Aaron R. Jensen

Methodologies for establishing validity in surgical simulation studies

BACKGROUNDnValidating assessment tools in surgical simulation training is critical to objectively measuring skills. Most reviews do not elicit methodologies for conducting rigorous validation studies. Our study reports current methodological approaches and proposes benchmark criteria for establishing validity in surgical simulation studies.nnnMETHODSnWe conducted a systematic review of studies establishing validity. A PubMed search was performed with the following keywords: validity/validation, simulation, surgery, and technical skills. Descriptors were tabulated for 29 methodological variables by 2 reviewers.nnnRESULTSnA total of 83 studies were included in the review. Of these studies, 60% targeted construct, 24% targeted concurrent, and 5% looked at predictive validity. Less than half (45%) of all the studies reported reliability data. Most studies (82%) were conducted in a single institution with a mean of 37 subjects recruited. Only half of the studies provided rationale for task selection. Data sources included simulator-generated measures (34%), performance assessment by human evaluators (33%), motion tracking (6%), and combined modes (28%). In studies using human evaluators, videotaping was a common (48%) blinding technique; however, 34% of the studies did not blind evaluators. Commonly reported outcomes included task time (86%), economy of motion (51%), technical errors (48%), and number of movements (25%).nnnCONCLUSIONnThe typical validation study comes from a single institution with a small sample size, lacks clear justification for task selection, omits reliability reporting, and poses potential bias in study design. The lack of standardized validation methodologies creates challenges for training centers that survey the literature to determine the appropriate method for their local settings.

Educational feedback in the operating room: a gap between resident and faculty perceptions

BACKGROUNDnImmediate feedback regarding performance in the operating room remains a key component of resident education. The aim of this study was to assess resident and faculty perceptions regarding postoperative feedback.nnnMETHODSnAnonymous surveys were distributed to residents and faculty members. Questions addressed the timing, amount, and specificity of feedback; satisfaction; and the definition and importance of feedback. Additional questions regarded the importance and frequency of feedback in 7 specific areas of surgical competency.nnnRESULTSnResident satisfaction with timing, amount, and specificity of feedback was significantly lower than faculty satisfaction. Perceptions of the importance of feedback for each of the 7 specific areas did not differ. Faculty members perceptions on the frequency of feedback were higher than residents perception in all competencies of feedback (5-point scale, all P values = .001).nnnCONCLUSIONSnThere are significant differences between resident and faculty perceptions regarding postoperative feedback. Although faculty members believed they delivered appropriate amounts of timely, quality feedback, this perception was not shared by residents.

The association of cyclic parenteral nutrition and decreased incidence of cholestatic liver disease in patients with gastroschisis

PURPOSEnThe aim of the study was to investigate the effect of prophylactic cycling of parenteral nutrition (PN) on PN-induced cholestasis in patients with gastroschisis.nnnMETHODSnRetrospective review of initial hospital admission charts for each patient with gastroschisis from 1996 to 2007 was performed.nnnRESULTSnOne hundred seven patients were analyzed (36 prophylactically cycled, 71 control). Prophylactic cycling of PN was initiated at a mean age of 23 days (range, 7-89 days). Patients were followed for a total of 4255 days with 27 developing hyperbilirubinemia (cycled, 5; continuous, 22). Time to hyperbilirubinemia was longer in the prophylactically cycled group (P = .005). Cumulative incidence of hyperbilirubinemia at 25 and 50 days of PN exposure was 5.7% and 9.8% (cycled) vs 22.3% and 48.8% (continuous). At any given time, children in the continuous group were 4.76 times more likely to develop hyperbilirubinemia (95% confidence interval, 1.62-14.00). After adjusting for confounding factors, children in the continuous group were 2.86 times more likely to develop hyperbilirubinemia (95% confidence interval, 0.86-9.53), but the difference was not significant (P = .088).nnnCONCLUSIONSnProphylactic cyclic PN is associated with a decreased incidence and prolonged time to onset of hyperbilirubinemia. Other factors, however, significantly affect this relationship. Prospective randomized investigation is warranted to investigate for a possible causal relationship.

Acquiring basic surgical skills: is a faculty mentor really needed?

