Boris Zevin

Simulation in Surgery What's Needed Next?

OBJECTIVE To review the current state of simulation use in surgery and to offer direction for future research and implementation of evidence-based findings. BACKGROUND Simulation-based training (SBT) in surgery has surged in recent years. Although several new simulators and curricula have become available, their optimization and implementation into surgical training has been lagging. METHODS Members of the Association for Surgical Education Simulation Committee with expertise in surgical simulation review and interpret the literature and describe the current status of the use of simulation in surgery, identify the challenges to its widespread adoption, and offer potential solutions to these challenges. The review focuses on simulation research and implementation of existing knowledge and explores possible future directions for the field. RESULTS Skill acquired on simulators has repeatedly and consistently been demonstrated to transfer to the operating room, and proficiency-based training maximizes this benefit. Several simulation-based curricula have been developed by national organizations to support resident training, but their implementation is lagging because of inadequate human resources, difficult integration of SBT into educational strategy, and logistical barriers. In research, lack of coordinated effort, flaws in study design, changes in simulator-validation concepts, limited attention to skill retention, and other areas are in need of improvement. CONCLUSIONS Future research in surgical simulation should focus on demonstrating the cost-effectiveness of SBT and its impact on patient outcomes. Furthermore, to enable the more widespread incorporation of best practices and existing simulation curricula in surgery, effective implementation strategies need to be developed.

Volume-outcome association in bariatric surgery: a systematic review.

Objective: To systematically examine the association between annual hospital and surgeon case volume and patient outcomes in bariatric surgery. Background: Bariatric surgery remains a technically demanding field with significant risk for morbidity and mortality. To mitigate this risk, minimum annual hospital and surgeon case volume requirements are being set and certain hospitals are being designated as “Bariatric Surgery Centers of Excellence.” The effects of these interventions on patient outcomes remain unclear. Methods: A comprehensive systematic review on volume-outcome association in bariatric surgery was conducted by searching MEDLINE, Cochrane Database of Systematic Reviews, and Evidence Based Medicine Reviews databases. Abstracts of identified articles were reviewed and pertinent full-text versions were retrieved. Manual search of bibliographies was performed and relevant studies were retrieved. Methodological quality assessment and data extraction were completed in a systematic fashion. Pooling of results was not feasible due to the heterogeneity of the studies. A qualitative summary of results is presented. Results: From a total of 2928 unique citations, 24 studies involving a total of 458,032 patients were selected for review. Two studies were prospective cohorts (level of evidence [LOE] 1), 3 were retrospective cohorts (LOE 3), 2 were retrospective case controls (LOE 3), and 17 were retrospective case series (LOE 4). The overall methodological quality of the reviewed studies was fair. A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies. Conclusions: There is strong evidence of improved patient outcomes in the hands of high-volume surgeons and high-volume centers. This study supports the concept of “Bariatric Surgery Center of Excellence” accreditation; however, future research into the quality of care characteristics of successful bariatric programs is recommended. Understanding the characteristics of high-volume surgeons, which lead to improved patient outcomes, also requires further investigation.

A consensus-based framework for design, validation, and implementation of simulation-based training curricula in surgery.

BACKGROUND Simulation-based training can improve technical and nontechnical skills in surgery. To date, there is no consensus on the principles for design, validation, and implementation of a simulation-based surgical training curriculum. The aim of this study was to define such principles and formulate them into an interoperable framework using international expert consensus based on the Delphi method. METHODS Literature was reviewed, 4 international experts were queried, and consensus conference of national and international members of surgical societies was held to identify the items for the Delphi survey. Forty-five international experts in surgical education were invited to complete the online survey by ranking each item on a Likert scale from 1 to 5. Consensus was predefined as Cronbachs α ≥0.80. Items that 80% of experts ranked as ≥4 were included in the final framework. RESULTS Twenty-four international experts with training in general surgery (n = 11), orthopaedic surgery (n = 2), obstetrics and gynecology (n = 3), urology (n = 1), plastic surgery (n = 1), pediatric surgery (n = 1), otolaryngology (n = 1), vascular surgery (n = 1), military (n = 1), and doctorate-level educators (n = 2) completed the iterative online Delphi survey. Consensus among participants was achieved after one round of the survey (Cronbachs α = 0.91). The final framework included predevelopment analysis; cognitive, psychomotor, and team-based training; curriculum validation evaluation and improvement; and maintenance of training. CONCLUSIONS The Delphi methodology allowed for determination of international expert consensus on the principles for design, validation, and implementation of a simulation-based surgical training curriculum. These principles were formulated into a framework that can be used internationally across surgical specialties as a step-by-step guide for the development and validation of future simulation-based training curricula.

