Reworking protocols of ophthalmic resident surgical training in the COVID-19 era – Experiences of a tertiary care institute in northern India

Purpose:Coronavirus Disease 2019 (COVID-19) pandemic has negatively impacted medical professionals in all fields of medicine and surgery in their academic, clinical and surgical training. The impact of surgical training has been described as ‘severe’ by most ophthalmology residents worldwide due to their duties in COVID-19 wards, disruption of outpatient and camp services.Methods:Ophthalmic surgery demands utmost accuracy and meticulousness. Fine motor proficiencies, stereoscopic skills and hand–eye coordination required can only be achieved by practice. So, a multileveled structured wet-lab teaching schedule was prepared for the residents and implemented to bridge this gap between theory and practice at our tertiary care institute. A semester-wise training schedule was made with the proper distribution of wet-lab and simulator training. Surgeries like phacoemulsification, scleral buckling, pars plana lensectomy and vitrectomy, trabeculectomy and intravitreal injections were practised by the residents on the goat eyes. Simulator training was provided for phacoemulsification and vitrectomy to increase the hand–eye coordination of the residents.Results:Residents noticed improvement in their surgical skills and ambidexterity post wet-lab and simulator training . It also increased their confidence and provided essential surgical skills required to be used in the operation theater later.Conclusion:It is imperative that wet-lab training be included in the residency training programme in this COVID-19 era.     

虚拟-现实手术模拟系统在眼科住院医师微创白内障手术培训中的应用效果

目的：探讨虚拟-现实手术操作训练在眼科住院医师微创白内障手术技能培训中的应用及效果。

方法：前瞻性对照研究。选取2019/2021年在南京医科大学附属眼科医院已完成3a住院医师规范化培训的20名年资相同的眼科住院医师为研究对象,通过理论考核后随机分为虚拟-现实手术操作训练(Dry-lab)组和实体动物手术操作训练(Wet-lab)组,每组各10名。Dry-lab组和Wet-lab组医师分别使用Eye SI虚拟手术模拟器和猪眼进行训练。训练结束后使用Eye SI虚拟手术模拟器和实体猪眼操作对两组住院医师的总体培训效果进行评分,使用虚拟手术模拟器对两组住院医师的模块培训效果进行评分,并采用问卷调查对两种培训方式进行客观评价。

结果：Dry-lab组医师两项操作考核总评分、模拟器考核评分、实体猪眼操作考核评分均显著高于Wet-lab组(88.03±1.34分 vs 80.35±2.87分,87.50±3.03分 vs 77.60±5.62分,88.57±1.89分 vs 83.10±3.22分,均P<0.01)。模拟器模块考核结果显示,Dry-lab组医师各模块考核评分及用时均显著优于Wet-lab组(P<0.01)。问卷调查结果显示,在培训新颖性、是否贴近真实手术体验、对显微手术技能提高的帮助程度、经过该培训是否有信心进行真实手术及手术培训的整体满意度方面,Dry-lab组医师对于培训方式的效果评价均优于Wet-lab组(P<0.05)。

结论：将虚拟-现实手术操作训练应用于眼科住院医师白内障手术技能培训可以显著提升住院医师的白内障显微手术操作技能,提高培训整体满意度,帮助住院医师在执业初期提升真实手术时的信心、心理素质、决策及处理能力,为建立眼科住院医师正式、规范化的白内障手术培训体系提供了新的标准和模式。     

Impact of simulator training on resident cataract surgery

Background

Virtual reality surgery simulation training improves resident performance as measured by the simulator itself and wet-lab performance. This study aims to determine whether virtual surgery simulator training improves actual resident cataract surgery performance.

Methods

The first 50 phacoemulsification cases of 20 residents, at a single residency program (Henry Ford Hospital), were retrospectively compared as two groups: before (2007–8) and after (2009–10) introduction of the Eyesi virtual surgery simulator to the surgical training program. Primary outcomes were the incidence of posterior capsule tears and operation duration. All residents received traditional didactic and wet-lab training. Instructor surgeons were surveyed for their impression of the simulator’s contribution to resident surgical training.