BACKGROUNDnWe evaluated the impact of expert instruction during laboratory-based basic surgical skills training on subsequent performance of more complex surgical tasks.nnnMETHODSnForty-five junior residents were randomized to learn basic surgical skills in either a self-directed or faculty-directed fashion. Residents returned to the laboratory 2 days later and were evaluated while performing 2 tasks: skin closure and bowel anastomosis. Outcome measures included Objective Structured Assessment of Technical Skill, time to completion, final product quality, and resident perceptions.nnnRESULTSnObjective Structured Assessment of Technical Skill, time to completion, and skin esthetic ratings were not better in the faculty-directed group, although isolated improvement in anastomotic leak pressure was seen. Residents perceived faculty-directed training to be superior.nnnCONCLUSIONSnOur data provided minimal objective evidence that faculty-directed training improved transfer of learned skills to more complex tasks. Residents perceived that there was a benefit of faculty mentoring. Curriculum factors related to training of basic skills and subsequent transfer to more complex tasks may explain these contrasting results.

Secondary Abdominal Compartment Syndrome in Children With Burns and Trauma: A Potentially Lethal Complication

Acute, rapid, and unimpeded increases in intra-abdominal pressure can lead to multiple organ dysfunction defined as the abdominal compartment syndrome (ACS). If this develops in the absence of obvious intra-abdominal injury, it has been termed secondary ACS (2° ACS). Massive fluid resuscitation in the presence of large burns or shock can lead to 2° ACS. The importance of early recognition and the need for urgent abdominal decompression have been recognized in adults; however, this has not been appreciated in the pediatric population. Medical records of four children diagnosed with 2°ACS were reviewed. Secondary ACS occurred in three children with burns and in one child with a traumatic brain injury. Three children underwent decompressive laparotomy, and one underwent successful percutaneous drainage. There were two survivors. Secondary ACS may be observed in burnt or traumatized children needing large volume resuscitation. Early recognition of 2° ACS by routine bladder pressure monitoring in this high-risk group of children may result in earlier decompression and a possible decrease in morbidity and mortality.

Short-term sleep deficits do not adversely affect acquisition of laparoscopic skills in a laboratory setting

BackgroundResidents often are sleep deprived after being on call. This study evaluated the effects of these sleep deficits on the acquisition of laparoscopic skills in the laboratory setting.MethodsThe amount of sleep on the preceding night was recorded for 40 residents undergoing surgical skills training. The residents underwent a pretest, training, practice, and a posttest using basic (pegboard, cup drop, rope pass) and task-specific (pattern cutting, clip application, loop application) drills. Time to completion, penalty score, and total score were assessed.ResultsSignificant improvements were seen in the time and total score for all six drills, with a significant decrease in penalty scores noted for the pegboard and rope pass drills. No significant differences in skill acquisition were attributable to amount of sleep.ConclusionTraining in the laboratory results in significant improvement of basic laparoscopic skills. Because short-term sleep deficits do not appear to hinder the acquisition of these skills, this model can be effectively applied, even after residents have been on call.

Laboratory-based instruction for skin closure and bowel anastomosis for surgical residents.

HYPOTHESISnMultimedia delivery of cognitive content paired with faculty-supervised partial task simulation for both excision of a simulated skin lesion with subsequent wound closure and hand-sewn bowel anastomosis would be an effective method for developing appropriate procedural skills among junior residents.nnnDESIGNnProspective cohort study.nnnSETTINGnUniversity-based surgical residency.nnnPARTICIPANTSnFirst- and second-year surgical residents (n = 45).nnnINTERVENTIONSnSurgical residents were given comprehensive instructional materials, including structured curricula with goals and objectives, text, figures, and narrated expert digital video, before the training session. A 4-hour, standardized, laboratory-based instruction session was then performed in small groups, which emphasized faculty-supervised practice. Residents were asked to (1) excise a skin lesion and close the wound and (2) perform hand-sewn bowel anastomosis. These 2 tasks were assessed before and after supervised practice. Performances were video recorded. Residents were surveyed before and after training.nnnMAIN OUTCOME MEASURESnTime to completion and Objective Structured Assessment of Technical Skill global rating scale score based on video recordings were evaluated by blinded reviewers. Final product quality was measured by anastomotic leak pressure and by wound closure aesthetic quality.nnnRESULTSnResidents perceived the laboratory training to be equal to training in the operating room for skin closure and superior to training in the operating room for bowel anastomosis. Residents perceived time spent on both tasks to be perfect. Mean objective scores improved significantly on 5 of 6 outcome measures.nnnCONCLUSIONSnJunior resident surgical performance improved substantially with 4 hours of laboratory-based, faculty-supervised practice. Both first- and second-year residents benefited from this training. These data show that curriculum-driven, faculty-supervised instruction in a laboratory setting is beneficial in the training of junior surgical residents.

