Ruth Blackham

Eliminating the limitations of manual crimping in stapes surgery: Mid-term results of 90 patients in the nitinol stapes piston multicenter trial

Objective: To present our mid‐term results of our multicenter study using the Nitinol self‐crimping stapes piston, focusing on the interindividual variations of postoperative air‐bone gap closures (ABGC), postoperative hearing results, and postoperative recurrences of conductive hearing loss and to compare these findings with our pilot group of patients.

Surgical simulators in training: are we there yet?

This edition of the Journal includes an important paper from the Department of Surgery within the University of Auckland which analyses trainees’ performance following their exposure to a surgical simulator. The simulator chosen for this study was a software application which features operative text, interactive anatomy, video and a virtual reality cognitive simulator. The surgical procedure chosen was laparoscopic appendicectomy and the validity of this package was tested on junior trainees in a randomized trial. The trainees reported that this simulation model for training was highly usable. The study also showed effectiveness for first but not second year trainees, with those who were exposed to the software training package performing better on a multiple choice exam which assessed the transfer of procedural knowledge. This paper provides an important addition to the scanty literature on the effectiveness of such learning environments. The virtual reality cognitive simulator used in the study is an example of a high-fidelity simulator which is also ‘high tech’. Other high-fidelity devices include those which are widely available, and expensive, such as LapSim, Lap-VR and the Mentor series of devices. Low fidelity accordingly refers to simulations which also tend to be ‘low tech’ such as cadavers, animal tissues and whole animal models, and also ‘box trainers’ which are popular for laparoscopic part task training. There appears to be a genuine desire by surgical trainers, training bodies and health services to embrace simulation as a component of training courses in one form or another. The use of simulated learning environments is eminently attractive from a number of contexts. Patients may be reassured that trainees have some experience in technical exercises prior to their exposure to patients. The adoption of safe working hours policies and significant increases in medical graduate numbers have limited trainees’ access to clinical material. Trainees may, through simulation, be exposed to standardized material delivered in a reproducible and predictable fashion in a controlled environment. Computer-interface surgical simulation training allowing trainees to interact with the computer has in fact been with us for well over a decade now. In 2004, ASERNIP-S reported on surgical simulation and found that while computer simulation generally showed better results than no training at all, it was not convincingly superior to standard training. Model simulation may have been better than standard training, and cadaver training may have been better than model training. So how far have we progressed since the publication of the ASERNIP-S Report? The advancement necessary for optimal and effective computer training is a combination of authentic instrumentation and appearance on monitors and the provision of tactile feedback through haptic technology. Arguably, the haptic simulators which have embraced the most success whether that be commercial or in the training arena have been those used to train in endoscopic navigation techniques. However, high-tech simulations in technical surgical skills training have not fared so well in finding their place in simulation labs. Indeed, we may conclude that the use of high-tech laparoscopic simulators has not been demonstrated to produce any training benefits over low-cost box trainers. Loveday et al. are to be commended on the efforts they went to in order that they would present a robust validation study to add some strength to a growing area which has unfortunately for the most part been led by commercial interests than the desire for academic enquiry. We are not quite there yet.

A short course for surgical supervisors and trainers: effecting behavioural change

Background:  The Supervisors and Trainers for the Surgical Education and Training (SAT SET) course was developed to assist surgical trainers in Australia and New Zealand with the transition to the new Surgical Education and Training framework. The aim of this study was to assess whether attendance at the course translated into behavioural change in surgical trainers and supervisors.

Acute Conversion of Early Sleeve Gastrectomy Leak to Roux-en-Y Gastric Bypass

The management of staple line disruption following sleeve gastrectomy is a controversial area. We propose a novel method of converting a leaking sleeve gastrectomy to a Roux-en-Y gastric bypass in the acute setting, regardless of whether the defect is able to be visualized. Our proposed method of undertaking a major surgical reconstructive procedure is seemingly counter to traditional surgical dogma, requiring two anastomoses within a potentially septic field. We present three cases of sleeve leak where the conversion to a gastric bypass acutely was completed successfully. Additionally the potential length of stay and number of procedures is decreased in a Roux-en-Y conversion compared to endoscopic therapeutic measures in the same setting.