Results

The nonsimulator and simulator groups each comprised 500 cases with 40 and 35 posterior capsule tears respectively. Capsular tear rates for the nonsimulator and simulator groups were 8.8 % and 10 % respectively for the first 25 cases, and 7.2 % and 3.6 % (P?=?0.11) respectively for cases 26 through 50 . The percentage of long cases (defined as >40 min) for cases 10 through 50 was 42.3 % and 32.4 % (P?=?0.005) for the nonsimulator and simulator groups respectively.

Conclusions

Virtual reality surgical simulator training mildly shortens the learning curve for the first 50 phacoemulsification cases. The less adept residents appear to benefit most.     

Virtual reality in ophthalmology training

Current training models are limited by an unstructured curriculum, financial costs, human costs, and time constraints. With the newly mandated resident surgical competency, training programs are struggling to find viable methods of assessing and documenting the surgical skills of trainees. Virtual-reality technologies have been used for decades in flight simulation to train and assess competency, and there has been a recent push in surgical specialties to incorporate virtual-reality simulation into residency programs. These efforts have culminated in an FDA-approved carotid stenting simulator. What role virtual reality will play in the evolution of ophthalmology surgical curriculum is uncertain. The current apprentice system has served the art of surgery for over 100 years, and we foresee virtual reality working synergistically with our current curriculum modalities to streamline and enhance the resident's learning experience.     

Entrenamiento quirúrgico con fantomas en cirugía de estrabismo

Background and purposeSimulation in surgical learning responds to ethical and pragmatic needs. Our purpose is to describe the effects on surgical skills of conducting a surgical training workshop on strabismus surgery with phantoms. Concern for patient safety makes it necessary to consider the use of simulators (virtual and three-dimensional physical) and animal models that allow the applicant to safely practice the procedures before facing a real case.Material and methodsRealization of a workshop with previous theoretical content and real practice with phantoms designed to simulate strabismus surgery (eyeball, six muscles, conjunctiva, eyelid and Tenon capsule inserted in the skull) of real anatomical dimensions. Satisfaction survey and subjective evaluation of learning by the student and the expert tutor according to the Kirkpatrick evaluation model.Results100% of the 26 students attending two courses (15 students in one course and 11 students in another course) and 100% of the three tutors who participated in both courses completed the survey. Twenty were resident doctors and 20 specialists in ophthalmology. The overall satisfaction of the students was 8.2 (± 0.68).ConclusionsAccording to the results of the Kirkpatrick training actions evaluation survey, the perception of students and tutors is that training with phantoms in strabismus surgery can help improve the skills necessary for safe and independent practice. The ultimate goal being to improve patient safety.     

A review of teaching methods and outcomes of resident phacoemulsification

Cataract surgery with phacoemulsification is a challenging procedure for surgeons in training to learn to perform safely, efficiently, and effectively. We review the auxiliary learning tools outside the operating room that residency programs have incorporated into their curriculum to improve surgical skills, including wet laboratory and surgical simulators. We then discuss different methods of teaching cataract surgery in the operating room. Our goal is to define a learning curve for cataract surgery. We demonstrate that complication rates decline significantly after a resident performs an average of 70 cases. We summarize the reported incidence and risk factors for complications in resident-performed cataract surgery to help identify cases that require a higher level of skill to improve visual outcomes. We suggest that future studies include details on preoperative comorbidities, risk stratification, resident skill level, and frequency of takeover by attending.     

Impact of a structured training program to enhance skills in phacoemulsification surgery

