An Objective Evaluation of a Multi-Component, Competitive, Selection Process for Admitting Surgeons into Higher Surgical Training in a National Setting

Background

Changing work practices make it imperative that surgery selects candidates for training who demonstrate the spectrum of abilities that best facilitate learning and development of attributes that, by the end of their training, approximate the characteristics of a consultant surgeon.

Aims

The aim of our study was to determine the relative merits of components of a program used for competitive selection of trainees into higher surgical training (HST) in general surgery.

Methods

Applicants (N = 98, males 69, mean age 31 years [range 29–40]) to the Royal College of Surgeons in Ireland program for HST in general surgery between 2006 and 2008 were assessed. Clinical, basic surgical training, logbook, research performance, and reference scores were evaluated. A total of 51 candidates were shortlisted and completed a further objective assessment of their technical skills and interview performances.

Results

Shortlisted candidates performed better (p < 0.003) on all assessed parameters. Compared with candidates who were not selected for HST, those who were selected (N = 31) significantly outperformed on individual assessments and overall (p < 0.0001). Logistic regression analysis showed that clinical, technical skills, and research assessments, but not interview, predicted (92.2 %) HST selection outcomes.

Conclusions

Candidates selected for the national HST program in Ireland consistently outperformed those who were not. The assessments reliably and consistently distinguished between candidates, and all of the assessed parameters (except interview) contributed to a highly predictive selection model. This is the largest reported dataset from an objective, transparent, and fair assessment program for selection of the next generation of surgeons.     

Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?

Background

Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel.

Methods

Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ² analysis.

Results

The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73 % compliance), 83 completed the baseline skills assessment, and 27 (33 %) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (n = 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (p < 0.0001). One surgeon (1.3 %) failed the skills certification, and nine (11.8 %) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34 % compliance). All achieved proficiency at skills, and 60 % passed the cognitive exam.

Conclusions

This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33 % and a certification failure rate of 13 % suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.     

Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial

Background

Several studies have demonstrated skills transfer after virtual reality (VR) simulation training in laparoscopic surgery. However, the impact of VR simulation training on transfer of skills related to laparoscopic colectomy remains not investigated. The present study aimed at determining the impact of VR simulation warm-up on performance during laparoscopic colectomy in the porcine model.

Methods

Fourteen residents naive to laparoscopic colectomy as surgeons were randomly assigned in block to two groups. Seven trainees completed a 2-h VR simulator training in the laparoscopic sigmoid colectomy module (study group). The remaining seven surgeons (control group) underwent no intervention. On the same day, all participants performed a sigmoid colectomy with anastomosis on a pig. All operations were video recorded. Two board-certified expert colorectal surgeons independently assessed performance during the colectomy on the swine. Examiners were blinded to group assignment. The two examiners used a previously validated clinical instrument specific to laparoscopic colectomy. The primary outcome was the generic and specific skills score values.

Results

Surgeons undergoing short-duration training on the VR simulator performed significantly better during laparoscopic colectomy on the pig regarding general and specific technical skills evaluation. The average score of generic skills was 17.2 (16.5–18) for the control group and 20.1 (16.5–22) for the study group (p = 0.002). The specific skills average score for the control group was 20.2 (19–21.5) and 24.2 (21–27.5) for the study group (p = 0.001). There was acceptable concordance (Kendall’s W) regarding the video assessment of generic (W = 0.78) and specific skills (W = 0.84) between the two examiners.

Conclusions

A single short-duration VR simulator practice positively impacted surgeons’ generic and specific skills performance required to accomplish laparoscopic colectomy in the swine model.     

Construct validity of nine new inanimate exercises for robotic surgeon training using a standardized setup

Background

As more surgeons choose to complete procedures robotically, validated training tools are needed so that they can acquire and maintain the technical skills required to proficiently use robotic systems. The purpose of this study was to show construct validity of nine new inanimate training exercises for robot-assisted surgery. The inanimate training exercises were designed to span several core technical skills required to use a robotic system.

