Oscar Traynor

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.

Role and feasibility of psychomotor and dexterity testing in selection for surgical training

The practice of Surgery has undergone major changes in the past 20 years and this is likely to continue. Knowledge, judgement and good technical skills will no longer be enough to safely practice surgery and interventional procedures. Fundamental abilities (e.g. psychomotor skills, visuospatial ability and depth perception) are critically important for catheter‐based interventions, NOTES, robotic surgery and other procedural interventions of the future. Not all individuals possess the same amount of these innate fundamental abilities and those less endowed are likely to struggle during surgical training and thereafter in surgical practice. In contrast to other high‐skill professions/industries (e.g. aviation) we do not have a tradition of testing prospective surgical trainees for abilities/attributes that we now recognize as being important for surgical practice. Instead, we continue to rely on surrogate markers of future potential (e.g. academic record). However, many studies have shown that psychomotor ability is an important predictor of both learning rate and performance for complex laparoscopic tasks. Psychomotor skills, visuospatial ability and depth perception can all be tested objectively by validated tests. At the Royal College of Surgeons in Ireland, all short‐listed candidates for Higher Surgical Training now undergo formal testing of both technical skills and fundamental abilities (psychomotor skills, visuospatial ability and depth perception). Reports on each candidate’s performance are supplied to the interview committee. Furthermore, a prospective database is being kept for correlation with future surgical performance. We believe that selection into surgical training should take account of attributes that we know are important for safe and efficient surgical practice.

Primary liver transplantation for autoimmune hepatitis: A comparative analysis of the European Liver Transplant Registry

The principal aim of this study was to compare the probability of and potential risk factors for death and graft loss after primary adult and pediatric liver transplantation in patients undergoing transplantation for autoimmune hepatitis (AIH) to those in patients undergoing transplantation for primary biliary cirrhosis (PBC; used as the reference group) or alcoholic cirrhosis (used as an example of a nonautoimmune liver disease). The 5‐year survival of patients undergoing transplantation for AIH (n = 827) was 0.73 [95% confidence interval (CI) = 0.67‐0.77]. This was similar to that of patients undergoing transplantation for alcoholic cirrhosis (0.74, 95% CI = 0.72‐0.76, n = 6424) but significantly worse than that of patients undergoing transplantation for PBC (0.83, 95% CI = 0.80‐0.85, n = 1588). Fatal infectious complications occurred at an increased rate in patients with AIH (hazard ratio = 1.8, P = 0.002 with PBC as the reference). The outcome of pediatric AIH patients was similar to that of adult patients undergoing transplantation up to the age of 50 years. However, the survival of AIH patients undergoing transplantation beyond the age of 50 years (0.61 at 5 years, 95% CI = 0.51‐0.70) was significantly reduced in comparison with the survival of young adult AIH patients (0.78 at 18‐34 years, 95% CI = 0.70‐0.86) and in comparison with the survival of patients of the same age group with PBC or alcoholic cirrhosis. In conclusion, age significantly affects patient survival after liver transplantation for AIH. The increased risk of dying of infectious complications in the early postoperative period, especially above the age of 50 years, should be acknowledged in the management of AIH patients with advanced‐stage liver disease who are listed for liver transplantation. It should be noted that not all risk factors relevant to patient and graft survival could be analyzed with the European Liver Transplant Registry database. Liver Transpl , 2010.

Video Gaming Enhances Psychomotor Skills But Not Visuospatial and Perceptual Abilities in Surgical Trainees

INTRODUCTION There is considerable interest in the identification and assessment of underlying aptitudes or innate abilities that could potentially predict excellence in the technical aspects of operating. However, before the assessment of innate abilities is introduced for high-stakes assessment (such as competitive selection into surgical training programs), it is essential to determine that these abilities are stable and unchanging and are not influenced by other factors, such as the use of video games. The aim of this study was to investigate whether experience playing video games will predict psychomotor performance on a laparoscopic simulator or scores on tests of visuospatial and perceptual abilities, and to examine the correlation, if any, between these innate abilities. METHODS Institutional ethical approval was obtained. Thirty-eight undergraduate medical students with no previous surgical experience were recruited. All participants completed a self-reported questionnaire that asked them to detail their video game experience. They then underwent assessment of their psychomotor, visuospatial, and perceptual abilities using previously validated tests. The results were analyzed using independent samples t tests to compare means and linear regression curves for subsequent analysis. RESULTS Students who played video games for at least 7 hours per week demonstrated significantly better psychomotor skills than students who did not play video games regularly. However, there was no difference on measures of visuospatial and perceptual abilities. There was no correlation between psychomotor tests and visuospatial or perceptual tests. CONCLUSIONS Regular video gaming correlates positively with psychomotor ability, but it does not seem to influence visuospatial or perceptual ability. This study suggests that video game experience might be beneficial to a future career in surgery. It also suggests that relevant surgical skills may be gained usefully outside the operating room in activities that are not related to surgery.

