Jad M. Abdelsattar

Do You See What I See? How We Use Video as an Adjunct to General Surgery Resident Education

OBJECTIVE Preparation of learners for surgical operations varies by institution, surgeon staff, and the trainees themselves. Often the operative environment is overwhelming for surgical trainees and the educational experience is substandard due to inadequate preparation. We sought to develop a simple, quick, and interactive tool that might assess each individual trainees knowledge baseline before participating in minimally invasive surgery (MIS). DESIGN A 4-minute video with 5 separate muted clips from laparoscopic procedures (splenectomy, gastric band removal, cholecystectomy, adrenalectomy, and inguinal hernia repair) was created and shown to medical students (MS), general surgery residents, and staff surgeons. Participants were asked to watch the video and commentate (provide facts) on the operation, body region, instruments, anatomy, pathology, and surgical technique. Comments were scored using a 100-point grading scale (100 facts agreed upon by 8 surgical staff and trainees) with points deducted for incorrect answers. All participants were video recorded. Performance was scored by 2 separate raters. SETTING An academic medical center. PARTICIPANTS MS = 10, interns (n = 8), postgraduate year 2 residents (PGY)2s (n = 11), PGY3s (n = 10), PGY4s (n = 9), PGY5s (n = 7), and general surgery staff surgeons (n = 5). RESULTS Scores ranged from -5 to 76 total facts offered during the 4-minute video examination. MS scored the lowest (mean, range; 5, -5 to 8); interns were better (17, 4-29), followed by PGY2s (31, 21-34), PGY3s (33, 10-44), PGY4s (44, 19-47), PGY5s (48, 28-49), and staff (48, 17-76), p < 0.001. Rater concordance was 0.98-measured using a concordance correlation coefficient (95% CI: 0.96-0.99). Only 2 of 8 interns acknowledged the critical view during the laparoscopic cholecystectomy video clip vs 10 of 11 PGY2 residents (p < 0.003). Of 8 interns, 7 misperceived the spleen as the liver in the splenectomy clip vs 2 of 7 chief residents (p = 0.02). CONCLUSIONS Not surprisingly, more experienced surgeons were able to relay a larger number of laparoscopic facts during a 4-minute video clip of 5 MIS operations than inexperienced trainees. However, even tenured staff surgeons relayed very few facts on procedures they were unfamiliar with. The potential differentiating capabilities of such a quick and inexpensive effort has pushed us to generate better online learning tools (operative modules) and hands-on simulation resources for our learners. We aim to repeat this and other studies to see if our learners are better prepared for video assessment and ultimately, MIS operations.

Video Skills Curricula and Simulation: A Synergistic Way to Teach 2-Layered, Hand-Sewn Small Bowel Anastomosis

BACKGROUND We sought to determine if general surgery (GS) interns could learn a side-to-side, 2-layered, hand-sewn small bowel anastomosis (HSBA) using an online instructional video and low-fidelity simulation model. METHODS A 3-hour HSBA technical skills training session was held among GS interns. Participants were asked to write down the steps for performing a side-to-side, 2-layered HSBA (pretest). An online 13-minute instructional video on HSBA was then viewed. Low-fidelity bowel simulators were then provided for deliberate practice under staff supervision. A posttest (identical to pretest) concluded the session. The maximum test score was 20 points. At 4 months later, a retention test was administered. Trainees were anonymously surveyed to determine the sessions educational value. Pretest, posttest, and retention test scores were compared. RESULTS Participants were 25 GS interns. The mean pretest score was 5 (range: 0-11). Posttest scores improved (mean = 15; range: 11-19, p = 0.016), whereas retention test scores were stable (mean = 14; range: 8-18). Of those who participated in retention testing (24/25), 7 had now performed a 2-layered HSBA, 11 had witnessed HSBA, and 6 had neither performed nor witnessed an HSBA since the educational session. Retention test scores were higher among those who had performed HSBA (mean = 16; range: 13-18) vs those who had not performed nor witnessed an HSBA (mean = 14; range: 8-18, p = 0.04). Mean Likert scores supported the educational value of the session. CONCLUSION Initial intern performance of HSBA was abysmal. A contemporary online video skills curriculum coupled with low-fidelity bowel simulators improved trainee knowledge of how to perform a 2-layered HSBA. This effect remained stable over 4 months.

Assimilating endocrine anatomy through simulation: a pre-emptive strike!

BACKGROUND We sought to determine if endocrine anatomy could be learned with the aid of a hands-on, low-cost, low-fidelity surgical simulation curriculum and pre-emptive 60-second YouTube video clip. METHODS A 3-hour endocrine surgery simulation session was held on back-to-back Fridays. A video clip was made available to the 2nd group of learners. A comprehensive 40-point test was administered before (pre-test) and after (post-test) the sessions. RESULTS General surgery interns (n = 26) participated. The video was viewed 19 times by 80% (12 of 15) of interns with access. Viewers outperformed nonviewers on subsequent post-testing (mean [SD], 29.7 [1.3] vs 24.4 [1.6]; P = .015). Mean scores on the anatomy section of the post-test were higher among viewers than nonviewers (mean [SD] 14.2 [.9] vs 10.3 [1.0]; P = .012). CONCLUSIONS Low-cost simulation models can be used to teach endocrine anatomy. Pre-emptive viewing of a 60-second video may have been a key factor resulting in higher post-test scores compared with controls, suggesting that the video intervention improved the educational effectiveness of the session.

Mental and physical workloads in a competitive laparoscopic skills training environment: A pilot study

Surgical trainees undergo demanding training to achieve high surgical task proficiency. Abounding clinical and educational responsibilities mandate efficient and effective training. This research measured resident workload during laparoscopic skills training to identify excessive workload and how workload impacted task performance. Twenty-eight surgical trainees performed a standardized surgical training task and completed a workload questionnaire while observers measured physiological stress, posture risk assessment, and task performance. Participants self-reported mental demands, physical demands, temporal demands, performance, effort, and frustration. Effort (12±4) and frustration (12±5) were the highest subscales while physical demand (8±4) was the lowest. All participants were observed performing the task in at-risk postures, with 21% exhibiting risk levels requiring immediate intervention. Physical demand was associated with posture risk assessment scores (p<0.05). Mental demand was positively (R2=0.20, p<0.05) and frustration was negatively (R2=0.18, p<0.05) associated with skin conductance range. A point increase in physical demand was associated with a six second increase in performance time (β=6.0, p=0.01). These results support the fact that human factors and ergonomic tools can be used to relate surgical skills performance with workload, stress, and posture risks.

Abstract: Adipofascial Flap Versus ADM

PurPoSe: Acellular dermal matrix (ADM) has gained popularity to enhance lower pole coverage in immediate implant or expander reconstruction. Advantages of ADM include improved rapid reconstruction, postoperative expander filling and lower capsular contracture. Potential trade-offs include higher seroma, infection and cost. Alternatives for implant coverage include local fascial flaps and inferior dermal flaps as autologous options in select patients. Given the controversy about the use of ADM, this study provides an intraoperative algorithm for its selective use and review of clinical outcomes in two-stage immediate breast reconstruction.