Methods

New (n = 30) and experienced (n = 11) robotic surgeons participated in the study. New robotic surgeons had not yet completed their first robotic surgery case and participated in this study before attending their robotic certification course. Experienced robotic surgeons had completed more than 200 robotic surgery cases. The raw scores from the exercises were reported so that other research groups could easily define custom proficiency levels. Example normalized scores that could be used in proficiency-based curricula were computed. These normalized scores balanced efficiency (completion time) and accuracy (exercise-specific errors) to measure performance. Finally, the setup was standardized using a custom docking model, which enabled consistent and repeatable completion of the inanimate exercises across surgeons.

Results

For all nine exercises, experienced robotic surgeons completed the exercises significantly faster than new robotic surgeons (p < 0.01). Similarly, experienced robotic surgeons achieved higher normalized scores than new robotic surgeons for all nine exercises (p < 0.01). Finally, consistent robot setup was achieved using the custom docking model based on an analysis of the robot kinematic data.

Conclusions

In summary, all nine inanimate exercises showed construct validity. The results suggest that the inanimate exercises along with the custom docking model can be used as part of proficiency-based curricula to improve robotic surgeon training.     

Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course

Introduction

The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa.

Methods

A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3.

Results

Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 ± 94 versus 132 ± 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification.

Conclusion

To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.     

Distribution of innate ability for surgery amongst medical students assessed by an advanced virtual reality surgical simulator

Background

Surgery is a craft profession requiring individuals with specific, well-documented innate aptitude for manipulative skills. Yet in most countries, the current selection process of surgical trainees does not include aptitude testing for the psychomotor and manipulative skills of candidates.

Methods

A total of 125 participants (121 medical students and four expert surgeons) performed all 26 exercises of the da Vinci Skills Simulator, with six exercises being identified as metrics of aptitude for manipulative and psychomotor skills. The expert surgeons were enrolled as the control group to validate the performance of the most talented students.

Results

Eight students (6.6 %) significantly outperformed the remaining 113, obtaining a median value of the sum of weighted overall score on the six selected exercises of 52.7 % versus 21.0 % (p < 0.001). In contrast, 14 students (11.6 %) performed significantly worse and well below the performance of the other 107, with a median value of overall score of 8.7 % versus 24.1 (p < 0.001). There was no statistically significant difference between expert surgeons (control group) and the eight talented students (62.1 % vs. 52.7 %, respectively; p = 0.368). No significant correlation between exposure to video games and overall score (ρ = 0.330) was observed.

Conclusions

In terms of innate aptitude for manipulative and psychomotor abilities, the present investigation has documented two subpopulations that fall outside the norm for the group of medical students recruited for the study: (i) a small group (6.6 %) with a high level and (ii) a larger cohort (11.6 %) with low level (significantly below the norm) innate aptitude for surgery. Exposure to video game experience did not appear to influence performances on the da Vinci Skills Simulator.     

Can Breast Surgeons Provide Breast Cancer Genetic Testing? An American Society of Breast Surgeons Survey

Background

Whether breast cancer surgeons are adequately trained, skilled, and experienced to provide breast cancer genetic assessment, testing, and counseling came under debate in September 2013 when a major third-party payer excluded nongenetics specialists from ordering such testing. A literature search having failed to uncover any study on breast surgeons’ skill and practice in this area, the American Society of Breast Surgeons (ASBrS) surveyed its members on their experience with the recognized crucial components of such testing.

Methods

In late 2013, ASBrS e-mailed a link to an online questionnaire to its U.S. members (n = 2,603) requesting a self-assessment of skills and experience in genetic assessment, testing, interpretation, and counseling. After approximately 6 weeks, the results were collated and evaluated.

Results

By January 2, 2014, 907 responses (34.84 %) had arrived from breast surgeons nationwide working in academic settings (20 %), solo or small group private practice (39 %), large multispecialty groups (18 %), and other settings. More than half said they performed 3-generation pedigrees, ordered genetic testing, and provided pre- and posttest counseling. Most noted that they would welcome continuing educational support in genetics.

