Kent R. Van Sickle

Prospective, Randomized, Double-Blind Trial of Curriculum-Based Training for Intracorporeal Suturing and Knot Tying

BACKGROUND Advanced surgical skills such as laparoscopic suturing are difficult to learn in an operating room environment. The use of simulation within a defined skills-training curriculum is attractive for instructor, trainee, and patient. This study examined the impact of a curriculum-based approach to laparoscopic suturing and knot tying. STUDY DESIGN Senior surgery residents in a university-based general surgery residency program were prospectively enrolled and randomized to receive either a simulation-based laparoscopic suturing curriculum (TR group, n=11) or standard clinical training (NR group, n=11). During a laparoscopic Nissen fundoplication, placement of two consecutive intracorporeally knotted sutures was video recorded for analysis. Operative performance was assessed by two reviewers blinded to subject training status using a validated, error-based system to an interrater agreement of >or=80%. Performance measures assessed were time, errors, and needle manipulations, and comparisons between groups were made using an unpaired t-test. RESULTS Compared with NR subjects, TR subjects performed significantly faster (total time, 526+/-189 seconds versus 790+/-171 seconds; p < 0.004), made significantly fewer errors (total errors, 25.6+/-9.3 versus 37.1+/-10.2; p < 0.01), and had 35% fewer excess needle manipulations (18.5+/-10.5 versus 27.3+/-8.6; p < 0.05). CONCLUSIONS Subjects who receive simulation-based training demonstrate superior intraoperative performance of a highly complex surgical skill. Integration of such skills training should become standard in a surgical residencys skills curriculum.

The pretrained novice: Using simulation-based training to improve learning in the operating room

Enabling trainees to acquire advanced technical skills before they begin the operating room experience benefits both trainee and patient. Whether medical students who had received exclusively simulation-based training could perform laparoscopic suturing and knot-tying as well as senior surgery residents was determined. Simulators were used to train 11 fourth-year medical students with no previous suturing experience to perform intracorporeal suturing and to successfully tie a free-hand intracorporeal knot. Students’ skills were assessed by the performance of the fundal suturing portion of a Nissen fundoplication in a porcine model. Their operative performance was evaluated for time, needle manipulations, and total errors. Results were compared to those of 11 senior-level surgery residents performing the same task. The study concluded that trainees could learn advanced technical skills such as laparoscopic suturing and knot tying by using simulation exclusively. The trainees and senior level surgery residents had a similar number of needle manipulations.

Comparing three pedagogical approaches to psychomotor skills acquisition

BACKGROUND We compared traditional pedagogical approaches such as time- and repetition-based methods with proficiency-based training. METHODS Laparoscopic novices were assigned randomly to 1 of 3 training conditions. In experiment 1, participants in the time condition practiced for 60 minutes, participants in the repetition condition performed 5 practice trials, and participants in the proficiency condition trained until reaching a predetermined proficiency goal. In experiment 2, practice time and number of trials were equated across conditions. RESULTS In experiment 1, participants in the proficiency-based training conditions outperformed participants in the other 2 conditions (P < .014); however, these participants trained longer (P < .001) and performed more repetitions (P < .001). In experiment 2, despite training for similar amounts of time and number of repetitions, participants in the proficiency condition outperformed their counterparts (P < .038). In both experiments, the standard deviations for the proficiency condition were smaller than the other conditions. CONCLUSIONS Proficiency-based training results in trainees who perform uniformly and at a higher level than traditional training methodologies.

A retrospective study evaluating the use of Permacol surgical implant in incisional and ventral hernia repair

BACKGROUND The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. METHODS Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. RESULTS Median follow-up time was 649 days (max: 2857), median age 57 years (range 23-91), and BMI 32 kg/m(2) (range 17.6-77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives-Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan-Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. CONCLUSIONS Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. CLINICAL TRIAL REGISTRATION NUMBER NCT01214252 (http://www.clinicaltrials.gov).

Current Status of Simulation-Based Training in Graduate Medical Education

The use of simulation in Graduate Medical Education has evolved significantly over time, particularly during the past decade. The applications of simulation include introductory and basic technical skills, more advanced technical skills, and nontechnical skills, and simulation is gaining acceptance in high-stakes assessments. Simulation-based training has also brought about paradigm shifts in the medical and surgical education arenas and has borne new and exciting national and local consortia that will ensure that the scope and impact of simulation will continue to broaden.

Virtual Reality Simulators: Valuable Surgical Skills Trainers or Video Games?

