Phillip G. Rowse

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.

Every Surgical Resident Should Know How to Perform a Cricothyrotomy: An Inexpensive Cricothyrotomy Task Trainer for Teaching and Assessing Surgical Trainees

OBJECTIVE Emergency cricothyrotomy is a rare but potentially lifesaving procedure. Training opportunities for surgical residents to learn this skill are limited, and many graduating residents have never performed one during their training. We aimed to develop and validate a novel and inexpensive cricothyrotomy task trainer that can be constructed from household items. DESIGN A model was constructed using a toilet paper roll (trachea and larynx), Styrofoam (soft tissue), cardboard (thyroid cartilage), zip tie (cricoid), and fabric (skin). Participants were asked to complete a simulated cricothyrotomy procedure using the model. They were then evaluated using a 10-point checklist (5 points total) devised by 6 general surgeons. Participants were also asked to complete an anonymous survey rating the educational value and the degree of enjoyment regarding the model. SETTING A tertiary care teaching hospital. PARTICIPANTS A total of 54 students and general surgery residents (11 medical students, 32 interns, and 11 postgraduate year 3 residents). RESULTS All 54 participants completed the training and assessment. The scores ranged from 0 to 5. The mean (range) scores were 1.8 (1-4) for medical students, 3.5 (1-5) for junior residents, and 4.9 (4-5) for senior-level residents. Medical students were significantly outperformed by junior- and senior-level residents (p < 0.001). Trainees felt that the model was educational (4.5) and enjoyable (4.0). CONCLUSIONS A low-fidelity, low-cost cricothyrotomy simulator distinguished the performance of emergency cricothyrotomy between medical students and junior- and senior-level general surgery residents. This task trainer may be ideally suited to providing basic skills to all physicians in training, especially in settings with limited resources and clinical opportunities.

Minimally invasive thymectomy: the Mayo Clinic experience

BACKGROUND The prevalence of minimally invasive thymectomy (MIT) is increasing and may have significant benefit to patients in terms of morbidity and post-operative recovery. Our aim was to review the Mayo Clinic experience of MIT. METHODS We reviewed data from all MIT cases collected in a prospectively maintained database from January 1995 to February 2015. Data were collected regarding patient demographics, perioperative management and patient outcomes. RESULTS A total of 510 thymectomies were performed in 20 years. Fifty-six patients underwent MIT (45 video-assisted thoracoscopy, 11 robotic-assisted). The median age was 55 years (range, 23-87 years) with male to female ratio of 25:31. Thymoma was the main pathologic diagnosis in 27/56 patients (48%), with 11/27 (41%) associated with myasthenia gravis (MG), and 16/27 (59%) non-MG. Other pathologies included 1/56 (2%) of each teratoma, lymphoma, lymphangioma, carcinoma and thymolipoma. There were 3/56 (5%) atrophic glands, 4/56 (7%) cysts, 6/56 (11%) benign glands and 11/56 (20%) hyperplastic. Mean blood loss (mL) and operative time (min) were significantly lower in the video-assisted thoracoscopic surgery (VATS) group compared to robotic (65±41 vs. 160±205 mL, P=0.04 and 102±39 vs. 178±53 min, P=0.001, respectively). There was no 30-day mortality. Post-operative morbidity occurred in 7/45 (16%) VATS patients (phrenic nerve palsy 7%, pericarditis 4%, atrial fibrillation 2%, pleural effusion 2%) and 1/11 (9%) robotic (urinary retention requiring self-catheterization). Reoperation was required in 1/3 of VATS patients with phrenic nerve palsy. There was no significant difference in length of hospital stay [VATS 1.5 days (range, 1-4 days) and robotic 2 days (range, 1-5 days) VATS; P=0.05]. Mean follow-up was 18.4 months (range, 1-50.4 months) with no tumor recurrences. CONCLUSIONS MIT can be performed with low morbidity and mortality. VATS is associated with reduced blood loss, operative times and earlier hospital discharge compared to robotic MIT.

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.

Facile conversion from biologic to mechanical prosthesis: A bailout for a hostile aortic root

Left ventricular outflow tract obstruction (LVOTO) due to early prosthetic aortic valve (AV) failure can be a complex re-operative problem especially in the presence of a hostile aortic root. We present a case of seventh time sternotomy for re-replacement of the AV using a less conventional approach.