Conclusions

Currently the majority of breast surgeons provide genetic counseling and testing services to their patients. They report practices that meet or exceed recognized guidelines, including the necessary elements and processes for best practices in breast cancer genetics test counseling. Because breast cancer genetic testing is grossly underutilized relative to the size of the U.S. BRCA mutation carrier population, these appropriate services should not be restricted but rather supported and expanded.     

Laparoscopic Surgical Skills are Significantly Improved by the Use of a Portable Laparoscopic Simulator: Results of a Randomized Controlled Trial

Background

There is growing evidence that training on virtual reality simulators leads to improved performance in the animate and human operating room. However, they are expensive, have a limited availability, and involve complex systems. Portable simulators are significantly cheaper, more user-friendly, and are flexible systems that are more suited to a surgical trainee’s busy schedule. The use of portable surgical simulators to train skills and reduce errors has never been evaluated in prospective, randomized clinical settings. The objective of this study was to determine if training on the portable Integrated Laparoscopic Simulator leads to improved performance of core laparoscopic skills.

Methods

Core laparoscopic skills were identified by five experienced laparoscopic surgeons and modeled into two exercises and three basic tasks. Twenty surgically naive medical students had baseline laparoscopic skills assessed on a fixed simulator. Participants were randomized to either 14 h training on a portable laparoscopic simulator over a 3 week period, or control with no training. At 3 weeks two expert laparoscopic surgeons blinded to the allocation of participants assessed their pre- and post-intervention performances recorded on a CD-ROM. The outcome measures included time to complete and global rating scores of clipping and dissection tasks.

Results

No differences were observed in baseline skills level between the two groups. The intervention group had better quality of scissors dissection (p = 0.0038) and improved clipping skills (p = 0.0051), and they took less time to accomplish the tasks (p = 0.0099) in comparison to control.

Conclusions

Training on the portable Integrated Laparoscopic Simulator significantly improved core laparoscopic skills in medical students with no prior experience.     

Development and evaluation of a simulator-based laparoscopic training program for surgical novices

Background

The use of simulation to train novice surgeons in laparoscopic skills is becoming increasingly popular. To maximize benefit from simulation, training needs to be delivered and assessed in a structured manner. This study aimed to define performance goals, demonstrate construct validity of the training program, and evaluate whether novice surgeons could reach the preset performance goals.

Methods

Nine expert laparoscopic surgeons established performance goals for three basic modules of an augmented-reality laparoscopic simulator. The three laparoscopic modules were used by 40 novice surgeons and 40 surgical trainees (postgraduate years [PGYs] 1–4). The performance outcomes were analyzed across the different groups (novice, PGYs 1 and 2, PGYs 3 and 4, expert) to determine construct validity. Then 26 recruited novices trained on the three modules with the aim of reaching the performance goals.

Results

The results demonstrated a significant difference in performance between all levels of experience for time (p < 0.001), motion analysis (p < 0.001), and error score (p < 0.001), thus demonstrating construct validity. All 26 novice surgeons significantly improved in performance with repetition for the metrics of time (p < 0.001) and motion analysis (p < 0.001). For two of the modules, the proficiency goals were reached in fewer than 10 trials by 80 % of the study participants.

Conclusion

Basic skills in laparoscopic surgery can be learned and improved using proficiency-based simulation training. It is possible for novice surgeons to achieve predefined performance goals in a reasonable time frame.     

Publication misrepresentation among urology residency applicants

Purpose

To assess the extent and types of publication misrepresentation among medical students applying to the urology residency program at the University of Washington. Research experience and publications are the selection criteria used to judge and rank urology residency applicants.

Methods

Electronic Residency Application Service (ERAS) applications submitted for the incoming class of 2011 for urology residency at the University of Washington were reviewed. All listed publications were verified against PubMed and Google search engines. Misrepresentation was defined as non-authorship of an existing article, authorship claimed of a nonexistent article, or first-authorship listed incorrectly.