Purpose:The aim of this study was to determine whether the introduction of a structured short-term phacoemulsification training program improved the ICO-OSCAR (International Council of Ophthalmology’s Ophthalmology Surgical Competency Assessment Rubric) score and the learning curve of the trainees and decreased the complication rates of the cases.Methods:This study was a retrospective, observational study conducted in a tertiary eye care hospital in India. The study was conducted from March 2018 to October 2019 based on a structured phacoemulsification training program introduced in January 2019. The trainees enrolled in the phacoemulsification training program were divided into two groups: Group 1 (n = 33), who underwent training before the introduction of the structured program, and Group 2 (n = 29), who underwent the training after the introduction of the structured training program. Each trainee performed 20 cases. Group 1 training consisted of wet-lab and phacoemulsification surgeries. Group 2 training program comprised three modules over 5 weeks and a preassessment examination. Premodule 1 imparted cognitive skills; Module 1 was on structured wet-lab, Module 2 was about phacoemulsification step surgery, and Module 3 had independent complete surgeries. Group 2 also underwent compulsory Observation of cases being performed in the operation theater, surgical video recording review, and formative feedback. Mean OSCAR score comparison was done for both the groups. The OSCAR score was also calculated case-wise to obtain the learning curve with respect to the entry and exit levels, by classifying the trainees in each group as Novice, Beginner, Advanced Beginner, or Competent. A comparison of the posterior capsular rupture (PCR) rates and vision at discharge of all the cases was done.Results:Group 2 had a significantly better mean OSCAR score than Group 1 (4.03 and 3.43, respectively; P < 0.001). The PCR rate of the cases was significantly lower in Group 2 than in Group 1 (9.14% and 20.30%, respectively; P < 0.001). Group 2 had a significantly better visual acuity outcome of the cases than Group 1. Group 1 started as Novice (OSCAR score: 2), whereas Group 2 started as Beginner (OSCAR score: 3). Group 2 reached the Advanced Beginner level eight to 10 cases prior to Group 1.Conclusion:A structured training curriculum can make a significant difference in the training experience of the trainees and enable better surgical outcomes and a decrease in the complication rates.     

Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort

Background: It is unclear whether differences exist in surgical complication rates and long‐term visual acuity outcomes between patients whose phacoemulsification cataract surgery was performed by ophthalmological trainees and those performed by consultants. Design: Prospective clinical cohort study. Participants: 1851 participants of the Cataract Surgery and Age‐related Macular Degeneration study, aged ≥64 years, had cataract surgery performed at Westmead Hospital, Sydney. Methods: Surgical complication rates and visual acuity at 24‐month postoperative visits were compared between patients who were operated on by trainees and those operated on by consultants. Main Outcome Measures: Surgical outcomes included operative complications recorded in surgical audit forms and 24‐month postoperative visual acuity. Results: Of 1851 patients, 1274 (68.8%) were reviewed 24 months after surgery. Of these, 976 had data on the type of surgeon who performed the operation. After excluding 152 challenging cases and three cases operated on by first‐year trainees at the beginning of their training, 821 patients were included in this study, of those, 498 were operated on by trainees and 323 by consultants. Habitual visual acuity ≥6/12 was achieved in 77.3% (n = 385/498) and 74.3% (n = 240/323), respectively, of the two groups of patients 24 months postoperatively. Of 514 patients who had surgical audit data, the major complication rate was numerically greater, but not significantly different for the 330 trainee‐operated (6.1%) patients, compared with the 184 consultant‐operated patients (2.7%, P = 0.091). Conclusions: We found relatively comparable complication rates and visual outcomes after 2 years between patients operated on by ophthalmological trainees and those by consultants, in a cataract surgical cohort at Westmead Hospital.     

Intensive cataract training: a novel approach

Purpose

To evaluate the safety of an intensive cataract surgery training programme.

Methods

An intensive cataract surgery training programme was implemented in August 2010 for year 3 ophthalmology trainees in the East Midlands Deanery North Rotation (United Kingdom). Trainees participated in extra-ocular surgery and 50 h of virtual reality cataract surgery simulator training over a 2-year period. Their third year comprised 6 months of intensive phacoemulsification training in a tertiary centre followed by a 6-month period of consolidation in a district general hospital. The complication rates and case numbers were evaluated after the first 2 years of implementation.

Results

At 2 years, three trainees had completed a full year of intensive training. In the first 6 months of training, Trainee 1 completed 156 cases, Trainee 2 completed 194 cases, and Trainee 3 completed 151 full cases as primary surgeons with an average rate of posterior capsule rupture (PCR) of 1%. At 12 months, Trainee 1 completed 291, Trainee 2 completed 318, and Trainee 3 completed 294 cases, with an average PCR rate of 0.66%. The trainees required 84 lists on average to complete 150 full cataract procedures.

Conclusion

The combination of simulation and the new intensive training programme is safer than the traditional programme for cataract surgery training.     

A simple do-it-yourself model of phacoemulsification for resident training

COVID-19 has immensely affected the training of ophthalmology residents; wet-lab training thus becomes of utmost importance. A simple cost-effective model for cataract surgery training of residents becomes the need of this hour. Hence, we aim to describe a new ‘Do It Yourself’ model with easily available material for beginners.     

