes have been developed to provide easy access to training, shorten the learning curve, and have been incorporated into microsurgical courses as a low-fidelity model for basic skills acquisition. This study compares the use of polyvinyl alcohol (PVA) gelatin tubes with silicone for resident microsurgical training.

MATERIAL AND METHODS

Residents were randomized into silicone (S) or PVA (P) groups and underwent the same training. Following basic instruction, microsurgical anastomoses were performed with the rat's aorta or carotid artery or both. Performance was assessed using the Objective Structured Assessment of Technical Skills (OSATS) score and 5 different items to assess the quality of the anastomosis. Posttest questionnaires were also conducted for qualitative assessment of both students' and trainers' experience with silicone and PVA in comparison with rat vessels.

RESULTS

OSATS score in Group P was higher than Group S (18.2 ± 2.6 vs 16.6 ± 2.5, p = 0.015). Results of anastomoses were similarly better in Group P based on OSATS score (19.3 ± 1.2 vs 17.7 ± 0.7, p = 0.027). Subjectively, both students and trainers found that PVA tubes resembled the rat aorta more closely than silicone. The number of rats used was also significantly lower in Group P than Group S (65 vs 75 total, p = 0.023).

CONCLUSION

PVA gelatin tubes may be a viable alternative to silicone for microsurgical training because this synthetic model mirrors better rat vessels and can improve training performance based on objective assessment while using less animals overall.

Robotic Pancreatoduodenectomy Biotissue Curriculum has Validity and Improves Technical Performance for Surgical Oncology Fellows

OBJECTIVE

Obtaining the proficiency on the robotic platform necessary to safely perform a robotic pancreatoduodenectomy is particularly challenging. We hypothesize that by instituting a proficiency-based robotic training curriculum we can enhance novice surgeons' skills outside of the operating room, leading to a shorter learning curve.

DESIGN

A biotissue curriculum was designed consisting of sewing artificial organs to simulate a hepaticojejunostomy (HJ), gastrojejunostomy (GJ), and pancreaticojejunostomy (PJ). Three master robotic surgeons performed each biotissue anastomosis to assess validity. Using video review, trainee performance on biotissue drills was evaluated for time, errors and objective structured assessment of technical skills (OSATS) by 2 blinded graders.

SETTING

This study is conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital.

PARTICIPANTS

In total, 14 surgical oncology fellows completed the biotissue curriculum.

RESULTS

Fourteen fellows performed 196 anastomotic drills during the first year: 66 (HJ), 64 (GJ), and 66 (PJ). The fellows' performances were analyzed as a group by attempt. The attendings' first attempt outperformed the fellows' first attempt in all metrics for every drill (all p < 0.05). More than 5 analyzed attempts of the HJ, there was improvement in time, errors, and OSATS (all p < 0.01); however, no metric reached attending performance. For the GJ, time, errors, and OSATS all improved more than 5 attempts (all p < 0.01), whereas only errors and OSATS reached proficiency. For the PJ, errors and OSATS both improved over attempts (p < 0.01) and reached proficiency; however, time did not statistically improve nor reach proficiency. The graders scoring correlated for errors and OSATS (p < 0.0001).

CONCLUSION

A pancreatoduodenectomy biotissue curriculum has face and construct validity. The curriculum is feasible and improves errors and technical performance. Time is the most difficult technical parameter to improve. This curriculum is a valid tool for teaching robotic pancreatoduodenectomies with established milestones for reaching optimum performance.

Video Coaching as an Efficient Teaching Method for Surgical Residents-A Randomized Controlled Trial

BACKGROUND

As surgical training is evolving and operative exposure is decreasing, new, effective, and experiential learning methods are needed to ensure surgical competency and patient safety. Video coaching is an emerging concept in surgery that needs further investigation.

DESIGN

In this randomized controlled trial conducted at a single teaching hospital, participating residents were filmed performing a side-to-side intestinal anastomosis on cadaveric dog bowel for baseline assessment. The Surgical Video Coaching (SVC) group then participated in a one-on-one video playback coaching and debriefing session with a surgeon, during which constructive feedback was given. The control group went on with their normal clinical duties without coaching or debriefing. All participants were filmed making a second intestinal anastomosis. This was compared to their first anastomosis using a 7-category-validated technical skill global rating scale, the Objective Structured Assessment of Technical Skills. A single independent surgeon who did not participate in coaching or debriefing to the SVC group reviewed all videos. A satisfaction survey was then sent to the residents in the coaching group.

SETTING

Department of Surgery, HôpitalMaisonneuve-Rosemont, tertiary teaching hospital affiliated to the University of Montreal, Canada.

PARTICIPANTS

General surgery residents from University of Montreal were recruited to take part in this trial. A total of 28 residents were randomized and completed the study.

RESULTS

After intervention, the SVC group (n = 14) significantly increased their Objective Structured Assessment of Technical Skills score (mean of differences 3.36, [1.09-5.63], p = 0.007) when compared to the control group (n = 14) (mean of differences 0.29, p = 0.759). All residents agreed or strongly agreed that video coaching was a time-efficient teaching method.

CONCLUSIONS

Video coaching is an effective and efficient teaching intervention to improve surgical residents' technical skills.