Results

Of the 198 total applications, 124 (63 %) applicants reported 541 publications, including 112 abstracts and 429 journal articles. 347 (65 %) articles and abstracts were verifiable. Misrepresentation of 12 (3.5 %) published articles was found in 9 applicants (7 %), which included self-promotion to first-authorship (6), followed by non-existent articles (5), and a repeated publication listing (1). On univariate analysis, higher age (p = 0.008), higher number of total publications reported (p < 0.001), additional graduate degree (p < 0.001), and foreign medical graduate (FMG) status (p < 0.001) were associated with misrepresentation. Due to the low incidence, the study was not adequately powered to perform a multivariate analysis.

Conclusions

Misrepresentation of publications listed in ERAS among urology applicants remains significant. Residency program directors should require applicants to submit copies of all of their publications, whether in print, in-press, or submitted to be placed as part of their application file.     

A Randomized Prospective Study Comparing Acquisition of Laparoscopic Skills in Three-Dimensional (3D) vs. Two-Dimensional (2D) Laparoscopy

Background

We aimed to compare the performance of novices with three-dimensional (3D) versus two-dimensional (2D) laparoscopy using Fundamentals of Laparoscopic Surgery (FLS) tasks.

Methods

Fifty-six novices with no uncorrected visual problems were randomly allocated to 2D and 3D groups. All candidates practiced FLS tasks on a box trainer until they achieved proficiency. Their performance was assessed by considering completion time, number of repetitions, and number of errors following the validated FLS proficiency criteria.

Results

Twenty-five participants in each group completed the training curriculum. The median performance time (in minutes) for the 3D group was 216, which was less than that of the 2D group of 247 min (P = 0.266). The median numbers of repetitions and errors were lower for the 3D group versus the 2D group: 108 versus 121 (P = 0.008) and 27 versus 105 (P < 0.001), respectively.

Conclusion

Stereoscopic vision improved accuracy in laparoscopic skills for novices, which was manifested in reduced numbers of repetitions and errors. However, it does not affect the global performance time across all tasks.     

Three-dimensional imaging improves surgical skill performance in a laparoscopic test model for both experienced and novice laparoscopic surgeons

Study objective

The objective of this study was to evaluate and compare the impact of three-dimensional (3D) imaging system on the performance of basic laparoscopic tasks in a test model by novice and experienced surgeons.

Design

Three tasks were performed in a test model by 30 surgeons, 15 experienced surgeons, and 15 with minimal laparoscopic experience. The tasks were performed using 2D and 3D vision systems.

Design classification

Canadian Task Force II-1.

Subjects

Fifteen experienced laparoscopic surgeons and fifteen novices with minimal laparoscopic experience.

Measurements

Performance times were recorded using both two-dimensional and 3D imaging system for each task.

Main results

Performance time for all skills was significantly (P < 0.02) shorter when using 3D imaging system. Performance times were reduced by 18–31 % using 3D imaging for all participants. Experienced surgeons performed the tasks faster and showed similar improvement while using 3D imaging system.

Conclusion

3D vision systems allow for significant improvement in performance times of basic laparoscopic tasks in a test model for both inexperienced and advanced laparoscopic surgeons. Experienced surgeons benefit as much as novices from 3D imaging system. This benefit should be weighed against the disadvantages of the 3D vision systems, mainly cost, decreased light, eye strain, headaches, and shorter focal lengths.     

Remote evaluation of laparoscopic performance using the global operative assessment of laparoscopic skills

Background

Although numerous assessment tools currently exist to evaluate laparoscopic surgical skills, no studies have demonstrated the reliability of such tools when used with telementoring technology. This study aimed to determine the reliability of the Global Operative Assessment of Laparoscopic Skills (GOALS) rating scale for assessing laparoscopic skills remotely and to identify how factors unique to remote assessment such as bandwidth and image quality influence its reliability.

Methods

Four trained observers evaluated 19 participants for their technical performance during a laparoscopic cholecystectomy using the GOALS assessment tool. One observer assessed the study participants directly in the operating room, whereas the three remaining observers were randomly assigned and blinded to a high- (1.5 Mbps), medium- (256 kbps), or low- (64.4 kbps) bandwidth restriction and observed remotely via Skype. The Maryland Visual Comfort Scale was used to evaluate the video quality of the respective connections.

