Giving Up the Burr: Teaching Minimally Invasive Surgery

Abstract

“I don’t let the fellows use the burr.” This has been a common response when I have asked my colleagues how they teach minimally invasive surgery (MIS). One surgeon remarked, “Look at the training you have done for yourself—industry labs, symposiums, visiting experienced surgeons and centers, cadaver courses, independent practice in the lab . . . it goes on and on. How can you expect your fellows to be able to be able to do all of that? This was a good question because there is a steep learning curve with MIS,2-5 but ultimately the implied answer was dissatisfying. The question presumes that the fellow would not be willing or able to replicate these experiences, and that, by extension, it is okay for us to not teach them. MIS is an exciting and evolving area of foot and ankle surgery, and as mentors to rising surgeons I believe that it is imperative to teach them as much as we can. Prospective fellows are making decisions on where to train based on the skills they will gain over the year. All of the applicants who I have interviewed this year specifically asked if they will learn MIS. Practices searching for a new foot and ankle surgeon will ask similar questions. This could be due to the marketability or simply the desire to have a partner trained in the newest techniques. Regardless, it is clear that many fellows want to develop an MIS practice as they move forward. MIS is unique in foot and ankle surgery because it relies almost entirely on feel and subtle hand control, and only the surgeon who is holding the burr will receive the critical tactile feedback. Open and arthroscopic surgery can be monitored visually by the attending and potential problems identified early and avoided. With MIS, this is not always the case and, therefore, a different level of trust and competence must be achieved to permit a trainee to learn. This does not come easily. All surgeons who teach residents will discover that giving up the knife is more challenging than expected. However, we have found that giving up the burr, or any instrument used to perform MIS surgery, is even harder. How, then, can we effectively teach MIS while protecting patient safety and achieving the best possible clinical outcome? In 2013, Dr DaRosa et al1 published a theory on teaching surgical skills to residents, and her basic framework is well suited to teaching MIS. The article describes 4 stages of learning and teaching with defined roles and requirements on both sides of the mentor-mentee relationship. The first stage is the “Show and Tell” stage where the surgery is performed by the attending who is explaining their reasoning and steps out loud. The second stage is “Smart Help” when the attending will assist actively and cue the trainee on the next step and help him or her to perform the procedure in stages. The third is “Dumb Help” when the trainee will lead the majority of the surgery on his or her own with minimal help or cues from the attending who is coaching finer points of the procedure. The last stage is the “No Help” stage where the attending allows the trainee to perform the surgery under careful monitoring but only intervenes if there is an issue of patient safety. They also describe signals to inform when the trainee is ready to advance to the next stage. Given the unique nature and skills required for MIS surgery, we propose an updated version of these stages and have adapted the table from the article to incorporate what we feel are critical steps in the learning pathway (Table 1). It is our hope that employing these techniques will allow other surgeons and their fellows to successfully implement a fruitful, effective, and most of all, safe learning environment The first hurdle for many fellows is to realize that MIS is fundamentally different from open surgery and that they will not be permitted the same level of freedom until they can demonstrate mastery of the skills in the cadaver lab. It requires a significant time investment beyond what they may expect otherwise to progress safely. This may cause frustration on both sides of the relationship. For the trainee, they may be surprised by how long it takes to learn the techniques and then be frequently corrected as they begin. 1021349 FAIXXX10.1177/10711007211021349Foot & Ankle InternationalMiller and Kaiser research-article2021