The Use of a Spring-Loaded Silo for Gastroschisis: Impact on Practice Patterns and Outcomes

OBJECTIVEnTo evaluate the impact of the use of a bedside-placed spring-loaded silo (SLS) on practice patterns and on outcomes for infants with gastroschisis.nnnDESIGNnRetrospective review comparing neonates with gastroschisis treated before and after the implementation of selective SLS placement.nnnSETTINGnTertiary referral center.nnnPATIENTSnOf 91 consecutive neonates admitted for initial treatment of gastroschisis between January 1998 and August 2007, 45 were admitted before and 46 were admitted after implementation of the SLS.nnnMAIN OUTCOME MEASURESnImmediate fascial closure rate, infection rate, time to fascial closure, time to initiation of enteral feeding, time to achievement of full enteral feeds, time of hyperalimentation requirement, and length of hospital stay.nnnRESULTSnThe rate of immediate fascial closure was lower in the postimplementation group (58% before vs 20% after implementation, P < .001). Overall length of stay, time to enteral feeding, and infection rates were not significantly different between the 2 groups.nnnCONCLUSIONSnThe use of an SLS placed at the bedside has resulted in lower immediate fascial closure rates for infants with gastroschisis without significant detrimental clinical outcome. The main benefit of using the bedside-placed SLS is the avoidance of urgent surgical intervention. For patients undergoing delayed fascial closure, use of the bedside SLS resulted in shorter times to definitive fascial closure.

Laparoscopic Versus Open Treatment of Congenital Duodenal Obstruction: Multicenter Short-Term Outcomes Analysis

BACKGROUNDnLaparoscopic repair of congenital duodenal obstruction has become popularized over the past decade. Comparative data on outcomes, however, are sparse. We hypothesized that laparoscopic repair of congenital duodenal obstruction could be performed with similar outcomes to traditional open repair.nnnPATIENTS AND METHODSnMedical records for all cases of congenital duodenal obstruction from 2005 to 2011 at three academic teaching hospitals were retrospectively reviewed. Patients were excluded from the analysis if they had confounding surgical diseases, did not have duodenoduodenostomy during the first hospital admission, had the repair performed before transfer from a referring hospital, or weighed less than 1.7u2009 kg at the time of surgery. Analysis was performed as intention to treat, with laparoscopic converted to open cases included in the laparoscopic group.nnnRESULTSnSixty-four cases were included in the analysis (44 open, 20 laparoscopic). Baseline characteristics were similar between the two groups with the exception that the open group, on average, underwent repair later than the laparoscopic group (6 days versus 4 days, respectively). Seven laparoscopic cases were converted to an open procedure (35%), most commonly for difficulty in exposing the decompressed distal duodenum. Laparoscopic repair did take significantly longer than open repair (145 minutes versus 96 minutes, respectively), but clinical outcomes were similar. Complications were rare and were similar between methods of repair. Two patients in the laparoscopic group required subsequent open revision.nnnCONCLUSIONSnLaparoscopic duodenoduodenostomy for congenital duodenal obstruction is a technically challenging procedure with a steep learning curve. Despite a relatively high conversion rate, clinical outcomes remained similar to the traditional open repair in selected patients.

Expanding Resident Conferences While Tailoring Them to Level of Training: A Longitudinal Study

OBJECTIVEnTo evaluate the effect of changing a 1-hour weekly all-resident didactic conference to an expanded 4-hour bimonthly level-specific didactic conference.nnnDESIGNnProspective outcome measures included an anonymous 10-item perceptions survey administered at 4 time points (preintervention, 6 months postintervention, 1 year postintervention, and 2 years postintervention), mean attendance rates preintervention and postintervention, and mean ABSITE scores preintervention and postintervention.nnnSETTINGnLarge university-based surgical residency.nnnPARTICIPANTSnSurgical residents (R1-R5, n = 75) were divided into junior (R1-R3, n = 56) and senior (R4-R5, n = 19) groups. Each group attended a session every other Wednesday.nnnRESULTSnSignificant improvements were observed in overall resident satisfaction (55% vs 80%, p < 0.005) and level-specific appropriateness of content (81% vs 94%, p < 0.001). Furthermore, resident attendance rates were improved substantially (33% vs 55%, p < 0.001). ABSITE scores were not affected significantly by the change in curriculum structure.nnnCONCLUSIONSnAn expanded, bimonthly level-specific didactic curriculum is more effective than a shorter, weekly all-resident conference as evidenced by resident attitudes and attendance. Additional benefits of the alternating schedule include a reduced number of residents in each conference and the availability of residents for clinical educational activities (eg, operative cases or clinic). Expanded educational time has allowed the introduction of nontraditional topics that include leadership, communication, practice management, professionalism, and technical skills training.