Experience of General Surgery Residents in the Creation of Small Bowel and Colon Anastomoses

BACKGROUND

With the introduction of stapling devices (SDs), the proportion of hand-sewn (HS) intestinal anastomoses (IAs) has declined. As more IAs are constructed with SDs, there are fewer opportunities for general surgery residents (GSRs) to acquire the skills for HS techniques during their training.

STUDY DESIGN

Data for this study were extracted from an existing database of all IAs performed at the Department of Surgery of the Morristown Medical Center since 2003. For the purposes of this study, a 5.5-year timeframe was used between July 2006 and 2011, which contained 1659 IA operations on adult patients with resident involvement. GSRs of the 5-year general surgery residency program were grouped by postgraduate year (PGY) for further analysis.

RESULTS

The number of all IAs created by each resident during the 5-year training was 67.2 on average. Most of these operations were done in the last 2 years of the training: 45.1% of all IAs in PGY5 and 37.3% of all IAs in PGY4. Of all, 1659 IAs performed in the study period, 711 (42.9% of total) were done laparoscopically and 948 (57.1% of all IAs) were done as open operations. Laparoscopic operations had a proportionally higher rate of SD use when compared to open cases (90.9% vs 82.4%). On average, each resident constructed 9.4 HS IAs (13.98% of all IAs) and 57.8 SD IAs (86.02% of total). Out of all anastomoses, ostomy reversals (30.7%) had the highest percentage of HS suturing followed by right colectomies (27.5%), ileal pouch-anal anastomoses and total colectomies and proctocolectomies (23.3%), small bowel resection (17.0%), and left colectomies (5.5%). Regardless of the location of the operation, stapled and sutured anastomoses had similar outcomes measured by the rate of anastomotic leaks. Residents used significantly more SDs in the creation of anastomoses than HS suturing in the PGY3, PGY4, and PGY5 years. We also documented that attending surgeons who are older more often used HS suturing than their younger colleagues when creating IAs.

CONCLUSIONS

The experiences of GSRs in IA operations are heavily weighted toward the use of SDs. There are select cases, however, when HS suturing can have an advantage over stapler use in anastomosis creation. Therefore, we believe that GSRs should continue learning, perfecting, and using the both techniques.

The Surgical Skill of a Novice Trainee Manifests in Time-Consuming Exercises of a Virtual Simulator Rather Than a Quick-Finishing Counterpart: A Concurrent Validity Study Using an Urethrovesical Anastomosis Model

OBJECTIVE

The purpose of this study is to determine an optimal training curriculum using a robotic virtual simulator (RVS) that enables unexperienced trainees to perform a complex task in a hands-on setting.

PATIENTS AND METHODS

This study was conducted in 2 phases. In the RVS phase, 43 participants sequentially completed 12 exercises consistent with all primary exercises in the EndoWrist manipulation and advanced needle-driving category, until the overall score reached more than 80% by repeated practice. In the hands-on phase using a robotic surgical system, 10 randomly selected trainees performed 8 sutures once, simulating urethrovesical anastomosis, and the console time was recorded.

RESULTS

The median total time and total attempts for the RVS phase was 195.2 minutes and 54 times, respectively. The trainees were divided by median total time, and times to accomplish each RVS exercise were then compared between the early- and the late-completion groups; among 12 exercises trained, 6 exercises (prolonged course) requiring significantly more time in the late-completion group were identified. The prolonged course occupied 88.18% of the total time and 77.61% of the total attempts. For participants the in hands-on phase, a multiple linear regression model showed that the time to accomplish the prolonged course was a single independent predictor of the console time (R(2) = 0.524, B = 0.05; p = 0.018).

CONCLUSION

After establishment of a high standard cutoff score, the time spent for the prolonged course showed a significant association with console time in hands-on training simulating urethrovesical anastomosis, implying educational efficacy of training involving time-consuming exercise in performance of a complex task.

Video Skills Curricula and Simulation: A Synergistic Way to Teach 2-Layered, Hand-Sewn Small Bowel Anastomosis

BACKGROUND

We sought to determine if general surgery (GS) interns could learn a side-to-side, 2-layered, hand-sewn small bowel anastomosis (HSBA) using an online instructional video and low-fidelity simulation model.

METHODS

A 3-hour HSBA technical skills training session was held among GS interns. Participants were asked to write down the steps for performing a side-to-side, 2-layered HSBA (pretest). An online 13-minute instructional video on HSBA was then viewed. Low-fidelity bowel simulators were then provided for deliberate practice under staff supervision. A posttest (identical to pretest) concluded the session. The maximum test score was 20 points. At 4 months later, a retention test was administered. Trainees were anonymously surveyed to determine the session's educational value. Pretest, posttest, and retention test scores were compared.

RESULTS

Participants were 25 GS interns. The mean pretest score was 5 (range: 0-11). Posttest scores improved (mean = 15; range: 11-19, p = 0.016), whereas retention test scores were stable (mean = 14; range: 8-18). Of those who participated in retention testing (24/25), 7 had now performed a 2-layered HSBA, 11 had witnessed HSBA, and 6 had neither performed nor witnessed an HSBA since the educational session. Retention test scores were higher among those who had performed HSBA (mean = 16; range: 13-18) vs those who had not performed nor witnessed an HSBA (mean = 14; range: 8-18, p = 0.04). Mean Likert scores supported the educational value of the session.