Results

The intraclass correlation coefficient (ICC) calculated for the total GOALS score demonstrated a statistically significant correlation of high, medium, and low bandwidths respectively with ICC 0.693 (95 % confidence interval [CI], 0.226–0.883), 0.518 (95 % CI 0.089–0.783), and 0.499 (95 % CI 0.025–0.781). There was a statistically significant difference in the overall perceived visual quality between the high/low (Z = ?3.222; P = 0.001) and the medium/low (Z = ?3.567; P < 0.001) bandwidth comparison but no difference between the high/medium bandwidths (Z = ?0.610; P = 0.542).

Conclusion

The data suggest that the GOALS assessment tool retains its reliability for intraoperative assessment of laparoscopic skills when used remotely. This is a key requirement in telesimulation programs allowing for structured feedback between the mentor and the mentee. This study quantifies the effect that bandwidth has on the reliability of remote assessment, demonstrating that higher bandwidths improve the utility of these tools.     

Construct and concurrent validity of a Nintendo Wii video game made for training basic laparoscopic skills

Background

Virtual reality (VR) laparoscopic simulators have been around for more than 10 years and have proven to be cost- and time-effective in laparoscopic skills training. However, most simulators are, in our experience, considered less interesting by residents and are often poorly accessible. Consequently, these devices are rarely used in actual training. In an effort to make a low-cost and more attractive simulator, a custom-made Nintendo Wii game was developed. This game could ultimately be used to train the same basic skills as VR laparoscopic simulators ought to. Before such a video game can be implemented into a surgical training program, it has to be validated according to international standards.

Methods

The main goal of this study was to test construct and concurrent validity of the controls of a prototype of the game. In this study, the basic laparoscopic skills of experts (surgeons, urologists, and gynecologists, n = 15) were compared to those of complete novices (internists, n = 15) using the Wii Laparoscopy (construct validity). Scores were also compared to the Fundamentals of Laparoscopy (FLS) Peg Transfer test, an already established assessment method for measuring basic laparoscopic skills (concurrent validity).

Results

Results showed that experts were 111 % faster (P = 0.001) on the Wii Laparoscopy task than novices. Also, scores of the FLS Peg Transfer test and the Wii Laparoscopy showed a significant, high correlation (r = 0.812, P < 0.001).

Conclusions

The prototype setup of the Wii Laparoscopy possesses solid construct and concurrent validity.     

Comparison between patient and surgeon perception of degenerative spine disease outcomes—a prospective blinded database study

Background

Few have studied the correlation between patients’ and spine surgeons’ perception on outcomes, or compared these with patient-reported outcome scores. Outcomes studies are increasingly important in evaluating costs and benefits to patients and surgeons, and in developing metrics for payer evaluation and health care policy-making.

Objective

To compare patients’ and surgeons’ assessment of spine treatment outcome in a prospective blinded patient-driven spine surgery outcomes registry, and to correlate perceived outcomes ratings to validated outcomes scores.

Methods

Patients filled out surveys at baseline, 3 months and 6 months postoperatively, including Visual Analog Scale (VAS), and Neck Disability Index (NDI) or Oswestry Disability Index (ODI). Outcome was rated independently by patients and surgeons on a 7-point Likert-type scale.

Results

Two-hundred and sixty-five consecutive adult patients were surgical candidates. Of these, 154 (58.1 %) opted for surgery, with 69 (44.8 %) cervical and 85 (55.2 %) lumbar patients. One hundred and thirty-five (87.7 %) had both patient and surgeon postoperative ratings. Surgeons’ and patients’ ratings correlated strongly (Spearman rho?=?0.53, p?<?0.0001, 45.9 % identical, 88.2 % +/? 1 grade). The surgeon rated outcomes were better than patients in 29.8 % and worse in 21.15 %. Patient rating correlated better with the most recent NDI/ODI and pain scores than with incremental change from baseline. In multivariate analysis, age, location (cervical vs lumbar), pain ratings, and functional scores (NDI, ODI) did not have significant impact on the discrepancy between patient and surgeon ratings.

