Abstract Background The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the ...operating room (OR). Methods Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores ≤15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status. Results Sixteen residents completed the study. There were no differences in baseline simulator (49.1 ± 17 vs 39.5 ± 16, P = .27) or OR scores (11.3 ± 2.0 vs 12.0 ± 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 ± 4 vs 60.5 ± 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 ± 2.2 ( P = .04), whereas the trained group improved by 6.1 to 17.4 ± 1.9 ( P = .0005 vs control; P < .0001 vs baseline). Conclusions This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.
Background
Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and ...to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care.
Methods
Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period. The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began. The primary outcome was functional walking capacity (6-min walk test 6MWT). The secondary outcomes included self-reported physical activity (CHAMPS questionnaire) and health-related quality of life (SF-36). Data are expressed as mean ± standard deviation or median (interquartile range IQR) and were analyzed using Chi-square and Student’s
t
test. All
p
values lower than 0.05 were considered significant.
Results
The prehabilitation and control groups were comparable in terms of age, gender, body mass index (BMI) and American Society of Anesthesiology (ASA) class. There was no difference in walking capacity at the first assessment (6MWT distance, 422 ± 87 vs 402 ± 57 m;
p
= 0.21). During the prehabilitation period lasting a median of 33 days (range, 21–46 days), functional walking capacity improved by 40 ± 40 m (
p
< 0.01). The postoperative complication rates and the hospital length of stay were similar. The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks (mean difference, 51.5 ± 93 m;
p
= 0.01) and 8 weeks (mean difference, 84.5 ± 83 m;
p
< 0.01). At 8 weeks, 81 % of the prehabilitated patients were recovered compared with 40 % of the control group (
p
< 0.01). The prehabilitation group also reported higher levels of physical activity before and after surgery.
Conclusion
In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).
Pilot studies have indicated that peroral endoscopic myotomy (POEM) might be a safe and effective treatment for achalasia. We performed a prospective, international, multicenter study to determine ...the outcomes of 70 patients who underwent POEM at 5 centers in Europe and North America. Three months after POEM, 97% of patients were in symptom remission (95% confidence interval, 89%–99%); symptom scores were reduced from 7 to 1 ( P < .001) and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg ( P < .001). The percentage of patients in symptom remission at 6 and 12 months was 89% and 82%, respectively. POEM was found to be an effective treatment for achalasia after a mean follow-up period of 10 months. Clinical Trials Gov Registration number: NCT01405417.
Background
Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during ...COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR).
Methods
In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2–3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired
t
-test was used to compare scores between the three assessment points.
Results
Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (
p
< 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (
p
< 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (
p
< 0.018) and A2(18 ± 4) (
p
< 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training.
Conclusion
The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.
To assess the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) physical laparoscopic simulator for construct and predictive validity and for its educational ...utility.
MISTELS is the physical simulator incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in their Fundamentals of Laparoscopic Surgery (FLS) program. MISTELS' metrics have been shown to have high interrater and test-retest reliability and to correlate with skill in animal surgery.
Over 200 surgeons and trainees from 5 countries were assessed using MISTELS in a series of experiments to assess the validity of the system and to evaluate whether practicing MISTELS basic skills (transferring) would result in skill acquisition transferable to complex laparoscopic tasks (suturing).
Face validity was confirmed through questioning 44 experienced laparoscopic surgeons using global rating scales. MISTELS scores increased progressively with increasing laparoscopic experience (n = 215, P < 0.0001), and residents followed over time improved their scores (n = 24, P < 0.0001), evidence of construct validity. Results in the host institution did not differ from 5 beta sites (n = 215, external validity). MISTELS scores correlated with a highly reliable validated intraoperative rating of technical skill during laparoscopic cholecystectomy (n = 19, r = 0.81, P < 0.0004; concurrent validity). Novice laparoscopists were randomized to practice/no practice of the transfer drill for 4 weeks. Improvement in intracorporeal suturing skill was significantly related to practice but not to baseline ability, career goals, or gender (P < 0.001).
MISTELS is a practical and inexpensive inanimate system developed to teach and measure technical skills in laparoscopy. This system is reliable, valid, and a useful educational tool.
OBJECTIVE:To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance.
...BACKGROUND:Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective—more task rather than procedure-oriented—and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety.
METHODS:Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items.
RESULTS:A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identifiedpsychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals.
CONCLUSIONS:This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.
Background
Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be ...competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted.
Methods
A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included “laparoscopic suturing” and “clinical competence.”
Results
Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies.
Conclusion
We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.
Background Endoscopic full-thickness resection (eFTR) is a minimally invasive method for en bloc resection of GI lesions. Objective The aim of this pilot study was to evaluate the feasibility of a ...grasp-and-snare technique for eFTR combined with an over-the-scope clip (OTSC) for defect closure. Design Nonsurvival animal study. Setting Animal laboratory. Animals Fourteen female domestic pigs. Interventions The eFTR was performed in porcine colons using a novel tissue anchor in combination with a standard monofilament snare and 14 mm OTSC. In the first group (n = 20), closure of the colonic defects with OTSC was attempted after the resection. In the second group (n = 8), an endoloop was used to secure the resection base before eFTR was performed. Results In the first group (n = 20), eFTR specimens ranged from 2.4 to 5.5 cm in diameter. Successful closure was achieved in 9 out of 20 cases. Mean burst pressure for OTSC closure was 29.2 mm Hg (range, 2-90; SD, 29.92). Injury to adjacent organs occurred in 3 cases. Lumen obstruction due to the OTSC closure occurred in 3 cases. In the second group (n = 8), the diameter of specimens ranged from 1.2 to 2.2 cm. Complete closure was achieved in all cases, with a mean burst pressure of 76.6 mm Hg (range, 35-120; SD, 31). Lumen obstruction due to the endoloop closure occurred in one case. No other complications or injuries were observed in the second group. Limitations Nonsurvival setting. Conclusions Colonic eFTR using the grasp-and-snare technique is feasible in an animal model. Ligation of the resection base with an endoloop before eFTR seems to reduce complication rates and improve closure success and leak test results despite yielding smaller specimens.
Background
The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to ...report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee.
Methods
A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate.
Results
A total of 7232 FLS tests were analyzed 64% male, 6.4% junior (postgraduate year—PGY1–2), 84% senior (PGY3–5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7). Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2–2.8) times higher than that of a PGY1–2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach’s alpha dropped to between 0.65 and 0.71, depending on the task being removed.
Conclusion
The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.
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