CONCLUSION

Initial intern performance of HSBA was abysmal. A contemporary online video skills curriculum coupled with low-fidelity bowel simulators improved trainee knowledge of how to perform a 2-layered HSBA. This effect remained stable over 4 months.

Effectiveness of learning advanced laparoscopic skills in a brief intensive laparoscopy training program

BACKGROUND

Intensive training programs arose from limitations in access to simulation centers. The aim of this study is to evaluate the effect and associated factors involved in an intensive course for learning advanced laparoscopic skills, which include validated teaching techniques.

METHODS

General surgeons and final-year residents were analyzed after completing an intensive 5-session advanced laparoscopy course. Initial (IA) and final assessment (FA) consisted in performing a jejunojejunal anastomosis in a live porcine model, measured using objective structured assessment of technical skill (OSATS) (GRS and SRS, that is, global rating scale and specific rating scale, respectively) and operative time (OT). The 3-session training was structured in a bench model with an ex vivo bowel. For the demographic analysis, 3 groups were defined according to the presentation of relevant changes in OSATS and in OT between IA and FA: group A, no changes; group B, change in 1 variable; and group C, change in both variables.

RESULTS

After the course, all 114 participants presented a significant improvement in OT (37 vs 24.6min, p < 0.001) and in OSATS; global rating scale (10.5 vs 16 points; p < 0.001) and Specific Rating Scale (8.5 vs 12.7 points; p < 0.001). In the IA, 70 (61%) participants completed the jejunojejunal anastomosis and 105(92%) in the FA (p < 0.01). In the FA, 56% of participants presented relevant changes in both variables (group C). This group was significantly younger (34 vs 45 vs 40y old; p < 0.001), had fewer years of surgical experience (2 vs 9 vs 5y; p < 0.001), and had a proportionally higher concentration of residents (p = 0.01).

CONCLUSIONS

This intensive course is set out as a viable alternative to teach basic skills in advanced laparoscopy in a short period of time, which is ideal for surgeons with difficult access to training centers. It remains necessary to establish the participant profile for which this type of course is most beneficial.

A 4-task skills examination for residents for the assessment of technical ability in hand trauma surgery

OBJECTIVES

The aim of this study was to evaluate a 4-task skills examination model for surgical trainees as a method of assessment of the different technical skills essential in hand trauma surgery.

DESIGN

Using established validation methodology, construct validity was assessed by comparing the performance of 2 groups of residents in surgery (group A: residents with any formation in microsurgery and hand surgery and group B: residents with specific formation in hand or microsurgery or both).

PARTICIPANTS AND SETTING

Overall, 19 residents in surgery with different degree of formation in hand and microsurgery participated in the study. All the residents performed 4 tasks on synthetic models consecutively: task 1-Z-plasty, task 2-metacarpal fracture fixation, task 3-tendon repair, and task 4-end-to-end anastomosis. The running order was awarded in a random drawing and 4 independent observers scored each resident.

RESULTS

There was a significant difference in performance in the overall score between groups A and B and particularly for tasks 1 and 4. All participants felt the 4 tasks were good models to learn the procedure and recommended this approach to younger residents.

CONCLUSION

This approach was based on a 4-tasks examination is the first model of evaluation of the different technical skills required for hand trauma surgery for residents. The results show a good differentiation between residents that have microsurgical and hand formation and those who do not have. This easy model can be easily integrated in the curriculum of residents, who want to specialize in hand surgery.

Simulation training improves resident performance in hand-sewn vascular and bowel anastomoses

BACKGROUND

Surgical training has recently emphasized simulation-based training of core surgical skills and tasks such as bowel and vascular anastomoses. This may increase efficiency of training within the operating room. Objective data regarding the effectiveness of instruction or monitoring progress in simulating vascular and bowel anastomoses are lacking. The aim of this study is to provide subjective and objective assessments of simulation-based training among residents in hand-sewn vascular and bowel anastomoses.

METHODS

Residents received vascular and bowel anastomoses training. Each resident fashioned anastomoses on both cadaveric saphenous veins and small bowel. The residents repeated the anastomoses 1 week later. Performances were assessed subjectively and objectively by questionnaire, operative time, objective structured assessment of technical skills (OSATS) score, and leak pressures of the finished anastomosis.

RESULTS

Of 14 residents, 12 felt more confident with bowel anastomoses after the laboratory session, and 10 were more confident with vascular anastomoses. For vascular anastomoses, the operating time decreased (15.4 vs 14.2 minutes, p = 0.3), OSATS scores improved (14.9 vs 15.6, p = 0.15), and leak pressures improved (38.9 vs 71.8psi, p = 0.001) from the first to the second workshop. For bowel anastomoses, the operating time decreased (23 vs 18 minutes, p < 0.001), OSATS scores improved (12.9 vs 14.4, p < 0.001), and leak pressures improved (17.7 vs 26.9psi, p < 0.001).