BACKGROUND Virtual reality (VR) and physical model (PM) simulators differ in terms of whether the trainee is manipulating actual 3-dimensional objects (PM) or computer-generated 3-dimensional objects (VR). Much like video games (VG), VR simulators utilize computer-generated graphics. These differences may have profound effects on the utility of VR and PM training platforms. In this study, we aimed to determine whether a relationship exists between VR, PM, and VG platforms. METHODS VR and PM simulators for laparoscopic camera navigation ([LCN], experiment 1) and flexible endoscopy ([FE] experiment 2) were used in this study. In experiment 1, 20 laparoscopic novices played VG and performed 0° and 30° LCN exercises on VR and PM simulators. In experiment 2, 20 FE novices played VG and performed colonoscopy exercises on VR and PM simulators. RESULTS In both experiments, VG performance was correlated with VR performance but not with PM performance. Performance on VR simulators did not correlate with performance on respective PM models. CONCLUSIONS VR environments may be more like VG than previously thought.

Commentary on "Gas-Free single-port transumbilical laparoscopic cholecystolithotomy: Preliminary report on eight cases"

BACKGROUND To explore the feasibility and safety of gas-free single-port transumbilical laparoscopic cholecystolithotomy. METHODS An incision of 1.5-2.0 cm was made through all layers of the umbilicus, and a specially designed silicone plug with three 5-mm ports was inserted. The surgical space was created by lifting the right abdominal wall with an abdominal suspension set. A laparoscope, S-type dissector, grasper,electric needle, and needle-holder were used to perform a cholecystolithotomy. The procedure was performed in 8 patients with gall stones. RESULTS All stones were successfully removed. No postoperative complications, such as bleeding or bile leakage, occurred. The operative time was 45-120 minutes (mean 77.5 ± 24). The mean length of hospital stay was 2 days, and no postoperartive analgesics were used. There were no visible scars on the abdominal wall. CONCLUSIONS The gas-free single-port transumbilical laparoscopic approach was safe and feasible for cholecystolithotomy. This approach expands the applications of laparoendoscopic single-site surgery and avoids the use of highly concentrated CO(2) in the body and its potential side effects.

The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care

OBJECTIVE To decipher if patient attitudes toward resident participation in their surgical care can be improved with patient education regarding resident roles, education, and responsibilities. DESIGN An anonymous questionnaire was created and distributed in outpatient surgery clinics that had residents involved with patient care. In total, 3 groups of patients were surveyed, a control group and 2 intervention groups. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents. The first pamphlet used an analogy-based explanation. The second pamphlet used literature citations and statistics. SETTING Keesler Medical Center, Keesler AFB, MS. University of Texas Health Science Center at San Antonio, San Antonio, TX. PARTICIPANTS A total of 454 responses were collected and analyzed-211 in the control group, 118 in the analogy pamphlet group, and 125 in the statistics pamphlet group. RESULTS Patients had favorable views of residents assisting with their surgical procedures, and the majority felt that outcomes were the same or better regardless of whether they read an informational pamphlet. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care. Further, 52% of patients in the control group agreed or strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% of the patients who read the analogy pamphlet and statistics pamphlet, respectively (p = 0.05). When we combined the 2 intervention groups compared to the control group, this significant difference persisted (p = 0.02). CONCLUSION Most patients welcome resident participation in their surgical care, but they expect to be asked permission for resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently.

M1525 Tissue Cytokines Reveal Gender Difference in Acute Cholecystitis

Background: Male sex is a predictor for poor outcomes in patients with cholecystitis. Socioeconomic factors or gender-dependent inflammatory modulation may contribute to negative clinical outcomes. Patients and Methods: Patients presenting with acute or chronic cholecystitis for laparoscopic cholecystectomywere prospectively enrolled in the study. Acute cholecystitis was defined as a patient with unrelenting right upper quadrant pain, tenderness, and/or elevated WBC count, temperature, or ultrasonographic signs of acute cholecystitis. Demographic and socioeconomic data were obtained with a detailed survey. Interstitial fluid from gallbladder fundus and infundibulumbiopsies were analyzed for inflammatory cytokines and estradiol using a multiplex cytometric bead assay and estradiol enzyme immunoassay. ANOVA and logistic regression was used for statistical analysis. The study was IRB approved. Results: Clinical data for 89 patients (27 men, 62 women; mean age 37 yrs, mean BMI 32) were analyzed; tissue cytokine results were available for 64 patients. A WBC > 11,000 (OR 2.7, CI 1,02-7.2, p=0.045) and a temperature >100° F correlated with acute cholecystitis. No difference in WBC count, temperature, BMI, insurance status, or level of education was encountered between genders. Patients with acute cholecystitis had higher interleukin and lower tissue estradiol levels than patients with chronic cholecystitis. Men with acute cholecystitis had significantly higher tissue levels of IL-1b, IL-8, and IL-10 but not IL-6 or Estradiol than women (table). Conclusion: Significant differences in tissue level cytokines by disease state and sex were encountered although clinical presentation and socioeconomic status for men or women was not significantly different. Tissue cytokine levels by disease state and gender