Efficacy of wet-lab training versus surgical-simulator training on performance of ophthalmology residents during chopping in cataract surgery

AIM: To analyze whether wet-lab training(WLT) or surgical-simulator training(SST) is better for ophthalmology residents to master the chopping technique.METHODS: Sixty ophthalmology residents(in their second year) and three cataract surgeons participated in the study. The residents were randomly separated into two groups, WLT group and SST group. The residents in WLT group were asked to perform 10 trials of chopping using pig eyes and scored by the surgeons, and then they performed and scored using simulator for one time. The residents in SST group underwent 10 trials of chopping using simulator, and the simulator scored each trail. Then, this group were asked to perform the chopping using pig eyes and scored by the surgeons. At last, we investigated the residents’ satisfaction about the training.RESULTS: The demographic characteristics had no significant differences between the two groups. Recorded by the simulator, the residents in SST group got significantly higher overall score(83.90±1.31) than WLT group(78.73±1.92, P=0.03). And the residents in SST group got less corner area injured, and they spend less time than WLT group(P<0.05). Moreover, the residents in WLT group used more ultrasonic energy value than SST group(P=0.03). However, scored by the surgeons, the residents in two groups got nearly the same overall score. The residents in WLT group performed better on the frequencies of posterior capsule torn and incisional stress(P=0.03, 0.008, respectively). In the survey, the residents in two groups held the same opinion that the training was helpful and they strongly recommended this training. And all of them enjoyed the training, and enjoyed being randomized in their own group. However, with respect to the realistic character, the residents thought that WLT was better than SST(P<0.001).CONCLUSION: Both of the Eyesi surgical-stimulator and the wet-lab improve the residents’ chopping ability and each has its own advantages. The combination of the two training ways could be considered to be a part of the training curriculum for new residents.     

Attitudes to research and research training among ophthalmologists and ophthalmology trainees in New Zealand

Purpose: To determine the attitudes to research and research training among ophthalmologists and ophthalmology trainees in New Zealand. Methods: A structured, self‐administered questionnaire was devised and after preliminary validation a postal survey was sent to all ophthalmologists and ophthalmology registrars and fellows in New Zealand. Results: A total of 82 replies were received from 115 questionnaires sent out; a response rate of 71.3%. An overwhelming majority found research to have benefited their education, clinical practice and career; 67.1% of the respondents intended to do research in the future. Although a majority (56.4%) felt research to be beneficial to ophthalmology training, 42.3% felt research would be of limited or no benefit when selecting candidates for vocational training. However, 97.5% of respondents felt that ophthalmology trainees should undertake some form of research during training, with most supporting small studies or case reports (44.4%) or a short structured training course in research (42.0%). Interestingly, 86.6% felt that research methodology and data analysis should be taught in a structured fashion with most supporting courses or seminars of a few weeks duration during the vocational training period. Many ophthalmologists felt inadequately equipped or trained to mentor and supervise trainees undertaking research and 41.5% of consultant ophthalmologists felt further training to fulfil this role would be beneficial. Conclusions: This survey suggests that New Zealand ophthalmologists generally approve of and support a place for research, possibly of a more structured design, during ophthalmology training.     

Virtual reality training improves wet-lab performance of capsulorhexis: results of a randomized,controlled study