DISCUSSION

After simulation-based training, residents performed vascular and bowel anastomoses more adeptly, quickly, and with a higher quality end product. Laboratory training can effectively improve residents' ability to perform anastomoses, which may result in increased efficiency of teaching in the operating room.

A NOVEL MODEL TO EVALUATE THE LEARNING CURVE IN MICROSURGERY: SERIAL ANASTOMOSIS OF THE RAT FEMORAL ARTERY

The rat's femoral artery is definitely the most frequently used model in microsurgical training for its easy dissection. Our model, consisting in the creation of several anastomoses in a row, helps the novice surgeon to assess his microsurgical level and to improve his capacity. Indeed, this leads to an amplification of the trainee surgeon's mistakes, which add up to each other as the anastomoses are performed. We propose a simple method to evaluate the surgeon microsurgical skills during the training.

Flap outcomes when training residents in microvascular anastomosis in the head and neck

OBJECTIVE

Microvascular anastomosis is generally performed by attending surgeons or fellows, with published success rates >95%. Since otolaryngology residents do not typically perform microvascular anastomosis, it is unknown if they achieve similar results. The objective of this study is to determine the success rate and complication rate during free flap reconstruction when microvascular anastomosis is performed in part by otolaryngology chief residents.

STUDY DESIGN

Multi-institutional retrospective review.

SETTING

Academic, tertiary-care referral centers.

SUBJECTS AND METHODS

Consecutive patients who underwent microvascular reconstruction by the Department of Otolaryngology from 2004 through 2011. All patients had >50% of the arterial and venous anastomoses performed by the chief resident.

RESULTS

The study included 93 consecutive free flaps in 88 patients: 43 radial forearm, 14 anterolateral thigh, and 36 fibula. There were 71 males and 22 females with mean age of 53. The pre-operative diagnosis was squamous cell carcinoma in 78%, with 27% of patients having previously received radiotherapy and 13% of patients having had previous neck surgery. There were no instances when resident-placed sutures required revision, nor was there a perceived need to revise such an anastomosis intraoperatively. Overall flap success rate was 97%. The anastomotic complication rate was 4.3%, with venous thrombosis in three cases and arterial hemorrhage in one case.

CONCLUSION

Overall free flap success rate and anastomosis-related complications with residents performing portions of the microvascular anastomosis are comparable to published studies. Otolaryngology chief residents can safely participate in microsuturing, which is a single facet in the broader skill set of a microvascular surgeon.

Is there good simulation basic training for end-to-side vascular microanastomoses?

BACKGROUND

Microvascular anastomosis is the cornerstone of free tissue transfers. Irrespective of the microsurgical technique that one seeks to integrate or improve, the time commitment in the laboratory is significant. After extensive previous training on several animal models, we sought to identify an animal model that circumvents the following issues: ethical rules, cost, time-consuming and expensive anesthesia, and surgical preparation of tissues required to access vessels before performing the microsurgical training, not to mention that laboratories are closed on weekends.

METHODS

Between January 2012 and April 2012, a total of 91 earthworms were used for 150 microsurgical training exercises to simulate vascular end-to-side microanastomosis. The training sessions were divided into ten periods of 7 days. Each training session included 15 simulations of end-to-side vascular microanastomoses: larger than 1.5 mm (n=5), between 1.0 and 1.5 mm (n=5), and smaller than 1.0 mm (n=5). A linear model with the main variables being the number of weeks (as a numerical covariate) and the size of the animal (as a factor) was used to determine the trend in time of anastomosis over subsequent weeks as well as the differences between the different size groups.

RESULTS

The linear model shows a significant trend (p<0.001) in time of anastomosis in the course of the training, as well as significant differences (p<0.001) between the groups of animals of different sizes. For microanastomoses larger than 1.5 mm, the mean anastomosis time decreased from 19.3±1.0 to 11.1±0.4 min between the first and last week of training (decrease of 42.5%). For training with smaller diameters, the results showed a decrease in execution time of 43.2% (diameter between 1.0 and 1.5 mm) and 40.9% (diameter<1.0 mm) between the first and last periods. The study demonstrates an improvement in the dexterity and speed of nodes execution.

CONCLUSION

The earthworm appears to be a reliable experimental model for microsurgical training of end-to-side microanastomoses. Its numerous advantages are discussed here and we predict training on earthworms will significantly grow and develop in the near future.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees

INTRODUCTION

Pancreatoduodenectomy (PD) has always been regarded as one of the most technically demanding abdominal procedures, even when carried out in high-volume centers by experienced surgeons. The reduction in higher surgical trainees working hours has led to reduced exposure, and consequently less experience in operative procedures. Furthermore, trainees have also become victims as health care systems striving for operating room efficiency, have attempted to reduce procedure duration by encouraging consultant led procedures at the expense of training. A strategy therefore needs to be developed to match the ability of the trainee with the complexity of the surgical procedure. As a PD can be deconstructed into a number of different steps, it may indeed be an ideal training operation for varying levels of ability.

METHODS

We describe our technique for PD and break it down to nine steps of varying technical ability making it suitable for many different stages of surgical training.

RESULTS

The complexity and variety of steps required to perform a PD makes it an ideal training operation from the junior surgical trainee to the most senior fellow, allowing the development of a wide range of skill sets.

