Dara O. Kavanagh

Is the skillset obtained in surgical simulation transferable to the operating theatre

BACKGROUND Simulated surgical training offers a safe and accessible way of learning surgical procedures outside the operating room. Training programs have been developed using simulated laboratories to train surgical trainees to proficiency outside the operating room. Despite the global enthusiasm among educators to enhance training through simulation-based learning, it remains to be elucidated whether the skill set obtained is transferrable to the operating room. METHODS Using standardized search methods, the authors searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web-Based Knowledge, as well as the reference lists of relevant articles, and retrieved all published randomized controlled trials. RESULTS Sixteen randomized controlled trials involving 309 participants were identified to be suitable for qualitative analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The mean Consolidated Standards of Reporting Trials score was 16 (range, 12-22). The studies showed considerable clinical and methodologic diversity. Operative time improved consistently in all trials after training and was the only objective parameter measurable in the live setting. Studies that used the Objective Structured Assessment of Technical Skills as their primary outcome showed improved scores in 80% of trials, and studies that used performance indicators to assess participants all showed improved scores after simulation training in all of the trials, with 88% showing statistical significance. CONCLUSIONS The current literature consistently demonstrates the positive impact of simulation on operative time and predefined performance scores. However, these reproducible measures alone are insufficient to demonstrate transferability of skills from the laboratory to the operating room. The authors advocate a multimodal assessment, including metrics, the Objective Structured Assessment of Technical Skills, and critical step completion. This may provide a more complete assessment of operative performance. Only then can it be concluded that simulation skills are transferable to the live operative setting.

The impact of aptitude on the learning curve for laparoscopic suturing

BACKGROUND Within surgery, several specialties demand advanced technical skills, specifically in the minimally invasive environment. METHODS Two groups of 10 medical students were recruited on the basis of their aptitude (visual-spatial ability, depth perception, and psychomotor ability). All subjects were tested consecutively using the ProMIS III simulator until they reached proficiency performing laparoscopic suturing. Simulator metrics, critical error scores, observed structured assessment of technical skills scores, and Fundamentals of Laparoscopic Surgery scores were recorded. RESULTS Group A (high aptitude) achieved proficiency after a mean of 7 attempts (range, 4-10). In group B (low aptitude), 30% achieved proficiency after a mean of 14 attempts (range, 10-16). In group B, 40% demonstrated improvement but did not attain proficiency, and 30% failed to progress. CONCLUSIONS Distinct learning curves for laparoscopic suturing can be mapped on the basis of fundamental ability. High aptitude is directly related to earlier completion of the learning curve. A proportion of subjects with low aptitude are unable to reach proficiency despite repeated attempts.

The role of oestrogen receptor α in human thyroid cancer: contributions from coregulatory proteins and the tyrosine kinase receptor HER2

Epidemiological, clinical, and molecular studies suggest a role for oestrogen in thyroid cancer. How oestrogen mediates its effects and the consequence of it on clinical outcome has not been fully elucidated. The participation of coregulatory proteins in modulating oestrogen receptor (ER) function and input of crosstalk with the tyrosine kinase receptor HER2 was investigated. Oestrogen induced cell proliferation in the follicular thyroid cancer (FTC)-133 cells, but not in the anaplastic 8305C cell line. Knockdown of the coactivator steroid receptor coactivator (SRC)-1 inhibited FTC-133 basal, but not oestrogen induced, cell proliferation. Oestrogen also increased protein expression of SRC-1 and the ER target gene cyclin D1 in the FTC-133 cell line. ERalpha, ERbeta, the coregulatory proteins SRC-1 and nuclear corepressor (NCoR), and the tyrosine kinase receptor HER2 were localised by immunohistochemistry and immnofluorescence in paraffin-embedded tissue from thyroid tumour patients (n=111). ERalpha was colocalised with both SRC-1 and NCoR to the nuclei of the tumour epithelial cells. Expression of ERalpha and NCoR was found predominantly in non-anaplastic tumours and was significantly associated with well-differentiated tumours and reduced incidence of disease recurrence. In non-anaplastic tumours, HER2 was significantly associated with SRC-1, and these proteins were associated with poorly differentiated tumours, capsular invasion and disease recurrence. Totally, 87% of anaplastic tumours were positive for SRC-1. Kaplan-Meier estimates of disease-free survival indicated that in thyroid cancer, SRC-1 strongly correlates with reduced disease-free survival (P<0.001), whereas NCoR predicted increased survival (P<0.001). These data suggest opposing roles for the coregulators SRC-1 and NCoR in thyroid tumour progression.

Does Aptitude Influence the Rate at which Proficiency Is Achieved for Laparoscopic Appendectomy

BACKGROUND The attainment of technical competence for surgical procedures is fundamental to a proficiency-based surgical training program. We hypothesized that aptitude may directly affect ones ability to successfully complete the learning curve for minimally invasive procedures. The aim was to assess whether aptitude has an impact on ability to achieve proficiency in completing a simulated minimally invasive surgical procedure. The index procedure chosen was a laparoscopic appendectomy. STUDY DESIGN Two groups of medical students with disparate aptitude were selected. Aptitude (visual-spatial, depth perception, and psychomotor ability) was measured by previously validated tests. Indicators of technical proficiency for laparoscopic appendectomy were established by trained surgeons with an individual case volume of more than 150. All subjects were tested consecutively on the ProMIS III (Haptica) until they reached predefined proficiency in this procedure. Simulator metrics, critical error scores, and Objective Structured Assessment of Technical Skills (OSATS) scores were recorded. RESULTS The mean numbers of attempts to achieve proficiency in performing a laparoscopic appendectomy for group A (high aptitude) and B (low aptitude) were 6 (range 4 to 7) and 14 (range 10 to 18), respectively (p < 0.0001). Significant differences were found between the 2 groups for path length (p = 0.014), error score (p = 0.021), and OSATS score (p < 0.0001) at the initial attempt. CONCLUSIONS High aptitude is directly related to a rapid attainment of proficiency. These findings suggest that resource allocation for proficiency-based technical training in surgery may need to be tailored according to a trainees natural ability.

The impact of a surgical boot camp on early acquisition of technical and nontechnical skills by novice surgical trainees

BACKGROUND Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program. METHODS New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills. RESULTS The scores for knowledge (53.8% vs 68.4%, P < .01), technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P < .01), and confidence levels improved significantly during boot camp. Skills improvements were still present a year later. CONCLUSION The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees.