Esther M. Bonrath

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

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.

Laparoscopic simulation training: Testing for skill acquisition and retention.

BACKGROUND Simulation in laparoscopy leads to skill acquisition. Although many curricula for simulation training have been described, the nature of skill deterioration remains unclear. We evaluated skill acquisition and retention after laparoscopic simulation training. METHODS Thirty-six novices in surgery (medical students) underwent a 5-day curriculum consisting of 9 skills of increasing complexity. Each subject underwent baseline and post-training evaluation after completion of the course. Skill retention testing was measured after 6 weeks (group 1; n = 18) and after 11 weeks (group 2; n = 18). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance. RESULTS Comparison of the baseline and post-training values revealed a significant learning outcome for all exercises in both groups (P < .001). In group 1, skill retention testing found no significant decrease in skill level when compared to post-training values in all but 1 task (extracorporeal knot tying; P = .007). In group 2, differences between skill retention and post-training evaluation were observed for 5 of the 9 tasks (transfer task, positioning, loop tie, extracorporeal knot, and intracorporeal knot; P ≤ .05 for each). CONCLUSION Basic laparoscopic skills can be learned successfully by novices in surgery using a compact curriculum. These skills are retained for at least 6 weeks. Eleven weeks after initial training, skill deterioration is likely, and therefore an opportunity for practice and repetition is desirable.

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

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.

Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance

Mental practice, the cognitive rehearsal of a task without physical movement, is known to enhance performance in sports and music. Investigation of this technique in surgery has been limited to basic operations. The purpose of this study was to develop mental practice scripts, and to assess their effect on advanced laparoscopic skills and surgeon stress levels in a crisis scenario.

Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis

Background Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes. Objective Descriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures. Methods Events (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases. Results Sixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were ‘inadequate use of force/distance (too much)’ (n=20, 30%) and ‘inadequate visualisation’ during grasping/dissecting (n=6, 9%), ‘inadequate use of force/distance (too much)’ using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively. Conclusions Analysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons’ understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.

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

BACKGROUND There is no comprehensive simulation-enhanced training curriculum to address cognitive, psychomotor, and nontechnical skills for an advanced minimally invasive procedure. OBJECTIVES 1) To develop and provide evidence of validity for a comprehensive simulation-enhanced training (SET) curriculum for an advanced minimally invasive procedure; (2) to demonstrate transfer of acquired psychomotor skills from a simulation laboratory to live porcine model; and (3) to compare training outcomes of SET curriculum group and chief resident group. SETTING University. METHODS This prospective single-blinded, randomized, controlled trial allocated 20 intermediate-level surgery residents to receive either conventional training (control) or SET curriculum training (intervention). The SET curriculum consisted of cognitive, psychomotor, and nontechnical training modules. Psychomotor skills in a live anesthetized porcine model in the OR was the primary outcome. Knowledge of advanced minimally invasive and bariatric surgery and nontechnical skills in a simulated OR crisis scenario were the secondary outcomes. Residents in the SET curriculum group went on to perform a laparoscopic jejunojejunostomy in the OR. Cognitive, psychomotor, and nontechnical skills of SET curriculum group were also compared to a group of 12 chief surgery residents. RESULTS SET curriculum group demonstrated superior psychomotor skills in a live porcine model (56 [47-62] versus 44 [38-53], P<.05) and superior nontechnical skills (41 [38-45] versus 31 [24-40], P<.01) compared with conventional training group. SET curriculum group and conventional training group demonstrated equivalent knowledge (14 [12-15] versus 13 [11-15], P = 0.47). SET curriculum group demonstrated equivalent psychomotor skills in the live porcine model and in the OR in a human patient (56 [47-62] versus 63 [61-68]; P = .21). SET curriculum group demonstrated inferior knowledge (13 [11-15] versus 16 [14-16]; P<.05), equivalent psychomotor skill (63 [61-68] versus 68 [62-74]; P = .50), and superior nontechnical skills (41 [38-45] versus 34 [27-35], P<.01) compared with chief resident group. CONCLUSION Completion of the SET curriculum resulted in superior training outcomes, compared with conventional surgery training. Implementation of the SET curriculum can standardize training for an advanced minimally invasive procedure and can ensure that comprehensive proficiency milestones are met before exposure to patient care.