Katherine M. McKendy

Reconstruction after major chest wall resection: Can rigid fixation be avoided?

BACKGROUND Rigid fixation is advocated as the best method to achieve good respiratory outcomes after chest wall resection at the expense of a high complication rate. The following study aims to examine the role of myocutaneous pedicled flaps, with or without soft prosthesis, in the reconstruction of small and large chest wall defects. METHODS All patients who underwent resection of chest wall tumors between 2003-2010 were identified from a prospectively entered database. Operative and postoperative outcomes were documented. Patients were stratified into 2 separate groups based on the size of the residual chest wall defect; the Small Defect (SD) group (<60 cm(2)) and the Large Defect (LD) group (>60 cm(2)). RESULTS Thirty-seven patients were identified over a 7-year period: 9 in the SD group and 28 in the LD group. Primary sarcoma was the most common indication for resection (57%). The mean size of the chest wall defect was 50.8 cm(2) in the SD group and 149.4 cm(2) in the LD group (P = .001). All patients underwent reconstruction with autologous tissue, nonrigid prosthesis, or a combination of the two. Prosthesis was used in 11% of patients in the SD group and 61% of patients in the LD group (P = .018). The rate of immediate postoperative extubation was 100% in the SD group and 89% in the LD group (P = .42). The rate of postoperative pneumonia was 7% in the LD group vs 0% in the SD group. The rate of surgical site infection was 7% in the LD group and 0% in the SD group. A subgroup analysis of the LD group demonstrated no statistical differences in any of the measured outcomes between patients in whom mesh prosthesis was used and patients in whom a myocutaneous flap alone was used. However, there was a clinical suggestion of prolonged ventilation in the subgroup where mesh was not used and of higher infection rates in the subgroup where mesh was used. CONCLUSION Small chest wall defects can be reconstructed with pedicled myocutaneous flaps alone without compromising respiratory outcomes. In carefully selected patients with moderate size defects larger than 60 cm(2), reconstruction with pedicled myocutaneous flap alone offers similar postoperative outcomes as reconstruction with nonrigid prosthesis, at the expense of a possible need for a short period of mechanical ventilation.

Multicenter proficiency benchmarks for advanced laparoscopic suturing tasks

BACKGROUND Advanced laparoscopic suturing (LS) tasks were developed based on a needs assessment. Initial validity evidence has been shown. The purpose of this multicenter study was to determine expert proficiency benchmarks for these tasks. METHODS 6 tasks were included: needle handling (NH), offset-camera forehand suturing (OF), offset-camera backhand suturing (OB), confined space suturing (CF), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons experienced in LS completed the tasks twice. Mean time and median accuracy scores were used to establish the benchmarks. RESULTS Seventeen MIS surgeons enrolled, from 7 academic centers. Mean (95% CI) time in seconds to complete each task was: NH 169 (149-189), OF 158 (134-181), OB 189 (154-224), CF 181 (156-205), UT 379 (334-423), and CS 416 (354-477). Very few errors in accuracy were made by experts in each of the tasks. CONCLUSIONS Time- and accuracy-based proficiency benchmarks for 6 advanced LS tasks were established. These benchmarks will be included in an advanced laparoscopic surgery curriculum currently under development.

Reliable assessment of operative performance.

BACKGROUND There is no consensus regarding the number of intraoperative assessments required to reliably measure trainee performance. This study used generalizability theory (GT) to describe factors contributing to score variance and to estimate the number of assessments needed to achieve high standards of reliability. METHODS While performing laparoscopic procedures, trainees were assessed by the attending surgeon using Global Operative Assessment of Laparoscopic Skills (GOALS). Data were collected prospectively (2-month intervals), assessing each trainee multiple times. Reliability coefficient was calculated using trainees, cases, and raters as factors. RESULTS Eighteen trainees were included for a total of 65 assessments. Total variance in scores was accounted for as follows: 66.1% by trainees, 31.6% by the interaction between trainees and cases, and 2.3% by raters. At least 3 cases are required for reliable scores using GOALS. CONCLUSIONS Trainees accounted for most of the variance in GOALS scores with a minimum of 3 cases required to improve the reliability of the scores obtained. These data may guide the implementation of performance assessments in surgical training programs.

Reliable Assessment of Performance in Surgery: A Practical Approach to Generalizability Theory.

When we assess residents performing surgery using various assessment instruments, how do we know that we are indeed measuring what we think we are measuring? In recent years, surgical training programs have begun to use performance assessment tools as a means of providing formative feedback to trainees, assessing their progress, as well as for the purposes of summative feedback and certification. For any given purpose, the reliability of assessment tools should be demonstrated. The surgical environment is highly variable and trainee performance depends on many external factors such as the type of surgical procedure being performed, the level of case difficulty, and the individuals involved in a case. All these external factors could affect the operative performance and assessment scores of trainees. Classic methods for estimating reliability, such as interrater reliability (raters), internal consistency (items), and test-retest reliability (cases), allow for separate evaluation of the effect of a given variable on trainee scores. This limits the accurate interpretation of the data as classic reliability measurements do not take into account the effects of the different variables on one another. In addition, in order to calculate test-retest reliability, each occasion needs to be the same or similar, which is less applicable for operative performance assessment in the real world, as each case (occasion) is different and is affected by external factors. For this reason, when assessing trainee performance in a variable work environment, reliability needs to be established using methods that can account for simultaneously interacting factors. One of the ways to address this variability is by using Generalizability Theory (GT). Instead of providing a reliability coefficient from a single factor, as in classic reliability methodology, GT integrates multiple potential factors, such as raters, items, and cases, into a single reliability coefficient. This theory has been used for simulation studies but few studies have examined the application

What are the Training Gaps for Acquiring Laparoscopic Suturing Skills

INTRODUCTION Advanced laparoscopic suturing is considered a challenging skill to acquire. The aim of this study was to investigate the learning process for advanced laparoscopic suturing in the operating room to understand the obstacles trainees face when trying to master the skill. METHODS A qualitative methodology using semistructured interviews and field observations was used. Data were analyzed using a Grounded Theory approach. Participants were general surgery residents and surgeons with advanced minimally invasive surgery (MIS) experience. RESULTS Ten MIS surgeons across different institutions and 15 local general surgery residents were interviewed. The semistructured interviews and field observations of 9 advanced MIS operations (27h) yielded the following 6 themes around the acquisition of laparoscopic suturing skills for residents: complexity, training misalignment, variability of opportunities, inconsistency of techniques, lack of feedback, and differing expectations. CONCLUSION There are several unmet training needs around laparoscopic suturing skills. Training for advanced laparoscopic skills requires more emphasis on coaching and the development of advanced models. This study heralded the need to incorporate advanced laparoscopic skills into the surgical simulation curriculum.

Development of a Model for the Acquisition and Assessment of Advanced Laparoscopic Suturing Skills Using an Automated Device

Background. Needs assessment identified a gap regarding laparoscopic suturing skills targeted in simulation. This study collected validity evidence for an advanced laparoscopic suturing task using an Endo StitchTM device. Methods. Experienced (ES) and novice surgeons (NS) performed continuous suturing after watching an instructional video. Scores were based on time and accuracy, and Global Operative Assessment of Laparoscopic Surgery. Data are shown as medians [25th-75th percentiles] (ES vs NS). Interrater reliability was calculated using intraclass correlation coefficients (confidence interval). Results. Seventeen participants were enrolled. Experienced surgeons had significantly greater task (980 [964-999] vs 666 [391-711], P = .0035) and Global Operative Assessment of Laparoscopic Surgery scores (25 [24-25] vs 14 [12-17], P = .0029). Interrater reliability for time and accuracy were 1.0 and 0.9 (0.74-0.96), respectively. All experienced surgeons agreed that the task was relevant to practice. Conclusion. This study provides validity evidence for the task as a measure of laparoscopic suturing skill using an automated suturing device. It could help trainees acquire the skills they need to better prepare for clinical learning.

A scoping review of assessment tools for laparoscopic suturing

BackgroundA needs assessment identified a gap in teaching and assessment of laparoscopic suturing (LS) skills. The purpose of this review is to identify assessment tools that were used to assess LS skills, to evaluate validity evidence available, and to provide guidance for selecting the right assessment tool for specific assessment conditions.MethodsBibliographic databases were searched till April 2017. Full-text articles were included if they reported on assessment tools used in the operating room/simulation to (1) assess procedures that require LS or (2) specifically assess LS skills.ResultsForty-two tools were identified, of which 26 were used for assessing LS skills specifically and 26 for procedures that require LS. Tools had the most evidence in internal structure and relationship to other variables, and least in consequences.ConclusionThrough identification and evaluation of assessment tools, the results of this review could be used as a guideline when implementing assessment tools into training programs.