The Need for Multiple Bypass Grafts in Repair of Right Coronary Artery to Coronary Sinus Fistulae

Coronary artery fistulas are rare anomalies with controversial management strategies. The two main treatment options are surgical repair and catheter embolization. This case report describes successful treatment of a complex right coronary artery-to-coronary sinus fistula by using a less conventional approach: multiple coronary artery bypass grafting.

Board 409 - Research Abstract Simulating Azygos Vein Ligation - Deliberate Practice is Invaluable (Submission #1187)

Introduction/Background General Surgery (GS) residents painstakingly learn to ligate vessels in continuity. Swift and skillful knot tying in the chest is a particular challenge to the burgeoning thoracic surgeon. We sought to assess baseline proficiency in ligating the azygos vein within a simulated chest among GS interns, medical students and thoracic surgery staff. Methods A low-fidelity chest model was constructed in the left lateral decubitus position using cardboard (scapula, ribs and chest wall), fabric (skin, subcutaneous tissue, muscle, fascia, esophagus, vagus and intercostal nerves, lung, mediastinal pleura and superior vena cava) and a 10 mL water filled balloon (azygos vein). GS interns (n = 34), medical students (n = 4) and thoracic surgery staff (n = 2) were asked to ligate the azygos vein in continuity through an eight cm diameter thoracotomy with a depth of 20 cm using 2-0 silk ligatures. Of the 40 participants, only staff surgeons had prior thoracic knot tying training. Scores were based on a 20-point grading scale including task completion, timing and completeness of lumen occlusion. Participants were surveyed anonymously and asked to rate degree of model realism, enjoyment and educational benefit using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results Thirty nine of 40 trainees completed the task. The mean score for GS interns was 9.2 (range 3–16, SD = 2.7), medical students 8.5 (range 5-10, SD 2.3, p = 0.54) and thoracic surgeons 18 (SD 0, p = 0.03). Mean task completion times among residents and medical students were slow (133 vs 132 seconds respectively). Staff surgeons were faster (mean = 36 seconds, p = 0.02). Proximal or distal azygos vein stump leaks of any kind occurred in 20% (13/68) of surgical resident veins, 38% (3/8) of medical student veins and none for staff. When azygos stumps were subjected to a force of 22.5N, 33% (4/12) of initial drip leaks worsened to unimpeded flow among surgical residents. Of the veins initially without leak, 2% (1/50) progressed to a detectable drip while 4% (2/50) progressed to unimpeded flow among surgical residents when stump force was applied. Survey response was 80%. Mean Likert scores for usefulness in teaching thoracic knot tying (4.6), utility in learning to tie in other difficult anatomic locations (4.6) and enjoyability (4.2) rated the highest. Trainees and staff felt that the model was acceptable with regards to realism (3.8) and usefulness as a practice tool (4.0). Conclusion This low-fidelity simulator is able to separate novice thoracic knot tiers from experienced surgeons. Participants validate its usefulness as a teaching tool with favorable response. This study further exposes the need for deliberate practice among young trainees. Disclosures None.

Board 302 - Research Abstract Evaluating General Surgery Residents Laparoscopic Skills via Low-Cost, Low-Fidelity Simulation: A Clever Use of Cloth and Felt (Submission #1185)

Introduction/Background Exploratory laparoscopy is a common surgical operation. While many laparoscopic virtual reality simulators exist, they are expensive and lack haptic feedback. We developed a low cost task trainer using a plastic box, cloth and felt for less than

Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications

15. We report our experience using this model to evaluate the laparoscopic skills of General Surgery (GS) senior residents. Methods Eighteen GS senior residents (11 PGY-3s and 7 PGY-5s) participated in a simulated laparoscopic repair of a perforated duodenal ulcer. The laparoscopic model consisted of a plastic box containing felt and cloth made to look like abdominal organs. The residents were assessed on their technique of inserting the camera, using bowel graspers, identifying structures, assessing the entire abdomen and closing the duodenotomy. All events were timed and videotaped for objective analysis. An in-house scoring system was utilized. Residents provided feedback regarding the utility of the exercise. Results Seventeen residents completed the scenario (time range: 5 – 11 minutes; mean 7 minutes). PGY-5 residents (range: 18-21; mean score=20) outperformed PGY-3 residents (range: 14 – 17; mean score=15.6), P<0.05. One model held up for all 17 evaluations (cost =