Simulation-based training and learning curves in laparoscopic Roux-en-Y gastric bypass.

Ex vivo simulation‐based technical skills training has been shown to improve operating room performance and shorten learning curves for basic laparoscopic procedures. The application of such training for laparoscopic Roux‐en‐

Development, Feasibility, Validity, and Reliability of a Scale for Objective Assessment of Operative Performance in Laparoscopic Gastric Bypass Surgery

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Error rating tool to identify and analyse technical errors and events in laparoscopic surgery

gastric bypass (LRYGBP) has not been reviewed.

Surgical Simulation in 2013: Why Is It Still Not the Standard in Surgical Training?

BACKGROUND There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale. STUDY DESIGN The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons. RESULTS A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbachs alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001). CONCLUSIONS The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.

Self Versus External Assessment for Technical Tasks in Surgery: A Narrative Review

Surgical error analysis is essential for investigating mechanisms of errors, events and adverse outcomes. Furthermore, it provides valuable information for formative feedback and quality control. The aim of the present study was to design and validate a technical error rating tool in laparoscopic surgery.

Comprehensive simulation-enhanced training curriculum for an advanced minimally invasive procedure: a randomized controlled trial

Received June 12, 2013; Revised September 25, 2013; Accepted Se 25, 2013. From the Department of Surgery, University of Toronto Grantcharov), Division of General Surgery (Grantcharov) and Research Centre of the Li Ka Shing Knowledge Institute St Michael’s Hospital, Toronto, Canada, Department of Surgery, P School of Medicine, University of Pennsylvania, Philadelph (Aggarwal), Division of Surgery, Department of Surgery and Imperial College London, London, UK (Aggarwal). Correspondence address: Boris Zevin, MD, Keenan Research C the Li Ka Shing Knowledge Institute, St Michael’s Hospital, 30 B Toronto, Ontario M5B 1W8, Canada. email: boris.zevin@mail.uto

Teaching nontechnical skills in surgical residency: A systematic review of current approaches and outcomes

BACKGROUND Self-assessment is an intricate component of continuing professional development and lifelong learning for health professionals. The agreement between self and external assessment for cognitive tasks in health professionals is reported to be poor; however, this topic has not been reviewed for technical tasks in surgery. OBJECTIVE To compare self and external assessment for technical tasks in surgery. METHODS MEDLINE, ERIC, and Google Scholar databases were searched for data from January 1960 to November 2011. Inclusion criteria were restricted to articles published in English in peer-reviewed journals, which reported on a comparison between self and external assessment for a technical task in a surgical specialty and involved medical students, surgical residents, surgical fellows, or practicing surgeons. Abstracts of identified articles were reviewed and pertinent full-text versions were retrieved. Manual searching of bibliographies for additional studies was performed. Data were extracted in a systematic manner. RESULTS From a total of 49 citations, 17 studies (35%) were selected for review. Eight of the 17 studies (47%) reported no agreement, whereas 9 studies (53%) reported an agreement between self and external assessment for technical tasks in surgery. Four studies (24%) reported higher self versus external assessment scores, whereas 3 studies (18%) reported lower self versus external assessment scores. Sixteen studies (94%) focused on retrospective self-assessment and 1 study (6%) focused on predictive self-assessment. Agreement improved with higher levels of participant training; with high-quality, timely, and relevant feedback; and with postprocedure video review. CONCLUSIONS This review demonstrated mixed results regarding an agreement between self and external assessment scores for technical tasks in surgery. Future investigations should attempt to improve the study design by accounting for differences between men and women, conducting paired and independent mean comparisons of self and external assessments, and ensuring that external assessments are valid and reliable.