DISCUSSION

Since the introduction of reduced working hours (48 h per week in Europe and 80 h per week in the USA) the "apprenticeship" model of surgical training has shifted towards a time-limited program with greater emphasis on supervision. Due to the complexity of surgery, and the perception of diminished levels of trainees' competency, a PD is often viewed as a consultant level operation. We believe that PD is an excellent model as it provides opportunities for trainees with varying levels of operative experience so that a PD could be considered the ideal "teaching case". Breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients' safety and allowing the surgery to be expedited in a timely manner.

Face, content and construct validity of a new realistic trainer for conventional techniques in digestive surgery

PURPOSE

Surgical simulation modules for "open" surgery are limited in contrast to well-studied and validated laparoscopic trainers. In this study, face, content and construct validity of a devised simulation module (Berlin Operation Trainer, BOPT) for handsewn anastomoses in digestive surgery were analysed.

MATERIALS AND METHODS

Participants of a skills course for digestive surgery (novices: 1-3 years of training; experts: more than 5 years of training) were timed on performing four defined handsewn digestive anastomoses on formalin fixed porcine intestine in the BOPT. Questionnaires were answered regarding impression with the simulation module concerning appearance and realism using a five-point Likert and a three-point forced choice scale. Face and content validities were evaluated based on the responses of participants and construct validity by comparing novices to experts. Data collected were analysed with Fisher's exact test and two-sample t test.

RESULTS

Twenty-two novices (median: second postgraduate year) and 26 experts (median: seventh postgraduate year) were enrolled in the study. The BOPT showed strong face and content validities with average scores for satisfaction parameters above 4.2 +/- 0.41 and 4.1 +/- 0.22, respectively. Construct validity was adequate for anastomosis simulation in the BOPT based on different percentages of anastomosis complete during set time between novices and experts as shown for simple (68.2% vs. 92.3%, p = 0.038) and for difficult anastomosis (18.2% vs. 50.0%, p = 0.021).

CONCLUSIONS

The BOPT is a suitable instrument for advanced surgical training for novices and experienced colleagues creating a realistic and demanding situation. Further studies have to evaluate if a more realistic preoperative training will support an effective transfer of learned techniques to the operating room.

Development of a microsurgery training system

Surgeons require significant training to acquire sufficient dexterity and hand-eye coordination to manipulate objects skillfully under the microscope. This paper presents a computer-based real-time simulation of microsurgery as well as the hardware setup. It presents a realistic physics-based elastic suture and blood vessel model, fast collision detection techniques, suture insertion process and novel approach of a haptic forceps. The simulation environment demonstrates a complete vascular suturing system to train skills such as grasping, suture placement, needle insertion and knot-tying running at 500 Hz, sufficient for physical realism.

Vascular Anastomosis Model: Relation Between Competency in a Laboratory-based Model and Surgical Competency

BACKGROUND

Previously, we presented a new, laboratory-based, vascular anastomosis model as a tool to objectively quantify surgical skill. The purpose of the present study was to determine the relation between the outcomes of vascular anastomosis in the laboratory and technical competency, when performing similar vascular anastomoses, in the operating room.

MATERIALS AND METHODS

Twenty-nine resident surgeons-in-training participated in the present study. All residents had at least one previous laboratory training session using the vascular anastomosis model. Then residents had to create a forearm arterio-venous bridge graft in the operating room (OR). Three measures were used to assess technical competency in the OR: completion time of the graft to vein anatomosis, leakage grade across the anastomosis, and the mini-objective structured assessment of technical skills (MOSAT) score. Similar outcomes obtained in the laboratory were used as predictors of OR outcomes. Significant predictors were identified using multiple linear regression and multiple ordinal logistic regression modelling.

RESULTS

Worse leakage in the laboratory predicted worse leakage in the OR, longer completion time and worse MOSAT score in the OR. Longer completion time in the laboratory was associated with longer OR completion time, but less leakage. Higher year of training and greater laboratory exposure were related to higher MOSAT score and shorter completion time in the OR, respectively.

CONCLUSIONS

Completion time and grade of anastomosis leakage measured in the laboratory were predictive of technical competency in the OR. The vascular anastomosis model may be useful for training in clinical surgery.

Postoperative video debriefing reduces technical errors in laparoscopic surgery

BACKGROUND

Because of the learning curve required to master laparoscopic procedures, there is a growing concern that patient safety may be compromised due to technical errors by a novice surgeon. We evaluated the effect of videotape debriefing on the performance of a complex laparoscopic procedure.

METHODS

Twenty-four surgical residents performed a laparoscopic jejunojejunal anastomosis under the supervision of a single laparoscopic surgeon. All procedures were videotaped. Half of the residents underwent video debriefing. Videotapes were analyzed for knot-tying time, anastomotic time, and frequency of minor technical errors and adverse events. The performance of the debriefed group was compared with a non-debriefed group.

RESULTS

Knot-tying time, minor errors, and anastomotic time were similar between the debriefed and non-debriefed groups. However, adverse events from technical errors were more frequent in the non-debriefed group (chi2 = 7.647, P = .006).