Giant perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass

Perforation of a marginal ulcer (MU) is a complication of Roux-en-Y gastric bypass that can be life-threatening. We report a case of a perforated MU that presented 7 months after surgery with several interesting points for discussion. Firstly, the presentation of the ulcer was cryptic with unreliable investigations. Secondly, the ulcer presented again even after anastomotic revision surgery. Finally, the ulcer and the sepsis associated with perforation presented after months of poor nutritional intake with profound hypoalbuminaemia. Perforated MUs causing malnutrition pose clinicians with the difficult decision of which operation to offer; patch repair, revision of the anastomosis or reversal surgery. This case illustrates that primary reversal surgery for a perforated recurrent MU may be the most appropriate surgical management in this clinical situation.

Light at the end of the virtual tunnel: why hasn't utilization of simulation changed?

The early promise of simulation being an essential complement to surgical education remains largely unfulfilled. Despite several decades of development in technology and non-technical simulation of skills and teams, the role of realistic models in surgical training has not paralleled the rise in other disciplines. Given aviation training in 2017 is almost synonymous with simulated learning activities and assessments, we must ask ourselves why this has not occurred in surgery. Historically, surgeons have been early adopters of new technology but cognizant of the fact that a model without measures of skill is ineffectual. As detailed by Satava et al., an initial framework is required for communication among educators, training bodies and credentialing organizations. Details of this infrastructure are required to provide validated metrics for objective surgical assessment, which led to the construction of standardized definitions and criteria. Some areas of surgery are indeed championing the cause of value-adding from an educational standpoint. The earliest developed methodology for proficiency-based progression was first described in detail by Gallagher et al. Based on this, a progressive training curriculum was developed by the Arthroscopy Association of North America utilizing both a model shoulder and cadaveric simulator. The protocol required trainees to master each skill set before progressing in training to the next level, validated in a series of papers assessing face, content and construct validity. The methodology optimizing trainee programme objectives also lent promise to assessment measures; however, it became readily apparent that curriculum development would first be required to formalize the defined metrics. Some groups have utilized Delphi methodology to this end for an entire discipline, such as gynaecology. The authors of this month’s Surgical Education paper have identified this chasm in the existing literature for laparoscopic appendicectomy in developing an evidence-based training curriculum for the procedure. However, it should be noted that the curriculum devised is based upon process measures such as time and efficiency with an apparent scotoma towards error measurements and other metrics of optimal surgical performance. Second, the achievement of a proficiency benchmark does not directly equate with proficiency as a surgeon; such validated metrics were derived from experienced clinicians with the attendant non-technical skills and decision-making capacity so important in the practicing surgeons’ professional life. The question remains while the technology and validation of the role of simulators in surgical education are changing, why utilization has not? The limitations include concrete factors such as lack of calibrated benchmarks and regional variation – while there is significant anecdotal homogeneity of routine operations in the Australasian context, the virtual reality trainers are an example where ‘good’ surgeons might score poorly as our methods differ from the North Americans in procedural detail, and vice versa. Less concrete is the apathy of decision-makers and a sense of political distrust, particularly in a climate of change with regard to revalidation procedures and credentialing requirements upon practicing clinicians. It is uncertain whether the future will involve standardized measures of operative skill in examinations of surgeons at any level. What is known is that any drive towards competency-based testing of surgeons should be driven by the profession rather than imposed via bureaucratic intervention. Neither the technology nor assessment methods to date are agreed upon widely enough to be applied to all patients like a driver’s test or aviation licence; however, there is an increasing push by patients and advocates alike for maintenance of the high standards the Colleges and Learned Societies seek to maintain. Surgeons aiming for excellence in both their own practice and those of their trainees should seek out opportunities to incorporate simulated tasks and procedures as part of their professional skill set.

Salutary Swan Song for the Starr Edwards Valve

The Starr-Edwards valve was the first manufactured valve to be used successfully as a cardiac valve replacement in 1960. Although superseded by newer valves over the decades it has achieved an excellent track record. It has unique features, namely a protective metal casing around the ball poppet and a large and thick sewing ring. We describe the last implant of this valve in Australia; it has now been withdrawn by the manufacturer. In this particular case, the unique features of this valve made the required surgery quite simple and avoided the need for complex mitral valve surgery in a very high-risk patient.

Complex Coronary Sinus Fistula in a 58-year-old Female

Coronary artery aneurysms and arterio-venous fistulae are uncommon malformations. We report the case of a 58-year-old woman with a large aneurysmal fistula arising from the left coronary tree and involving the entire coronary sinus venous system, resulting in significant left-to-right shunt. We discuss the management of aneurysmal fistulae of the coronary arteries, and the merits of prophylaxis for thrombotic complications of large aneurysms. We recommend consideration of warfarinisation in addition to aspirin of such patients post-operatively.