Purpose  To investigate, whether capsulorhexis training on the EYESi surgical simulator improves wet-lab operating performance of surgical novices. Methods  Randomized, masked experimental study. Thirty-one medical students and 32 ophthalmological residents were randomized to either virtual reality (VR) training, or control. Initially and after 3 weeks each participant performed three capsulorhexis tasks in a porcine wet-lab. In between, participants from the VR training groups completed two training trials on the EYESi surgical simulator (VRmagic, Mannheim, Germany). VR training consisted of basic skill tasks and capsulorhexis tasks of increasing difficulty, and preset performance goals had to be reached for each task. All wet-lab procedures (n = 372) were recorded on DVD, and assessed by a masked observer. Each wet-lab capsulorhexis was evaluated with regard to five criteria (circularity, size, centering, time, tissue protection) using a predefined scoring system with a maximum overall score of 10 points (2 per criterion). The primary outcome measure was the intra-individual difference in the average overall performance score between the first and second wet-lab capsulorhexis procedures. Ten operation videos were additionally assessed by three further investigators to determine interobserver agreement. Results  Inter-observer agreement regarding the overall performance score was high (ICC = 0.91). Compared to control groups, VR-trained students and residents showed significant improvement in their median wet-lab capsulorhexis overall performance score compared to controls (+3.67 vs +0.33 points, P = 0.001 and +3.33 vs ±0.00 points, P < 0.0001). The capsulorhexis performance of VR-trained students and residents was also more consistent with a lower standard deviation of scores compared to controls (SD 1.3 vs 2.1 and 1.2 vs 1.7 points respectively). Conclusions  Structured capsulorhexis training on the EYESi to reach specific target criteria significantly improved wet-lab capsulorhexis performance. Data was presented at DOG 2008, Berlin, Germany. Financial support: VRmagic GmbH, Mannheim, Germany. The sponsor had no role in the design or conduct of this research. No conflicting relationship exists for any author. The authors have full control of all primary data, and agree to allow Graefe's Archive for Clinical and Experimental Ophthalmology to review their data upon request.     

Performance in the Duke-Elder ophthalmology undergraduate prize examination and future careers in ophthalmology

Aims

Cognitive factors (eg, academic achievement) have had a significant role in selecting postgraduate surgical trainees in the past. This project sought to determine the role of a national undergraduate ophthalmology prize examination (Duke–Elder examination) in the selection of postgraduate ophthalmology trainees. This would also serve as a quality assurance exercise for the assessment, in which the ultimate aim is to encourage trainees into ophthalmology.

Methods

A retrospective analysis of the top 20 ranked candidates in the Duke–Elder examination from 1989 to 2005 (except 1995) was carried out to determine which of them subsequently entered the ophthalmic training and General Medical Council Specialist Registers.

Results

Out of the top 20 candidates in the exam, 29.5% went into specialist training in ophthalmology. Some appeared in the top 20 more than once, with 56% of them going into ophthalmic training, but they had a similar median time to enter training as those who appeared in the top 20 once. There was no significant evidence to suggest that the overall median ranking scores between the UK medical schools differed (P=0.23; Kruskal–Wallis test). However, there was a marked difference in frequency of top 20 candidates from each medical school, which could not be explained by the size of the medical school alone.

Conclusion

It is difficult to conclude from these findings the importance that the Duke–Elder examination has in the selection of trainees into ophthalmology. The role of cognitive factors in selection into postgraduate medical/surgical training is discussed, along with the potential academic criteria, which may influence interview scores.     

Animal and cadaver human eyes for residents’ surgical training in ophthalmology

In ophthalmology residency programs surgical training plays a vital role in creating confident and skillful surgeons. As almost all ophthalmic surgery needs microscope training, creating a well-taught environment for hand-eye coordination, ocular tissue handling, and anticipation of complications is essential. Wet lab training with animal or cadaver human eyes offers diverse possibilities. We conducted a thorough literature search on various databases to identify the existing literature on wet labs. The results revealed constructive efforts for training novice surgeons in all surgical ophthalmology subspecialties. Wet lab models were initially used only to practice cataract surgery; however, now various complex ocular procedures can be practiced. Ocular surface, corneal, iris, lenticular, scleral, vitreoretinal, extraocular, eyelid, and other adnexal surgeries were reproduced and mastered in many ways. Importantly, with repeated surgical practice, residents gained an increasing level of confidence with enhanced surgical accuracy. In addition, we propose a few novel techniques of various other procedures.     

Redrawing vitreoretinal surgical training program in the COVID-19 era: Experiences of a tertiary care institute in North India

Purpose:The COVID-19 pandemic has brought medical and surgical training to a standstill across the medical sub-specialties. Closure of outpatient services and postponement of elective surgical procedures have dried up opportunities for training vitreoretinal trainees across the country. This “loss” has adversely impacted trainees’ morale and mental health, leading to feelings of uncertainty and anxiety. Therefore, there is an urgent need to redraw the surgical training program. We aimed to describe a systematic stepwise approach to vitreoretinal surgical training.Methods:We introduced a three-pronged approach to vitreoretinal surgical training comprising learn from home, wet lab and simulator training, and hands-on transfer of surgical skills in the operating room in our institute.Results:Encouraging results were obtained as evaluated by feedback from the trainees about the usefulness of this three-pronged approach in developing surgical skills and building their confidence.Conclusion:The disruption caused by the COVID-19 global pandemic should be used as an opportunity to evolve and reformulate surgical training programs to produce competent vitreoretinal surgeons of the future.     