CONCLUSIONS

Postoperative video debriefing is an effective educational tool for reducing adverse events during a complex laparoscopic procedure.

Objective surgical skill assessment: the diagonal operating matrix☆

There is an urgent need for structured surgical training and assessment due to the reduction in the training duration with the European Working Time Directive (EWTD). We propose a model for objective skill assessment, the PAR-Diagonal Operating Matrix (PAR-DOM) which breaks down the task of vascular anastomosis into clearly defined skills. The PAR-DOM is made up of a 3x5 table and progress is made along vectors defined on the x-axis as PAR and on the y-axis as four levels. PAR defines three skills at each level. Each skill is graded from 1-3 (this may be taken as below average, average, above average). The skills at various levels are: Level 0 - Posture, Address, Relaxation; Level 1 - Pick-up, Airtime, Rotation; Level 2 - Placing, Angles, Rhythm; Level 3 - Precision, Adaptability, Reproducibility; Level 4 - Pace, Awareness, Relations. The PAR-DOM matrix provides a graphic representation of the progress of trainees over their training period assigned for them to stay with the trainer and also help identify individual strengths and weaknesses.

Learning curve, surgical results and operative complications for kidney transplantation in mice

Murine transplant models of vascularized organs are very useful for immunobiological studies. However, the technique of kidney transplant is complex and very demanding. Here, results of the first successive 50 syngeneic transplantations performed by an experienced microsurgeon are reported. Complications and survival rates were recorded and analyzed over the different training phases. While the operative time and warm ischemia time dramatically reduced after 40 transplants (warm ischemia after 40 transplants 33.1+/-5.0 min vs. 55.2+/-4.6 min for the first 10 transplants, P<0.001), the average early vascular anastomosis patency rate markedly increased (80% vs. 10% in the first than transplants, P<0.01). Intraoperative failures were 56% (n=28), death during the first 7 days was 18% (n=9), and death after contralateral nephrectomy (>day 7) was 10% (n=5). Only 8% (n=4) of the animals survived long-term. Despite large experience with microsurgery, there is a relative long learning curve for mouse kidney transplantation.

A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents

BACKGROUND

Robotic surgery offers all the advantages of laparoscopy with additional increased accuracy. The use of robotic surgery has increased in the past 5 years. It has proven particularly useful in complex surgical procedures such as intracorporeal intestinal anastomosis. As the prevalence of robotic surgery increases, so will the need for residents to be able to perform surgery using the robotic system. Our goal was to compare hand-sewn, laparoscopic, and robotic suturing techniques performed by midlevel residents using a porcine intestinal model.

METHODS

Fifteen residents unfamiliar with the robotic suturing technique participated in performing an initial hand-sewn suture line and then were randomized with cross-over to laparoscopic or robotic suturing. Completion time, leak pressure, number of sutures per cm, and difficulty level were assessed.

RESULTS

The mean leak pressure for hand-sewn, laparoscopic, and robotic suturing was 9.5, 3.2, and 11.4 mm Hg, respectively. The laparoscopic group had 6 and the robotic group had 1 suture line that was inadequate for testing. Suture breakage was common in the robotic group. The anastomosis was considered hard by 92% in the laparoscopic group versus 17% in the robotic group. The time it took to complete 1 cm of anastomosis was .9, 8.7, and 8.3 minutes for hand-sewn, laparoscopic, and robotic suturing, respectively.

CONCLUSION

The robotic suture line performed by midlevel residents was superior to laparoscopy, although the time for anastomosis was equivalent.

A New Vascular Anastomosis Model: Relation between Outcome and Experience

BACKGROUND

Vascular anastomosis is a complex task that requires multiple skills. Existing training methods lack the ability to objectively quantify surgical skill. In this study we tested a new vascular anastomosis model for bench training.

MATERIALS AND METHODS

Surgical performance was assessed based on the new vascular anastomosis training model. Thirty- eight subjects were asked to (1) close the end of a 6-mm polytetrafluoroethylene (PTFE) graft, using a continuous suturing technique with 6-0 polypropylene; (2) perform end-to-end and (3) end-to-side anastomosis using the same materials and techniques.

RESULTS

The mean age (sd) of all participants was 28.3 (2.1) years. More surgically experienced trainees did better in all measures of technical skill. Although there was a tendency for those with previous experience with the training model to do better in terms of the technical outcomes, these differences were not statistically significant. Multivariable analysis revealed that level of surgical training and type of anastomosis were the only significant factors related to completion time.

CONCLUSIONS

Our study confirmed the impact of increasing surgical experience on the technical skills of surgical trainees. Trainees with higher levels of training made fewer errors and completed the procedures faster than those with lower levels of training.

Laboratory-based vascular anastomosis training: A randomized controlled trial evaluating the effects of bench model fidelity and level of training on skill acquisition

BACKGROUND

Although there is growing evidence that practice on bench model simulators can improve the acquisition of technical skill in surgery, the degree to which these models have to approximate real-world conditions (model fidelity) to optimize learning is unclear. Previous research suggests that low-fidelity models may be adequate for novice learners. The purpose of this study was to assess the effect of model fidelity and surgical expertise on the acquisition of vascular anastomosis skill.