Conclusions

Patients’ and surgeons’ global outcome ratings for spinal disease correlate highly. Patients’ ratings correlate better with most recent functional scores, rather than incremental change from baseline.     

Seasoned Surgeons Assessed in a Laparoscopic Surgical Crisis

Objective

Maintenance of certification is a relatively new concept in the United States, and there is no mandatory retirement for surgeons. Our aim was to compare technical and team performance of surgeons of different ages in a simulated laparoscopic surgical crisis and validate a potential recredentialing tool for surgeons.

Methods

Using a single-blinded protocol, the performance of six “Seasoned” surgeons >55 years (mean 64, range 55–83) was compared to six “control” surgeons <55 years (mean 46, range 34–53) in a simulation. Surgical teams established pneumoperitoneum, trocar access, and managed intraabdominal hemorrhage in a simulated laparoscopic cholecystectomy while videotaped as part of an IRB protocol. Surgeons’ performance was scored using validated technical and team performance scales.

Results

All of the “seasoned” surgeons relegated the use of unfamiliar technology to their assistants. All control surgeons achieved intraabdominal pneumoperitoneum themselves. Mean blood loss for seasoned surgeons and control surgeons was 2,555 versus 2,725 ml (NS), respectively. After recognition of bleeding in the unstable patient, senior surgeons converted to an urgent laparotomy case after 2.4 vs. 3.3 min for control group (NS). No difference was observed in overall technical and team abilities (p?=?NS). On debriefing, 85% of surgeons recommended simulation for training and recertification.

Conclusions

Seasoned surgeons can use their assistant surgeon well to assure a safe and effective operation. Mandatory operating room retirement based on age may be arbitrary and should be replaced by performance measures. Simulation may prove a valuable tool for self -assessment and recredentialing.     

Can virtual reality simulators be a certification tool for bariatric surgeons?

Background

Construct validity of virtual laparoscopic simulators for basic laparoscopic skills has been proposed; however, it is not yet clear whether the simulators can identify the actual experience of surgeons in more complex procedures such as laparoscopic Roux-en-Y gastric bypass. This study tested the ability of the Lap Mentor simulator to recognize the experience in advanced laparoscopic procedures and to assess its role in the certification of bariatric surgeons.

Methods

Twenty surgeons were divided into two groups according to their experience in laparoscopic and bariatric surgery. The general group included 10 general surgeons performing between 75 and 100 nonbariatric laparoscopic procedures. The bariatric group included 10 bariatric surgeons performing between 50 and 100 laparoscopic bariatric procedures. Participants were tested on the simulator in one basic task (task 1: eye–hand coordination) and in two tasks of the gastric bypass module (task 2: creation of the gastric pouch; task 3: gastrojejunal anastomosis).

Results

Comparing the groups, no significant differences were found in task 1. Analyzing the results from the gastric bypass module (bariatric vs. general), in task 2, significant differences (p < 0.05) were found in the median volume of the gastric pouch (21 vs. 48 cm³), in the percentage of fundus included in the pouch (8.4 vs. 29.4 %), in the complete dissection at the angle of His (10 vs. 3), and in safety parameters. In task 3, significant differences were found in the size and position of enterotomies.

Conclusions

The Lap Mentor may be proposed as a certification tool for bariatric surgeons because it also recognizes their specific skills in the technical details of the procedure that affect long-term results. Furthermore, the possibility of analyzing the performance in detail can help define areas where the surgeon is lacking. These findings indicate a potential role of the Lap Mentor in tailoring the training to maximize improvement.     

Impact of Team Familiarity in the Operating Room on Surgical Complications

Background

The quality of surgical performance depends on the technical skills of the surgical team as well as on non-technical skills, including teamwork. The present study evaluated the impact of familiarity among members of the surgical team on morbidity in patients undergoing elective open abdominal surgery.