Response to: The use of coarsened exact matching to evaluate treatment mode in the rib fracture patient

To the Editor, We thank Amaral et al. for their interest in our work. As mentioned in their letter, the management of traumatic rib fractures is controversial, in particular the use of thoracic epidural analgesia. Recent guidelines do not strongly advocate for their use, and only provide a “conditional use” recommendation based on “very low quality” evidence. As pointed out in their letter, the lack of consensus regarding the effectiveness of thoracic epidural analgesia is due in part to significant heterogeneity in study designs. However, a meta-analysis of randomized trials comparing epidural and nonepidural analgesia for blunt traumatic rib fractures have also failed to demonstrate a benefit in favor of epidural analgesia, albeit with a small overall number of patients. Observational studies also demonstrate equivocal results. These data highlight the limited generalizability of any single-center study. There may be considerable differences in patient population, injury patterns, and management algorithms from one setting to another. With regards to epidural analgesia, there is particularly significant variation in the medications and protocols used within the epidural infusion itself, as well as in the nonepidural analgesic management. Amaral et al. performed a similar analysis to our study using their own data, but they report differing results in that epidural analgesia was associated with improved outcomes compared with nonepidural analgesia. While we agree with their detailed explanation about the limitations of matching based only on observed variables, their analysis further reinforces the limited generalizability of a single-institution study. The fact that a similar study methodology, that is a matched analysis based registry data, would produce wholly discrepant results from a separate data set suggests that there are likely to be important differences between the two data sets, and by inference between the individual institutions. This should be the focus of discussion rather than the statistical method employed, which are all imperfect when it comes to analyses based on observational data. Further data from single-institution studies may only further muddy the proverbial waters based on the factors discussed above. Ideally, the question of epidural analgesia

A Learner-Created Virtual Patient Curriculum for Surgical Residents: Successes and Failures.

OBJECTIVE To determine the feasibility and effectiveness of a learner-created virtual patient (VP) curriculum for postgraduate year 2 surgical residents. DESIGN Using a social-constructivist model of learning, we designed a learner-created VP curriculum to help postgraduate year 2 residents prepare for their in-training surgical examination. Each resident was assigned to create a VP curriculum based on the learning objectives for this examination, and VP cases were then disseminated to all residents for completion. To measure the learning effects of the curriculum, participants completed 2 simulated in-training examinations, both at the beginning and at the end of the intervention. Study participants also participated in a focus group and completed an online questionnaire about the perceived learning value of the curriculum. SETTING The study was conducted at the McGill University Health Centre, a tertiary care hospital in Montreal, Canada. PARTICIPANTS In total, 24 residents from 7 surgical specialties completed both the pretest and posttest, as well as took part in the creation of a VP curriculum. Of those 24 residents, only 19 residents completed the cases created by their peers, with 7 completing greater than 50% of the cases and 12 completing less than 50%. In all 17 residents responded to the online questionnaire and 11 residents participated in the focus group. RESULTS The VP curriculum failed to improve scores from pretest (59.6%, standard deviation = 8.1) to posttest (55.4%, standard deviation = 6.6; p = 0.01) on the simulated in-training examination. Nonetheless, survey results demonstrated that most residents felt that creating a VP case (89%) and completing cases created by their peers (71%) had educational value. Overall, 71% preferred active participation in a curriculum to traditional didactic teaching. The focus group identified time-related constraints, concern about the quality of the peer-created cases, and questioning of the relationship between the curriculum and the Surgical Foundations examination as barriers to the success of the curriculum. CONCLUSIONS Despite the fact that a learner-created VP curriculum did not improve scores on a mock in training examination, residents viewed this intervention as a valuable educational experience. Although there were barriers to the implementation of a learner-created curriculum, it is nonetheless important to try and integrate pedagogical concepts into the instructional design of curricula for surgical residents.