METHODS

Twenty-seven surgical residents participated in this institutional review board-approved study. Junior residents (postgraduate year 1 and 2) and senior residents (postgraduate year 4 or higher) were randomized into two groups: low-fidelity (n = 13) and high-fidelity (n = 14) model training. Both groups were given a 3-hour hands-on training session: the low-fidelity group used plastic models, and the high-fidelity group used human cadaver arms (brachial arteries) to practice graft-to-arterial anastomosis. One week later, all subjects participated in an animal laboratory in which they performed a single vascular anastomosis on a live, anesthetized pig (femoral artery). A blinded vascular surgeon scored candidate performance in the animal laboratory by using previously validated end points, including a checklist and final product analysis score.

RESULTS

Acquisition of skill was significantly affected by model fidelity and level of training as measured by both the checklist (P = .03) and final product analysis (P = .01; Kruskal-Wallis). Specifically, junior residents practicing on high-fidelity models scored better on the checklist (P = .05) and final product analysis (P = .04). Senior residents practicing on high-fidelity models scored better on final product analysis (P < .05).

CONCLUSIONS

Training in the laboratory does improve skill when assessed in a realistic setting. Both expertise groups showed better skill transfer from the bench model to live animals when practicing on high-fidelity models. For vascular anastomosis, it is important to provide appropriate model fidelity for trainees of different abilities to optimize the effectiveness of bench model training.

Teaching intestinal transplantation in the rat for medical student

Technical difficulties hamper the widespread use of intestinal transplantation in rats. We evaluated the feasibility in training this microsurgical model for medical students. Thirty eight students were assessed. After information about intestinal transplantation in rats, they spontaneously agreed to be trained for this procedure. The course consisted of 4-h weekly lessons during 4-month period. The teaching process includes assessment in four phases: I) conception of intestinal transplantation and rat anatomy; II) basic microsurgery training; III) donor operation; IV) donor/recipient operation. Wistar rats were used as donors and recipients in one-step small bowel transplantation. All students (100%) reached phase II, seven students (18.42%) reached phase III and two students (5.26%) reached phase IV. Decreased interest about the theme, lack of time and patience, frustration and/or inability were all reasons given by the student that may have contributed to the low rate of success. Medical students achieved a low rate of completion for training in rat intestinal transplantation microsurgical procedures.

Microsurgery training card: a practical, economic tool for basic techniques

The Microsurgery Tranining Card is a useful, practical, economic, easily assembled and used device, and provides a valuable tool for basic microsurgical training, especially for residents and fellows in teaching programs.

Laparoscopic Urethrovesical Anastomosis: A Model to Assess Surgical Competency

PURPOSE

To create a model for the evaluation of resident competency and performance of laparoscopic skills in compliance with Accreditation Council for Graduate Medical Education (ACGME) outcome assessment guidelines for urology residency programs.

MATERIALS AND METHODS

A model of laparoscopic interrupted urethrovesical anastomosis was developed using chicken skin from a local supermarket. Eight residents at various training levels utilized a simulator with a camera-operating assistant to practice placing interrupted stitches. The time necessary for completion of an anastomosis and the quality of the anastomosis were documented.

RESULTS

The time required to recreate a simulated urethrovesical anastomosis by placing six interrupted stitches declined from an initial mean of 60.75 minutes to 20.5 minutes after each resident had performed 20 anastomoses each. The mean improvement was 39.5 minutes, with one postgraduate year-3 resident demonstrating an improvement of 50 minutes.

CONCLUSION

This model can be used by ACGME-certified urology residency programs to assess the laparoscopic skills of residents.

The surgical efficiency score: a feasible, reliable, and valid method of skills assessment

BACKGROUND

Technical skills assessments are being increasingly used in surgical residency programs, with the objectivity and validity of several techniques well established. However, many of these methods are labor and time intensive, limiting their feasibility. This study aims to compare more efficient techniques of skills appraisals with an established gold standard.

METHODS

Thirty surgeons completed 2 previously validated laboratory-based surgical models: small bowel anastomosis and vein patch insertion. Gold standard evaluation was the Objective Structured Assessment of Technical Skills (OSATS) method. "Efficient" techniques used were (1) quality of final product (FP); (2) snapshot assessment (SS), in which task performance was edited to a 2-minute sound bite and scored with OSATS; and (3) the surgical efficiency score (SES), a combination of final product quality and hand-motion analysis. All human observer evaluations used retrospective video analysis with 3 trained observers. Nonparametric tests were used to analyze the results.

RESULTS

With respect to small bowel anastomosis, correlations with OSATS were as follows: FP 0.341 (P=.07), SS 0.577 (P<.001), and SES 0.842 (P<.001). For vein patch insertion, the correlations were as follows: FP 0.545 (P=.001), SS 0.609 (P<.001), and SES 0.700 (P<.001). Interobserver concordance was high for both models with respect to FP (Cronbach's alpha 0.80 for small bowel anastomosis and 0.84 for vein patch insertion). With respect to SS, interobserver reliability was high for vein patch insertion (Cronbach's alpha 0.80) but only moderate for small bowel anastomosis (0.59).