Training Surgical Skills Using Nonsurgical Tasks—Can Nintendo Wii™ Improve Surgical Performance?

BACKGROUND It has been suggested that abilities in nonsurgical tasks may translate to the surgical setting, with video gaming attracting particular attention because of the obvious similarities in the skills required. The aim of this study was to assign laparoscopic novices prospectively to receive a period of structured practice on the Nintendo Wii™ (Nintendo of America, Inc, Redmond, Washington) and compare their performance of basic laparoscopic tasks before and after this session to control subjects. METHODS In all, 22 medical students with no prior laparoscopic or video game experience were recruited to the study. They were randomized into 2 groups: group 1 served as the control and group 2 was the Wii™ group. All subjects performed 2 physical (bead transfer and glove cutting) and 1 virtual laparoscopic simulated tasks on the ProMIS surgical simulator (Haptica, Boston, Massachusetts). Performance metrics were measured. The same tasks were repeated an average of 7 days later, and between the 2 sessions, the subjects in the Wii™ group had structured practice sessions on the Wii™ video game. RESULTS Taken together, all subjects improved their performance significantly from session 1 to session 2. For the physical tasks, the Wii™ group performed better on session 2 for all metrics but not significantly. The Wii™ group showed a significant performance improvement for one metric in the bead transfer task compared with controls. For the virtual task, there was no significant improvement between sessions 1 and 2. CONCLUSIONS The novice subjects demonstrated a steep learning curve between their first and second attempts at the laparoscopic tasks. Practicing on the Wii™ was associated with a trend toward a better performance on session 2, although the difference was not significant. This finding suggests that a more intensive practice schedule may be associated with a better performance, and we propose that training on non-surgical tasks may be a cheap, convenient, and effective addition to current training curricula.

NOVEL METHOD FOR ASSESSMENT AND SELECTION OF TRAINEES FOR HIGHER SURGICAL TRAINING IN GENERAL SURGERY

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty‐two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short‐listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree’s or diplomas that had been obtained through part‐time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short‐listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post‐graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability α = 0.89 and good statistical power (range 0.95–0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.

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.

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure

Objective To assess the effect of proximate or immediate feedback during an intensive training session. The authors hypothesised that provision of feedback during a training session would improve performance and learning curves. Methods Twenty-eight trainee surgeons participated in the study between September and December 2008. They were consecutively assigned to group 1 (n=16, no feedback) or group 2 (n=12, feedback) All the participants performed five hand-assisted laparoscopic colectomy procedures on the ProMIS surgical simulator. Efficiency of instrument use (instrument path length and smoothness) and predefined intraoperative error scores were assessed. Facilitators assisted their performance and answered questions when asked. Group 1 participants were given no extra assistance, but group 2 participants received standardised feedback and the chance to review errors after every procedure. Data were analysed using SPSS V.15. Mann–Whitney U tests were used to compare mean performance results, and analysis of variance was used to calculate within-subject improvement. Results Group 1 achieved better results for instrument path length (23 874 mm vs 39 086 mm, p=0.001) and instrument smoothness (2015 vs 2567, p=0.045) However, group 2 (feedback) performed significantly better with regard to error scores (14 vs 4.42, p=0.000). In addition, they demonstrated a smoother learning curve. Inter-rater reliability for the error scores was 0.97. Conclusion The provision of standardised proximate feedback was associated with significantly fewer errors and an improved learning curve. Reducing errors in the skills lab environment should lead to safer clinical performance. This may help to make training more efficient and improve patient safety.

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook

BackgroundThere is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.MethodsRetrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009.Results104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.ConclusionsA centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.

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.