Essentials of setting up a wet lab for ophthalmic surgical training in COVID-19 pandemic

Wet labs are an extremely important training tool, especially in times of a global COVID-19 pandemic, where surgical training can be minimal. They help the trainee learn and practice in a risk-free environment, without an imminent of a complication or failure, also allowing them the chance to execute the steps of a surgery repeatedly. We summarize all the key ingredients required from setting up a wet lab to improve the surgical skill of the trainees. The review also discusses various eyeball fixating devices, preparation of the eye for various types of ocular surgeries, and the role of simulation-based training in today''s scenario.     

Adoption of newer teaching methods to overcome challenges of training in ophthalmology residency during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has disrupted training programs across all specialties. Surgical specialties, such as ophthalmology, that need continued microsurgical training are affected the most. The pandemic has resulted in ophthalmology residents being taken off their regular duties in ophthalmology and inducted into COVID duties. The focus on COVID care has de-emphasized training in ophthalmology. We highlight the challenges that teachers face in continuing the training programs of theory, clinical skill, and surgical skill transfer. Embracing technology is the need of the hour. We discuss the multiple options available to enable continued training programs and emphasize the need for all training institutes to include technology as an additional component of their training curricula.     

年轻眼科医师基于手术模拟器的小切口白内障囊外摘除手术培训的有效性评估

目的：探讨基于手术模拟器操作训练在眼科年轻医师小切口白内障囊外摘除手术培训的有效性评估。方法：前瞻性对照研究。选取2020/2022年在沈阳何氏眼科医院已完成至少3a住院医师规范化培训的眼科专业住院医师或刚取得主治证书的眼科主治医师共48名为研究对象,通过小切口白内障囊外摘除手术相关理论培训及考核后,随机分为模拟器手术操作训练组(试验组)和实体动物眼手术操作训练组(对照组),每组各24名。试验组和对照组医师分别使用手术模拟器和猪眼进行训练。训练结束后使用手术模拟器和实体猪眼操作对两组研究对象进行考核评分,并对两组医师的总体培训效果进行有效性评估。结果：手术模拟器考核评分及用时比较,试验组研究对象在各步骤考核用时均低于对照组(均P&#x003C;0.05)。试验组研究对象在角膜穿刺注入黏弹剂、娩核及水密角膜穿刺口操作评分与对照组比较均无差异(P&#x003E;0.05),其余步骤评分,试验组均高于对照组(均P&#x003C;0.05)。实体动物眼考核评分,试验组研究对象各步骤考核评分均高于对照组(均P&#x003C;0.05)。试验组研究对象在巩膜切口、角巩膜隧道、连续环形撕囊、水分离及转核至前房、娩核步骤手术模拟器与实体动物眼考核评分比较均无差异(P=0.068、0.126、0.960、0.520、0.206); 在穿刺注入黏弹剂、隧道穿刺进入前房及水密角膜穿刺口考核中,模拟器评分均低于实体动物眼(P=0.007、0.014、&#x003C;0.01); 在皮质吸除、人工晶状体植入操作考核时模拟器评分要高于实体动物眼操作评分(P=0.035、&#x003C;0.01)。结论：将手术模拟器操作训练应用于眼科年轻医师小切口白内障囊外摘除手术技能培训,可以显著提升医师的白内障显微手术操作技能,为建立眼科年轻医师规范化的白内障手术培训提供了新的模式及思路。     

Using endoscopy to teach cataract surgery

Current methods of teaching cataract surgery include lectures, wet-lab sessions, and participation in real surgery. We describe a new method using a microendoscopic cyclophotocoagulation device during phacoemulsification cataract extraction and posterior chamber intraocular lens (IOL) implantation in 4 eyes of 4 patients. Endoscopic visualization during surgery aided in construction of the corneal incision, location of the capsulorhexis edge, and estimation of the lens groove depth. It also demonstrated clinical findings not observable with the surgical microscope such as misplaced IOL haptics and residual lens cortex. Use of the endoscope enhanced the educational value of the surgery and the final surgical outcome.