CONCLUSIONS

The surgical efficiency score and snap shot assessments both show significant correlations with the traditional OSATS appraisals and suggest that skills assessment can be made more feasible. Correlations were closer with the former and interobserver concordance more variable with the latter, suggesting the surgical efficiency score as the most reliable of the methods evaluated.

Training protocol for feline renal transplantation, using rat vascular anastomosis

Renal transplantation (RTx) has been a potential treatment for renal failure in pet cats. We developed a training protocol for the microsurgical skills required for feline RTx using rat vessels, which are the same size as the feline renal artery and vein. Using interrupted sutures, the transected abdominal aorta was reestablished in an end-to-end fashion. Venous anastomosis was performed with a continuous running suture in an end-to-side fashion between the portal vein and inferior vena cava. In the arterial anastomotic model, technical errors were checked by postoperative hemorrhaging. Those failures in the venous anastomotic model, technical errors were confirmed by the rat's death. Histological examinations of the epithelialization at the anastomotic site were evaluated in both groups. After training, nine cases of feline RTx were performed safely, using an adequate microsurgical technique.

‘Surgical skills box’: a new training aid for surgical trainees

Introduction: Surgical trainees now receive less operating experience with the reduction in junior doctor hours.

Design: We designed a simple, portable, versatile ‘surgical skills box’ which allowed surgical trainees to practise vascular anastomosis, suturing, tonsil ties, hand ties and grommet insertion.

Discussion: With surgical trainees now receiving reduced operating experience it is more important than ever for them to practise their surgical skills outside the operating theatre environment.

Objective Assessment of Small Bowel Anastomosis Skill in Trainee General Surgeons and Urologists

INTRODUCTION

The object of this study was to compare the technical ability of general surgery and urology trainees to perform a small bowel anastomosis using a life-like bench model.

METHODS

Forty subjects were divided into two groups based on the stage of their training. Specialist registrars (SpRs) trained for 1 to 3 years were defined as junior SpRs, and those with 4 to 6 years of training were defined as senior SpRs. They were asked to perform a small bowel anastomosis on a standard latex model using the same equipment, suture material, and standardized instructions. Trainees were assessed by three trained observers based on a global rating scale.

RESULTS

Interrater reliability was 0.83 for the general surgical group and 0.88 for the urology group. The median scores obtained by the junior SpRs were lower than those achieved by the senior SpRs, and general surgical trainees consistently performed better than their matched urology group. This difference reached statistical significance for the senior group.

CONCLUSIONS

Global rating scores provide a reliable, valid method for assessing technical skills between specialties when performing a small bowel anastomosis. We provide reasons why general surgeons may be more proficient at this task than urologists. These findings have possible application to identifying trainees who need additional training and may also provide a mechanism to ensure competence in this task.

Do workshops improved the technical skill of vascular surgical trainees?

AIMS

Adjuncts to conventional surgical training are needed in order to address the reduction in working hours. This purpose of this study was to objectively assess the efficacy of workshop training on simulators.

METHODS

Fifteen consecutive participants of the European Vascular Workshop in 2003 and 2004 were recruited to this study. Participants performed a proximal anastomosis on a commercially available abdominal aortic aneurysm simulator, were then given intensive training on sophisticated models for 3 days and re-assessed. Pre- and post-course procedures were videotaped and independently reviewed by three assessors (tapes were blinded and in random order). The operative end product was similarly assessed. Four measures of technical skill were used: generic skill, procedural skill; a five point technical rating of the anastomosis (assessed using validated rating scales) and procedure time. Non-parametric tests were used in the statistical analysis.

RESULTS

The video assessment scores for aneurysm repair increased significantly following completion of the course (p=0.006 and p=0.004 for generic and procedural skill, respectively). End product assessment scores increased significantly post-course (p=0.001) and participants performed aneurysm repair faster following the course (p<0.05). Inter-observer reliability ranged from alpha=0.84-0.98 for the three rating scales pre- and post-course.

CONCLUSION

Objective improvements in technical performance follow intensive workshop training. Participants' perform better, faster, and with an improved end product following the course. Such adjuncts to training play an important part in a focused integrated programme that addresses reduced work hours.

Laparoscopic vascular anastomoses: does robotic (Zeus–Aesop) assistance help to overcome the learning curve?

BACKGROUND

Considerable training is necessary to master laparoscopic suturing and knot-tying. Robotic systems are assumed to facilitate these skills and shorten the learning curve. The effect of laparoscopic experience and robotic assistance on the learning curve of vascular anastomoses was studied.

METHODS

A laparoscopically experienced surgeon and a laparoscopically inexperienced surgeon made alternating laparoscopic vascular anastomoses and robot-assisted laparoscopic vascular anastomoses using a Zeus-Aesop surgical robotic system with various prosthetic conduits and suture materials in a laparoscopic training box.

RESULTS

Neither laparoscopic method influenced the quality score or leakage rate, but with laparoscopic experience, significantly fewer failures were made. Suturing and knot-tying were faster with laparoscopic experience both with and without the robotic system, and fewer stitch actions and knot actions were performed. The learning curves of both surgeons were not improved by the robotic system.

CONCLUSIONS

Experience is the most important factor in the performance of laparoscopic vascular anastomoses. The robotic system was not helpful in shortening the learning curve.