Methods

A retrospective analysis was performed to compare the surgical outcomes of patients who underwent major abdominal operations between the first month (period I) and the last month (period II) of a 6-month period of continuous teamwork (stable dyads of one senior and one junior surgeon formed every 6 months). Of 117 patients, 59 and 58 patients underwent operations during period I and period II, respectively, between January 2010 and June 2012. Team performance was assessed via questionnaire by specialized work psychologists; in addition, intraoperative sound levels were measured.

Results

The incidence of overall complications was significantly higher in period I than in period II (54.2 vs. 34.5 %; P = 0.041). Postoperative complications grade <3 were significantly more frequently diagnosed in patients who had operations during period I (39.0 vs. 15.5 %; P = 0.007), whereas no between-group differences in grade ≥3 complications were found (15.3 vs. 19.0 %; P = 0.807). Concentration scores from senior surgeons were significantly higher in period II than in period I (P = 0.033). Sound levels during the middle third part of the operations were significantly higher in period I (median above the baseline 8.85 dB [range 4.5–11.3 dB] vs. 7.17 dB [5.24–9.43 dB]; P < 0.001).

Conclusions

Team familiarity improves team performance and reduces morbidity in patients undergoing abdominal surgery.     

Meaningful assessment method for laparoscopic suturing training in augmented reality

Background

To be an effective training tool, a laparoscopic simulator has to provide metrics that are meaningful and informative to the trainee. Time, path length and smoothness are often used parameters, but are not very informative on the quality of the performance. This study aims to validate a newly developed assessment method for laparoscopic suturing on the ProMIS augmented reality simulator, and compares it with scores of objective observers.

Methods

Twenty-four participants practised their suturing skills on the augmented reality suturing module: experienced participants (n = 10), >50 clinical laparoscopic suturing experience; and novice participants (n = 14), without laparoscopic experience. The performances were recorded and assessed by two unrelated observers and compared with the assessment scores. The assessment score was a calculation of time spent in the correct area and quality (strength) of the knot. To test the accuracy of the individual assessment parameters, we compared these with each other.

Results

The experienced participants had significantly higher performance scores than the novice participants in the beginner-level mode (mean 95.73 vs. 60.89, standard deviation 2.63 vs. 17.09, p < 0.001, independent t-test). The performance scores of the assessment method (n = 43) correlated significantly with the scorings of the objective observers (Spearman’s rho 0.672; p < 0.001). The parameter time spent in correct area had a calculated significant correlation with the strength of the knot (n = 229, Spearman’s rho 0.257, p < 0.001), but this was clinically irrelevant.

Conclusion

This assessment method is a valid tool for objectively assessing laparoscopic suturing skills. Although assessment parameters can correlate, to provide informative feedback it is important to combine meaningful measurements in the assessment of suturing skills.     

Teaching residents may affect the margin status of breast-conserving operations

Purpose

The current study was performed to evaluate the effects of teaching surgical residents on the margin status after lumpectomy.

Methods

A retrospective review of all patients from July 2006 to Nov 2009 was performed. The impact of the technical ability of surgical residents to perform lumpectomy was evaluated to determine if there was an effect on the margin status. A logistic regression analysis was performed to adjust for clinical variables known to affect the margin status.

Results

Of 106 patients, 19 % had positive margins. Residents with unsatisfactory technical skills had a positive margin rate of 34 % compared to 8 % for residents with satisfactory skills (p = 0.004). In the multivariate logistic regression analysis, the operating surgeon remained significantly associated with a positive margin status. Operations performed by residents with satisfactory technical skills or by attending surgeons were less likely to have positive margins than those performed by residents with unsatisfactory technical skills (OR 0.26, 95 % CI 0.08–0.86; p = 0.03). After a mean follow-up of 60 months, the breast cancer-specific survival rate was 94 %, and there were no local recurrences as a first event.

Conclusions

The technical ability of residents may affect the margin status after lumpectomy. The importance of teaching surgical residents needs to be considered in future quality of care evaluations.